Treatment of Alcoholism
and Addiction
Steven R. Ey, M.D.
Medical Director
Genesis Chemical Dependency Unit
South Coast Medical Center
Laguna Beach, CA
April 14, 2005
Addiction Reward Pathway
Admission Labs
 Labs (BAL, CBC, Chem 22, Mg, TSH, RPR,
lipase, UDS, UA, pregnancy test)
 PPD
 CXR
 EKG
 Acetaminophen and salicilate level as
indicated
Absorption and Metabolism
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Sites include stomach, small intestine, and colon
Dependent on gastric emptying time
Metabolized primarily in the liver by oxidation
Alcohol dehydrogenase exhibits zero-order kinetics
(15 mg/dl/hr)
 Proportional to body weight
 Microsomal ethanol oxidizing system (MEOS)
 Alcohol inhibits cytochrome P-450
Alcohol Breakdown
 Alcohol
ADH
Acetaldehyde
ALDH
Acetic acid and water
Alcohol Intoxication
 20-99mg% loss of muscular coordination,
change in behavior
 100-199mg% ataxia, mental impairment
 200-299mg% obvious intoxication, nausea
and vomiting
 300-399mg% severe dysarthria and amnesia
Alcohol Intoxication cont.
 400-600mg% coma occurs
 600-800mg% decreased respirations and
blood pressure, obtundation, often fatal
 Important to remember the role of tolerance
in all these categories
Management of Alcohol
Intoxication
 Cardiovascular and respiratory support to control
blood pressure and maintain airway
 Intravenous fluids (“Banana Bag-NS, thiamine,
MVI, Folate, B-12)
 Assess for other drug use especially benzo’s or
opioids as antagonists can be used
 Closely monitor until withdrawal begins and then
start treatment
Monitoring Alcohol
Withdrawal
 MSSA (Modified Selective Severity
Assessment)
 CIWA-A (Clinical Institute Withdrawal
Assessment for Alcohol)
 Advantage for personnel to monitor progress
and treat accordingly
 Disadvantage is cookbook approach
Withdrawal Signs and
Symptoms
 Tremor
 Agitation
 Autonomic changes (BP, HR, Temp.)
 Seizures
 Sensorium changes (eg, hallucinations,
confusion)
Withdrawal Syndrome Stage 1
 Begins within 24 hours
 Lasts up to 5 days
 90% of cases do not go beyond stage 1
 Other symptoms include depressed mood,
anxiety, diaphoresis, headache,
nausea/vomiting, etc.
Withdrawal Syndrome Stage 2
 Mostly untreated or undertreated in stage 1
 Same signs and symptoms in stage 1 only
more severe
 Hallmark is hallucinations (generally
perceived as benign)
 Usually occurs 48 hours after last drink
Withdrawal Syndrome Stage 3
 Usually occurs 72 hours after last drink
 Delirium Tremens (acute reversible organic
psychosis) has 2% mortality
 Lacks insight into hallucination, often
disoriented and labile
 Seen in persons with severe alcoholism
and/or significant medical problems
Detoxification Treatment
 Begin benzodiazepine at onset of withdrawal
symptoms
 Be cautious that symptoms are withdrawal
and not intoxication
 If uncertain repeat BAC to be sure it is
decreasing before sedating detoxification
meds are instituted
Detox Pharmacology
 Benzodiazepine and Barbiturate equivalents:
 Diazepam 10mg
 Lorazepam 2mg
 Phenobarbital 30mg
 Chlordiazepoxide 25mg
 Oxazepam 30mg
Detox Pharmacotherapy
 Know 2-3 drugs well for routine detox (e.g.,
Diazepam 10-20 mg Q1 hr prn withdrawal)
 Magnesium sulfate 2 gm for severe withdrawal
(esp. in seizure risk)
 Daily thiamine 100 mg, folate 1mg, and MVI
 Push fluids
 Supportive therapy (eg hypertension meds, etc.)
 Stage 3 withdrawal usually requires iv fluids, foley
catheter, soft restraints, etc.
Alcohol Withdrawal Seizures
 More common in untreated alcoholics
 Should hospitalize if first seizure
 Need to be evaluated for other causes (eg, head
injury, CVA, or CNS infection, etc.) if first seizure
or history not clear
 Work up includes brain imaging and EEG
 1 in 4 patients have a second seizure within 6-12
hours
 Must report any seizure to County Health Dept. and
inform patient not to drive
Alcohol Withdrawal Seizures
 Mostly Grand mal seizures
 Usually 24-48 hours after last drink but may
be within 8 hours
 BAC does not have to be zero
 Less than 3% become status epilepticus
 Increased risk if prior seizure or detoxing off
sedative hypnotic as well
GABA and NMDA Neuronal
Receptors
Substance Abuse, J Lowinson, MD.
Third Edition, 1997, page 129.
Kindling and Seizures
Alcohol Withdrawal Seizure
Treatment
 Parenteral benzodiazepines (eg, ativan 2 mg or
valium 10 mg iv stat)
 Seizure precautions
 Valium 10-20 mg q1 hour prn or scheduled taper
 Anti-convulsants are generally not indicated unless
the diagnosis is in doubt
 Work up if 1st seizure
 Report to County Health Dept. and no driving until
cleared
Pharmacotherapy Treatment
 Disulfiram
 Naltrexone
 Acamprosate
Disulfiram
 Deterrent therapy
 Inhibits metabolism of alcohol by blocking
acetaldehyde dehydrogenase
 Acetaldehyde is toxic product causing the reaction
(flushed, tachycardia, diaphoresis, nausea,
headache, etc.)
 Metronidazole and alcohol may cause disulfiram
like reaction
Disulfiram (cont.)
 Prescribing tips (read the label for alcohol if
not sure)
 Monitor liver enzymes
 May cause psychosis
 Evaluate need for patient to take in front of
staff
Naltrexone
 Opiate blocker
 Evidence for reduced cravings and relapse
rates
 23% relapsed vs. 54% placebo during 12
week study
 Definition of relapse
Volpicelli, 1992
Naltrexone cont.
 VA study Dec 13, 2001 NEJM
 627 veterans given 12 mo Naltrexone, or 3
mo. Naltrexone and 9 mo placebo, or 12 mo
placebo
 No statistically significant difference in #
days to relapse at 13 weeks, and no
difference in % days drinking at 52 weeks
Krystal, et al. NEJM Volume 345, pg.
1734-39, Dec 13, 2001
Acamprosate
 Affinity for GABA A and GABA B receptors
 Inhibits glutamate effect on NMDA receptors
 Now available in the United States
Acamprosate cont.
 Multiple studies in Europe show it effectiveness
and safety
 Tempesta, et al. (2000) found abstinence rate 57.9%
with acamprosate versus 45.2% with placebo
 Sass, et al. (1996) found at the end of 48 weeks of
treatment and 48 more weeks of follow-up that 39%
of the acamprosate group vs. 17% of the placebo
group remained abstinent
Case Scenario #1
 40 y.o. male admitted with BAC 460 mg/dl.
 Communicates clearly
 History of recent Alcohol Withdrawal
Seizure
 History of multiple AMA’s during detox in
the past
Case Scenario #1 Treatment
 Patient has high tolerance so medicate appropriately
 Monitor closely and repeat BAC to ensure it is
decreasing
 May use Librium 100 mg po or Phenobarbital 130
mg im to decrease risk of seizure
 Start valium 10-20 mg q 1 hour prn (or Ativan)
 Begin thiamine 100 mg, folate 1 mg, & MVI daily
 2 gm MgSO4 if withdrawal difficult or Mg low
 Consider Depakote or Dilantin but not necessary
Case Scenario #2
 55 y.o. female drinking 1 bottle wine per day
and taking xanax 4 mg. per day
 Smokes 1 pack per day cigarettes
 Complains of hip pain, fell 1 week ago
Case Scenario #2 Treatment
 Alcohol detox with usual meds or Phenobarbital
 Slow klonopin taper as outpatient is one option but
there are more (eg anti-seizure meds and quick
taper in hospital) to detox off of Xanax
 Smoking cessation program
 Don’t forget to check the hip pain.
Case Scenario #3
 30 y.o. female drinking 1-2 bottles of wine
per day
 History of Bulimia nervosa, last binge/purge
3 months ago
 History of multiple relapses
Case Scenario #3 Treatment
 Pregnancy test positive!
 OB/GYN consult but you can order an
ultrasound now
 Always treat as if they will keep the baby
 Detox med of choice is Phenobarbital
 Extended care in dual diagnosis program
Opioid Dependence
 Physiologic dependence versus addiction
 Common opioids
 Rx drugs on the streets, etc.
 Abuse patterns
Opioid Withdrawal Signs
 COWS Scale
 Elevated HR & BP, diaphoresis, restlessness,
pupil size, bone or joint aches, runny nose or
tearing, GI upset, tremor, yawning, anxiety
or irritability, gooseflesh skin
 Score items stage to withdrawal
Opioid Treatment
 Clonidine 0.1 mg every 2 hours prn
 Benzodiazepine or barbiturate prn (eg,
Phenobarbital 15-30 mg every 3 hours prn)
 NSAID
 Muscle relaxant (eg, methacarbamol)
 Bentyl for abdominal cramps
 Sleeping agent (eg, temazepam)
Opioid Treatment (cont.)
 Subutex (buprenorphine)
 Suboxone (buprenorphine/naloxone)
 Sublingual administration of partial opioid
agonist
 Must be certified through DEA to use
Treatment with Suboxone
 Certification requires ASAM, Addiction
Psychiatry, or 8 hour training course
 Capacity to provide or to refer patients for
necessary ancillary services
 Treat no more than 30 patients at one time
Opioid Case #1
 45 y.o. female taking increasing doses of
hydrocodone per day
 Currently on 90 mg per day
 Repeatedly calling office, loses prescriptions
 No pain etiology to explain use of narcotics
Opioid Case #1 Treatment
 Recommend inpatient detox in CD program
 Consider outpatient detox only in reliable,
motivated patient
 Clonidine 0.1 mg q 2 hrs. prn, NSAID,
Muscle relaxant, bentyl, benzo’s for anxiety
and insomnia
 Most CD programs using suboxone now
Sedative/Hypnotic Dependence
 Difficult to detox
 Seizure prophylaxis important
 Rebound anxiety needs to be treated
 Methods to obtain meds include legitimate
prescriptions, prescription fraud, multiple
MD’s or clinics, internet, foreign countries
and the street
Sedative/Hypnotic Treatment
 Taper as outpatient 10% of dose per week as
outpatient
 Quick taper as inpatient with anti-seizure
meds
 Consider valproic acid or other anti-seizure
med for equivalent doses of valium 30 mg.
per day or more (based on clinical
experience)
Sedative/Hypnotic Case #1
 32 yo male taking xanax for 3 years
 Began with xanax 0.5 mg. BID
 Now taking 6 mg. per day for 3 months
 Also on SSRI
 No history of seizure
Sed/Hyp Case #1 Treatment
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Equivalent dose of valium 60 mg. per day
Likely to have seizure if stops abruptly
Recommend inpatient detox
Start valproic acid 250 mg. QID, keep on
therapeutic dose minimum 6 weeks
 Substitute benzo or barb with limited doses for 5-7
days
 Consider zyprexa or equivalent
 Continue SSRI
Psychostimulants
 Detox not a covered benefit
 Medical complications usually bring patient
to ER
 May admit for workup of Chest pain, CVA,
seizure, etc.
 Referral to program
Nicotine
 Fagerstrom Test
 Nicotine Replacement (gum, patches)
 Bupropion
 Support Groups