Alcoholism II: Epidemiology and Treatment

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Alcoholism II Epidemiology and Treatment

• Martha J Wunsch MD
• Addiction Medicine
• January 16, 2006

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Learning Objectives

• Describe the epidemiology of alcohol use, heavy
  drinking, and binge drinking in the US
• List the signs and symptoms of alcohol withdrawal
  and alcohol intoxication.
• List the pharmacological interventions, including
  medications, doses, and dosage interval, in the
  treatment of acute alcohol withdrawal.
•  List medications available for the treatment of
  alcoholism

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National Survey on Drug Use and Health

• Samples from all 50 states are carefully
  structured
• Utilizes personal interviews of subjects
• Computer assisted for sensitive information
• Assures confidentiality
• Recent frequency of drinking excludes sips
• Current (past month) use - At least one drink in
  the past 30 days (includes binge and heavy
  use).Binge use - Five or more drinks on the
  same occasion (i.e., at the same time or within a
  couple of hours of each other) at least once in
  the past 30 days (includes heavy use).Heavy use
  - Five or more drinks on the same occasion on at
  least 5 different days in the past 30 days.

http//oas.samhsa.gov/NSDUH
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Alcohol drinking patterns

• All results are similar to 2002 and 2003
• Current Drinkers About half (50.3 percent) or
  121 million people
• Binge Drinkers More than one fifth (22.8
  percent) or 55 million people
• Heavy Drinking 6.9 percent or 16.7 million
  people.

Americans, age 12 years or older in 30 days prior
to the survey
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Underage Drinking Past Month Alcohol Use among
Persons Aged 12 to 20, by Geographic Region 2003
and 2004
National Survey on Drug Use and Health, 2004
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Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Age 2004
National Survey on Drug Use and Health, 2004
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Current, Binge, and Heavy Alcohol Use among
Persons Aged 12 or Older, by Race/Ethnicity
2004
National Survey on Drug Use and Health, 2004
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Education and Alcohol UseAdults 18 years and
older

• ?Education ? Rates of current drinking in past
  month
• Less than a high school education 36.4 percent
  were current drinkers
• College graduates 67.6 percent were current
  drinkers.
• ?Education ? Rates of heavy drinking in past
  month
• College graduates increased from 2003 (5.3) to
  2004 (6.4)
• Less than high school education decreased from
  2003 (7.9) to 2004 (6.25)
• Binge drinking
• Increased among college graduates, from 20.2
  percent in 2003 to 21.9 percent in 2004.

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Heavy Alcohol Use among Adults Aged 18 or Older,
by College Attendance and Age 2004
National Survey on Drug Use and Health, 2004
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Association with Illicit Drug use and Tobacco

• Among the 16.7 million heavy drinkers aged 12 or
  older,
• 32.2 percent were current illicit drug users.
• Persons who did not use alcohol in the past month
  were less likely to have used illicit drugs in
  the past month
• Drinking levels also were associated with tobacco
  use.
• 61.2 of heavy drinkers smoked cigarettes in the
  past month
• 21.1of non-binge current drinkers were current
  smokers
• 16.3 who did not drink alcohol in the past
  month were current smokers.
• Smokeless tobacco and cigar use also were more
  prevalent among heavy drinkers than among
  non-binge drinkers and nondrinkers.

National Survey on Drug Use and Health, 2004
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Driving Under the Influence of Alcohol in the
Past Year among Persons Aged 16 or Older, by Age
2004
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Alcohol in the Workplace Research Institute on
Addictions

• Telephone interviews
• 2,805 employed adults in 48 states
• 18-65 years old
• Sample designed to survey entire workforce
• Alcohol intake and work previous 12 months
• Drank w/in 2 hours of work
• Drank during workday
• Work under influence or with a hangover

Fronel Journal of Studies on Alcohol, January 2006
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Alcohol in the Workplace 15 work under the
influence

• 2.3 million workers (1.8 percent of the
  workforce) have consumed alcohol at least once
  before coming to work
• 8.9 million workers (7.1 percent of the
  workforce) have drank alcohol at least once
  during the workday.
• Usually during lunch breaks, though some drink
  while working or during other breaks.
• 2.1 million workers (1.7 percent of the
  workforce) worked under the influence of alcohol
  and
• 11.6 million workers (9.2 percent of the
  workforce) worked with a hangover.

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Alcohol in the Workplace 15 work under the
influence

• More likely among young, unmarried males
• Highest among management, sales,
  arts/entertainment/sports/media, food service,
  building and ground management
• Higher among those working nonstandard shift

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Effects of alcohol consumption

• Varies with age, size, gender, food intake, and
  prior experience with alcohol
• Usual drink contains 10-12 grams of absolute
  alcohol
• Usual drink increases blood alcohol concentration
  ( BAC) by 15-20 mg/dl
• 10-12 grams of alcohol are metabolized each
  houror 15-20 mg/dl

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Alcohol Intoxication
mg/100ml blood( mg or mg/dl)
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Serum alcohol 600-800 mg

• Progressive obtundation
• Decreases in respiration, BP, body temperature
• Urinary incontinence or retention
• Death
• Loss of airway protective reflex/obstx tongue
• Pulmonary aspiration of gastric contents
• Respiratory arrest due to CNS depression

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Treatment of overdose Supportive while alcohol
is metabolized
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Alcohol Overdose

• Establish an airway, support ventilation
• Establish IV access, replace fluid loss 20cc/hr
  for insensible loss
• Evaluate cardiovascular status
• Control bleeding
• Treat shock with plasma expanders
• Monitor Urine output and send urine for
  toxicological screen
• If benzodiazepine involvement
• Administer Romazicon ( antagonist) 1 mg IV over
  1-3 minutes, 5 mg over 10 minutes. Repeat in
  20-30 minutes if needed
• Gastric lavage only if pills taken in last 4-6
  hours

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Alcohol Overdose

• If opioid involvement
• Narcan 0.4mg IV/IM. Repeat in 20-30 minutes if
  needed
• Obtain more history and continue physical
  assessment, including neurologic status
• Draw serum toxicological screen, evaluate liver
  and renal function, CBC.
• Do not utilize gastric lavage since alcohol is
  rapidly absorbed
• Aggitation
• Utilize support and reassurance primarily
• If necessary, CAREFUL use of short acting
  benzodiazepine (lorazepam) haloperidol
• Be aware of increased obtundation due to use of
  another sedative hypnotic drug

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Alcohol Withdrawal
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Clinical Syndromes

• Minor Alcohol Withdrawal
• Seizures
• Major Alcohol Withdrawal or Delirium Tremens

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Alcohol Withdrawal
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Pathophysiology

• Alcohol is a depressant
• Chronic exposure causes compensatory changes in
  inhibitory and excitatory neurotransmitters
• Down regulation of inhibitory system ( GABA)
• Up regulation of excitatory system
• Inhibition of autonomic adrenergic system
• Effects of neuronal calcium channels, glutamate
  receptors, cAMP, CRF

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Pathophysiology

• Sudden relative deficiency in GABA
• Causes anxiety, increased psychomotor activity,
  lowered seizure threshold
• Rebound increased activity of brain and
  peripheral noradrenergic systems
• Increased sympathetic activity
• ?HR, ?BP,tremor, diaphoresis, anxiety
• Extraordinarily disquieting for the patient

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Minor Alcohol Withdrawal

• Onset 6-24 hours after last drink
• Reflects fall of alcohol serum level, may occur
  before BAC0
• Occurs in up to 50 of alcohol dependent
  individuals upon cessation of drinking
• Higher in hospitalized patient with medical
  problems (diabetes, trauma, pneumonia)
• Usually will abate without progressive to major
  alcohol withdrawal

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Minor Alcohol Withdrawal

• Signs/Symptoms
• Anxiety, sleep disturbance, vivid dreams,
  anorexia, nausea, headache
• Physical Exam
• Tachycardia, increased blood pressure,
  hyperactive reflexes, sweating, hyperthermia.
• Tremor tongue, arms with extension
• Hallucinations
• Perceptual Distortions of visual, auditory,
  tactile nature
• Sensorium is usually clear and patient realizes
  that these are not real

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Treatment Monitor closely for progression of
symptoms

• Assess for concurrent medical problems ( HX and
  PE)
• GI, Cardiac, Infections, Neurological
• Nutrition Poor absorption, poor diet
• CBC, electrolytes, Ca, Mg, Phosphate, Liver
  enzymes, urine drug screen, pregnancy test
• Monitor for increasing autonomic instability
• 5-8 of patients will require pharmacological
  treatment
• Evidence of increasing disorientation
• Begins w/in 12 hours, peaks at 48-72 hours, and
  reduced by 4-5 days.
• Protracted Abstinence Syndrome 6 months
• Depression Suicide rate in alcoholics in higher
  than general population

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Clinical Institute Withdrawal AssessmentAlcohol
(CIWA-Ar)

• Objectively quantify the severity of withdrawal
• Well documented validity and reliability
• 2-5 minutes to administer
• Useful in in-patient, psychiatric, general
  hospital settings
• American Society of Addiction Medicine link
• http//www.asam.org/Addiction20Medicine20Essenti
  als/INSERT20jan-Feb202001.pdf
• Scoring indicates severity of syndrome

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Alcohol Related Seizures

• Affect lt5 of alcohol dependent individuals
• Develop 24-48 hours after cessation of drinking
• Rarely (lt3) progress to status epilepticus
• May relate to pre-existing brain damage,
  associated medical problems, seizures unrelated
  to alcohol, lowering of threshold.
• Increased in patients with benzodiazepine or
  other sedative-hypnotic withdrawal, those with
  repeated bouts of withdrawal, those with a hx of
  prior w/d seizure

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Treatment

• Evaluate for underlying cause other than alcohol
  withdrawal
• Infection, metabolic, trauma, pre-existing
  seizure disorder
• Benzodiazepines (Lorazepam 1-2 mg IV)
• Support of Airway, Oxygen
• TREAT WITHDRAWAL from alcohol aggressively!

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Major Withdrawal Delirium Tremens

• Appear 72-96 hours after the last drink
• Signs and symptoms mimic those of mild withdrawal
  but are much more pronounced
• Severe Autonomic Instability
• Marked tachycardia, tremor, diaphoresis, fever
• Global confusion, disorientation to time and
  place.
• Hallucinations are frequent and patient has no
  insight that they are not real
• Marked psychomotor agitation
• Severe disruption of sleep-wake cycle.
• Duration with treatment hours-days
• Patient will have protracted abstinence syndrome
  

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Major Withdrawal Delirium Tremens

• Patients at risk for DTs
• Not related to amount of daily intake or duration
  of heavy drinking
• Increased prevalence
• Severe withdrawal
• High alcohol at time of presentation ( gt300
  mg/dl)
• Presentation after withdrawal seizure
• Older individuals ( Women 35 years, men 45 years)
• Significant medical problems
• History of prior severe withdrawal

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Pharmacological Management

• Key Concept Medically control withdrawal by
  giving a long acting cross tolerant medication
  until CIWAlt 8-10 for 24 hours. Then taper dose by
  20 each day, keeping dosage interval THE SAME.
• Monitor VS and CIWA-Ar every 4 hours until
  stable, then every 8 hours.
• Utilize Benzodiazepines or Phenobarbital Enhance
  GABA-induced sedation
• Symptom triggered dosages for CIWA gt8
• Patient will require less overall medication
• Scheduled dosages, held with sleep or sedation
• May be better on a general medical floor
• Thiamine 100 mg IV or IM X 3 days, then MVI

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Symptom Triggered Medication Regimens

• Administer one of the following medications PO
  every hour when CIWA-Ar is gt8-10
• Diazepam 10-20 mg
• Oxazepam 30-60 mg
• Lorazepam 2-4 mg
• Phenobarbital 30-60 mg
• Repeat CIWA-Ar one hour after every dose to
  assess need for further medication
• Loading dose of patient until comfortable and
  CIWA-Ar is lt8-10
• Best utilized with mild withdrawal
• Patient will essentially self taper

http//www.asam.org/publ/withdrawal.htm
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Structured Medication Regimens

• Diazepam 10 mg every 6 hours for four dosages,
  then 5 mg every 6 hours for eight dosages
• Offer PRN dosages of 5 mg between scheduled for
  emergence of symptoms
• Lorazepam 2 mg every four hours for six dosages,
  then 1 mg every four hours for 12 dosages.
• Offer PRN dosages of 1 mg between scheduled for
  emergence of symptoms
• Best utilized with a patient in moderate-severe
  withdrawal

http//www.asam.org/publ/withdrawal.htm
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Increasing evidence of withdrawal, agitation,
hallucinations despite oral medication

• !!MUST HAVE EQUIPMENT FOR RESPIRATORY SUPPORT ON
  HAND!!
• Intravenous Diazepam
• 5 mg SLOWLY every 5 minutes until patient is
  lightly sedated
• If needed, increase to 10 mg X 2 doses, then 20
  mg every 5 minutes X 2
• IV Lorazepam
• 2 mg over 5 minutes until patient is lightly
  sedated X2
• If needed increase to 4 mg every 5 minutes X2

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Pharmacological Management

• NOT useful in the treatment of W/D
• IV Alcohol drip Short acting, toxic agent
• Haloperidol Decrease seizure threshold, should
  ALWAYS be used with Bz if needed
• Beta-adrenergic blocking agents
• Treat the symptoms of ANS only, not the cause
• No anticonvulsant activity
• May increase delirium, especially in elderly
• MASK the signs of withdrawal which indicate
  worsening course of disease

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Medication Assisted Treatment after the crisis

• Useful adjuvant to psychosocial treatment that
  will increase compliance

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Naltrexone (Revia)

• Treatment Improvement Protocol (TIP) 28
• Outlines guidance for use of medication
• http//ncadi.samhsa.gov/govpubs/BKD268/28c.aspx
• When used as an adjunct to psychosocial therapies
  for alcohol-dependent or alcohol-abusing patients
  will reduce
• The percentage of days spent drinking
• The amount of alcohol consumed on a drinking
  occasion
• Relapse to excessive and destructive drinking
• Dose 50 mg/day
• Monitor Liver Function Tests at initiation and
  throughout tx
• Avoid combination with other hepatotoxic
  medications

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Disulfram ( Antabuse)

• Sensitizing agent, inhibits aldehyde
  dehydrogenase
• 30 minute unpleasant reaction with ingestion of
  alcohol
• Mild Flushing, ? HR, palpatations,? BP
• Moderate N,V,SOB, sweating, blurred vision,
  confusion
• Severe Marked tachycardia, hypotension,
  bradycardia, cardiac arrest due to vagal
  stimulation with emesis
• CV collapse, CHF, Seizures
• Hepatotoxic Monitor LFTs closely, esp w/ relapse
  to drinking

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Disulfram (Antabuse)

• Efficacy in prevention of relapse has not been
  demonstrated
• Use outside of a structured treatment program is
  not indicated
• In SELECTED samples of alcoholics may be helpful
• Business trip with known risks of relapse
• Dose 250-500 mg q day
• Start at a lower dose to decrease GI side effects
• Avoid alcohol for two weeks after use because of
  irreversible binding to enzyme.

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Acamprosate (Campral)

• Amino Acid Derivative active in both GABA and
  Glutamate neurotransmitter systems
• Glutamate receptor modulator
• Affects the balance of inhibitory/excitatory
  systems in alcoholism
• Contraindicated in patients with decreased renal
  function
• creatinine clearance 30 mL/min
• Dose (333 mg) Two tablets three times daily

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Summary

• Alcoholism is prevalent in some populations
• If minor alcohol withdrawal is treated
  appropriately and aggressively you will avoid
  progression to DT
• Consider use of medication assisted modalities
  for your patients in treatment