Addiction Issues in Critical Care

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Addiction Issues in Critical Care

• Kevin Kunz M.D.,M.P.H.,FASAM

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Overview of Todays Talk

• Addiction What is it?
• Complications of addiction
• Treatment of overdose and withdrawal
• Alcohol
• Opioids
• Methamphetamine

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The United States of Drugs
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Addiction

• Addiction is a primary, chronic, neurobiologic
  disease, with genetic, psychosocial, and
  environmental factors influencing its development
  and manifestations.

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Addiction The 5 Cs

• Control of drug use is lost
• Consequences of use
• Continued use despite consequences
• Craving
• Compulsive use

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Physical Dependence or Addiction?

• Physical dependence is a normal physiologic
  response to the medical use of certain drugs
• Addiction involves the non-medical use of drugs

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Preventable Causes of death

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Total attributed
Tobacco Deaths

• 530,000 Deaths / Year
• 23 of all Deaths
• 38 of all Cancer Deaths
• 24 Cardiovascular Deaths
• 40 Respiratory Deaths
• Etc. Etc.

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Mesolimbic pathway
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Alcohol Withdrawal Syndrome

• EtOh is a CNS depressant
• Enhances GABA effect
• Sedation, muscle relaxation, raised seizure
  threshold
• Inhibits autonomic adrenergic systems
• Particularly in the locus ceruleus
• EtoH decrease or abstinence causes rebound
• Relative GABA deficiency leads to anxiety,
  increased psychomotor activity, seizure kindling
• Rebound sympathetic adrenergic activity leads to
  tachycardia, HBP, tremor, diaphoresis

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Alcohol Overdose and Withdrawal

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Alcohol Overdose

• .02-.1mg mood, personality, behavior changes,
  loss of muscle coordination
• .1-.2 mg prolonged reaction time, ataxia,
  in-coordination, mental/neurologic deficits
• .2-.4 mg obvious intoxication, nausea, vomiting,
  hypothermia,dysarthria, amnesia
• .4-.8mg coma
• .6-.8 mg death
• Treatment Supportive only, no known antagonist

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Subtypes of Alcohol Withdrawal A,B,C

• Each type may present alone, or with others
• Each type is variable in intensity
• Type A GABA receptor associated, symptoms
  similar to a hangover
• Type B Hyperadrenergic, a physiologic,
  metabolic rebound/rush
• Type C mesolimbic/dopaminergic, cognitive
  changes, psychosis, delirium

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AWS Type A

• Type A GABA associated
• Uneasiness, Sense of foreboding
• Motor hyperactivity
• Dysphoria, lability of mood
• Sensitivity/reaction to abrupt sensory stimuli
• Anxiety, Insomnia
• Treatment of Type A withdrawal?
• A GABA agonist
• Benzodiazepines
• Barbiturate
• AEDs ( gabapentin, others)

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Type A Treatment Caveats

• Tendency to use benzopiazepines (BNZ) in too low,
  or too high a dose
• Librium and Valium contraindicated in liver
  disease use Ativan
• Potential adverse effects may complicate and
  prolong withdrawal
• BNZ and barbiturates may cause ataxia,
  over-sedation, respiratory depression,
  disinhibition, cognitive disruption

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AWS - Type B

• Type B adrenergic rebound
• Tachycardia, palpitations
• Hypertension
• Chills, diaphoresis
• Fever, hypermetabolic state
• Pilo-erection, mydriasis
• Nausea/vomiting/diarrhea
• Treatment of Type B withdrawal?
• Alpha and beta adrenergic blocking agents
• (clonidine, propanolol, atenolol, others)

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Type B Treatment Caveats

• Beta Blockers
• Contraindications
• Volume depletion, asthma/COPD, CHF, sick sinus
  syndrome, high-grade conduction blocks
• Potential Adverse Effects
• Hypotension, bradycardia, bronchospasm
• Alpha Blockers
• Contraindications
• As above except asthma/COPD
• Potential Adverse Effects
• Hypotension, bradycardia, confusion (rare)

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AWS Type C

• Type C mesolimbic/dopaminergic
• Attention deficit, disorientation
• Hyper-alertness, psychomotor agitation
• Impaired short-term memory and reasoning
• Visual and auditory hallucinations
• Delirium
• Treatment of Type C withdrawal?
• Neuroleptics
• (Haldol, droperidol, Risperdal, Zyprexa)

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Delirium and Delirium Tremens

• delirium can occur with or without the tremens
• tremens refers to the extreme Type B
  withdrawal signs and symptoms
• appears 3-4 days after the last drink
• continues an average of 2-3 days, with a range
  from a few hours to over 30 days

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Classic Delirium

• Tom Sawyer described it in his father
• Incidence of 5 in hospitalized AWS pts
• Abrupt onset is usual
• Global confusion and disorientation
• Patient in a separate psychic reality
• Auditory and visual hallucinations
• No insight to condition, can be frightening
• Agitation, increased psychomotor activity common
• Disturbed sleep cycle

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Risk Factors for Delirium

• Often no identifiable risk factor other than
  decrease/abstinence of alcohol
• Poor Correlation Duration of heavy drinking and
  amount of daily intake
• High blood alcohol on admission (greater than
  300mg/dl)
• Age
• Co-morbidity
• GI Bleed,trauma,Hx of past AWS,malnutrition,
  concurrent drug use, etc.

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Type C Treatment Caveats

• Haldol, Droperidol
• Contraindications
• Prolonged QT interval, Parkinsons, hypotension
• Potential Adverse Effects
• Heavy sedation, dystonic reactions, Parkinsonian
  crisis, neuroleptic malignant syndrome,
  pro-convulsant
• Risperdal, Zyprexa
• Relative Contraindication cost
• Potential Adverse Effects
• Pro-convulsant, at high dose may exacerbate
  pre-existing psychotic disorder

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Delirium Rx in Kona

• Haldol 2.5 5mg IV q 4H prn
• Benadryl 25-50mg/d to prevent dystonia
• Ativan (Valium if liver OK), IV q 2-4 hours prn
• Pentobarbital protocol if Haldol fails
• Sublinqual atypical neuroleptics now being used
  in some settings
• Hydration, monitoring and correction of
  lytes/minerals, restraints when needed
• Minimize dose of all meds, make patient
  comfortable, conscious sedation not necessary

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Other EtOh Related Neurologic Disorders

• Intermediate Brain Syndrome
• Wernickes Encephalopathy
• Korsakoffs Psychosis
• Alcoholic Dementia
• Alcoholic Cerebellar Degeneration
• Alcoholic Polynauropathy
• Central Pontine Myelinolysis

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Central Pontine Myelinolysis

• Edema of the pons, caused by sudden/quick
  correction of hyponatremia
• Dysarthria
• Dysphagia
• Rapid onset paraparesis or quadriparesis

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Wernicke Korsakoff

• Wernickes Disease
• Caused by thiamine deficiency
• Diagnostic triad mental disturbance (apathy,
  confusion, etc), sixth nerve palsy (and
  nystagmus), ataxia
• Delay in treatment risks permanent damage
• Korsakoffs Psychosis
• Profound deficit in retentive memory, learning
• Intelligence and verbal abilities preserved
• Confabulation
• Often follows Wernickes Disease

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Thiamine and Wernicke-Korsakoff

• Thiamine 100mg IV to every EtOhic ASAP
• Give thiamine before glucose solution
• Then give thiamine 100 mg daily IV or PO
• Thiamine is used to prevent Wernickes disease,
  and to treat Korsakoffs psychosis

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Seizures

• Seizures reported in 11-35 of patients
  withdrawing from EtOh in hospital setting
• Usually grand mal and single, or a burst of
  several over 1-6 hours
• Always rule-out other causes subdural,
  stimulant (and tramadol) induced not uncommon
• Phenytoin is not prophylactic, and not indicated
  for Rx - use BNZ

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Common AWS Treatment Errors
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National plane crash
Imagine 3 full jumbo jets crashing to the earth
daily. That is the number of lives we lose to
tobacco each day.
C. Everett Koop M.D. Surgeon General 1981-1989
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CVA

• 25 of all Strokes

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Heroin ad
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.opioid receptor model

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Receptor Mediated Actions

• Mu
• Supraspinal analgesia
• Respiratory depression
• GI stasis
• Urinary retention
• Bradycardia
• Euphoria
• Pruritis
• Physical dependence
• Kappa
• Supraspinal analgesia, sedation, miosis,
  hyperalgesia
• Sigma
• Dysphoria, hallucinations, hypertonia,
  tachycardia, tachypnea

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Opioid Drug Classes

• Agonist
• Relieve pain and alter mood
• Antagonist
• Displace or block opioids from receptors, no mood
  altering effect
• Mixed agonist/antagonist
• Have both agonist and antagonist actions

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.morphine molecule

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Opioid Adverse Effects

• Sedation
• Respiratory depression
• Nausea, vomiting, sweating
• Constipation (no tolerance)
• Miosis (no tolerance)
• Truncal rigidity
• Hypotension
• Histamine release
• GI effects decreases HCl, secretions, propulsive
  waves sphincter of Oddi spasm
• Inhibition of urinary voiding reflex
• Tolerance, dependence, addiction(rare)

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Antagonists

• Naloxone (Narcan)
• Naltrexone ( Trexan, Revia)
• Nalmefene ( Revex)

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Opioid Overdose

• Pinpoint pupils (later dilated)
• Respiratory depression
• Coma

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Opioid Adverse Effects

• Sedation
• Respiratory depression
• Nausea, vomiting, sweating
• Constipation (no tolerance)
• Miosis (no tolerance)
• Truncal rigidity
• Hypotension
• Histamine release
• GI effects decreases HCl, secretions, propulsive
  waves sphincter of Oddi spasm
• Inhibition of urinary voiding reflex
• Tolerance, dependence, addiction(rare)

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Opioid Overdose

• Pinpoint pupils (later dilated)
• Respiratory depression
• Coma

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Rx for Opioid Overdose

• Airway and ventilation
• Opioid antagonist (Narcan)
• Dilute .4 mg in 10cc saline, titrate to effect
• Be alert to rebound sympathetic response
  arrhythmias, pulm. Edema
• Can precipitate major withdrawal syndrome

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Topics of Discussion

• State the main ideas youll be talking about

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Topic One

• Details about this topic
• Supporting information and examples
• How it relates to your audience

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Topic Two

• Details about this topic
• Supporting information and examples
• How it relates to your audience

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Topic Three

• Details about this topic
• Supporting information and examples
• How it relates to your audience

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Real Life

• Give an example or real life anecdote
• Sympathize with the audiences situation if
  appropriate

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What This Means

• Add a strong statement that summarizes how you
  feel or think about this topic
• Summarize key points you want your audience to
  remember

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Next Steps

• Summarize any actions required of your audience
• Summarize any follow up action items required of
  you