Back to basics!Substance abuse/drug addiction/withdrawal

March 19, 2012Dr. Gabrielle Cyr

PGY-3 resident, psychiatryUniversity of Ottawa

Objectives

• Key objectives– Determine whether the patient is in need of

emergency care because of withdrawal symptoms or other complications

• Objectives– Take an efficient/focused addictions history– List/interpret clinical/laboratory findings which are

key to the processes of exclusion/differentiation and diagnosis

– Conduct and effective initial plan of management for a patient with substance abuse

Why do we care?

• Anybody can be affected (++ common)

• All specialties of medicine

• Major psychosocial/functionnal impacts

• Potentially lethal

Basics of addiction

• Genetic vulnerability

• Environmental factors– Low socioeconomic status– Chaotic background– Etc…

• Repeated use

Creating an addiction

• Drugs→ activation of the reward system of the brain (mesolimbic dopamine system)→flooding of Dopamine

• Repeated use = changes in function

• ↓Dopamine/Dopa receptor production→ need ↑amounts of drugs to create pleasure

Substances

• Depressants– Alcohol– Benzodiazepines– Barbiturates– Opioids

• Stimulants– Amphetamines– Cocaine– Cannabis– Hallucinogens (MDMA, LSD, Psilocybin, Mescaline)

Taking a substance history

• Recent (last 6 months-1 year)/past pattern of abuse– Type of substance/route of administration– Quantity/frequency of use/schedule– Severity of use (abuse vs dependence)

• Impacts of use– Social/occupationnal/legal (DUI, probation, CAS

involvement, etc.)– Medical complications (IV DU, etc.)

Taking a substance history

• Family history of substance use

• Current/past withdrawal symptoms, severe withdrawal reactions (DT’s, withdrawal seizures, etc.)

• Past treatments for addictions

• Support system

Physical examination

• Cognition/LOC/Orientation

• Signs of intoxication (toxidromes)/withdrawal– Vitals– Skin (signs of liver failure, needle marks, etc.)– Pupils– Etc.

• +/- complete physical exam

DSM-IV criteria: abuse

A. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period:1. recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home2. recurrent substance use in situations in which it is physically hazardous3. recurrent substance-related legal problems4. continued use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by effects of a substance

B. The symptoms have never met the criteria for substance dependence for this class of substance

DSM-IV criteria: dependence

• 3 or more occurring over 12 months:– tolerance– withdrawal– larger amounts or longer period of time– unsuccessful efforts to cut down or control– time spent obtaining, using, recovering– activities given up or reduced– continued use despite problems

Standard drinks…

Canada’s low risk alcohol drinking guidelines

• No more than:

– Women ≤ 10 drinks/week (≤ 2 drinks/day most days)

– Men ≤ 15 drinks/week (≤ 3 drinks/day most days)

– In one sitting:• Women, no more than 3 drinks• Men, no more than 4 drinks

– Plan a few non drinking days/week

CCSA, Canada's Low-Risk Alcohol Drinking Guidelines, November 2011

Alcohol - assessment

• Always screen;– CAGE questionnaire

• Have you ever felt the need to CUT down on your drinking?

• Ever felt ANNOYED by criticism of your drinking?• Ever felt GUILTY about your drinking?• Ever had a drink first thing in the morning? (EYE

OPENER)

– Score 0 or 1 (≥ 2 = significant)– Quick / sensitive 75-85%

Alcohol - assessment

• Investigations– LFT’s (GGT, AST:ALT ratio 2:1)– CBC (↑MCV, anemia, thrombocytopenia) – For baseline and monitoring

• Potential complications– Cardiac (HTN, cardiomyopathy)– GI (GI tract cancers, gastritis, bleeds)– Neuro (Wernicke-Korsakoff)

Potentially deadly withdrawals…

• Alcohol

• Benzodiazepines/Barbiturates

• GHB…

Alcohol/Benzodiazepine withdrawal

– Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100), also labile BP

– Increased hand tremor– Insomnia– Nausea or vomiting– Transient visual, tactile, or auditory hallucinations or

illusions– Psychomotor agitation– Anxiety– Grand mal seizures

• Withdrawal seizures: 6-48 hrs• DT’s: up to 24-72 hrs

Stages of change

Alcohol/benzo withdrawal management

• Have to follow motivation for change– Stages of change– Motivationnal interviewing

• Outpatient management:– Mild-moderate problem (set drinking goals)– No history of severe withdrawal– Good support/regular follow-up– AA

Community outpatient treatment (Ottawa)

• The Royal Substance Use and Concurrent Disorders Program

• Sandy Hill Addictions and Mental Health• Rideauwood Addiction and Family Services• Amethyst Women’s Centre• Serenity Renewal for Families• LESA (Lifestyle Enrichment for Senior Adults)• CMHA

Alcohol/benzo withdrawal management

• Non medical detoxification/residential treatment– Patient intoxicated/mild withdrawal– Can take own medication– Medically stable– Short stay only

Residential treatment (Ottawa)

• Empathy House

• Serenity House

• Sobriety House

• VESTA

• Maison Fraternité

• The ROMHC Meadow Creek

Alcohol/benzo withdrawal management

• Medically supervised detoxification (inpatient)– Severe alcohol/benzodiazepine withdrawal

• Delirium tremens• Alcohol withdrawal seizures• Past history/current

– Polysubstance use and medical comorbidities (severe CAD, etc.), high dose benzos

– Pregnancy

Alcohol/benzo withdrawal management

• Inpatient treatment/medical detox– Front loading

• High doses, early in withdrawal state• Diazepam 10-20mg q 1-2h for CIWA ≥10, goal is

CIWA ≤ 8/sedation• Useful in ER

– Fixed dosing• Diazepam/Lorazepam QID with PRN doses q2-4h• Useful if past history DT’s/seizures

Alcohol/benzo withdrawal management

• Be careful!– For ALL patients

• Thiamine 100mg IM for 3 days, then PO (up to 2 months)

– Lorazepam safer if hepatic function unknown

Alcohol addiction treatment

• Disulfiram (Antabuse)– Blockade of Aldehyde dehydrogenase

• Flushing/nausea+vomiting/hypotension on ingestion of alcohol

– Aversive agent– Mild LFT elevation, risk of fatal hepatotoxicity

(rare)

Alcohol addiction treatment

• Naltrexone– Opioid antagonist– May reduce cravings for alcohol– SE: nausea+vomiting, headaches, fatigue– Contra-indications: Increased LFT’s, pregnant

+breastfeeding, opioid dependence

Opiate withdrawal

• Nausea/vomiting, diarrhea, sweating, lacrimation• Piloerection• Pupillary dilatation• Myalgias• Dysphoric mood, insomnia, anxiety

• Not life threatening, but uncomfortable

Opiate cessation

• Stopping «cold turckey»– Supportive measures,Clonidine as adjunct

• Tapering schedule with long-acting opiate– Equivalence; decrease by 10%/week

• Maintenance treatment– Methadone (full agonist)– Buprnorphine/Naloxone (Suboxone) (partial agonist)

Methadone replacement

• Synthetic opioid

• Useful if high dose opiate abusers, addicted for a long time, relapses, etc.

• MD’s need a special license to order

• Usually daily pick-up at pharmacy

Safe prescribing – controlled substances

• Under Canada’s Controlled Drugs and Substances Act– Narcotics and other drugs of potential for abuse

(methylphenidate, benzodiazepines and barbiturates)

– Need to correctly identify patient– Information can be collected by Narcotics Safety

and Awareness Act (NSAA)– Should never write repeats on narcotic prescription

Nicotine…

• Counselling, advice

• Nicotine replacement therapy– Patch, gum, inhaler, lozenges– Usually treat for up to 2-3 months

• Bupropion (Zyban)– Usually 2 months of treatment, up to 1 year – Contraindicated in Seizure disorder

Nicotine…

• Varenicline (Champix)– Some studies have showmn exacerbation of

pre-existing psychiatric conditions – so monitor

– Usually treat for 3 months

Prevention/harm reduction strategies

• Safer environment to use substances– Supervised injection sites

• Safer use of substances– Crack pipe programs, needle exchange programs

• Alternative safe substances– Methadone Maintenance

• Modification/Management of related risk behaviours– HIV/STD screening– Safe sex education– Condoms

References

• Dr Willow’s presentation, substance use

• DSM-IV

• Toronto Notes

• Up to date

• Narcotics Safety and Awareness Act

• Canada’s low risk alcohol drinking guidelines