Alcohol Use Disorder¶
Barrington Hwang, Kristopher Kast
Background¶
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50% of hospitalized pts drink alcohol; at-risk alcohol use is >14 drinks/week or >5 drinks in a sitting (for men; for women and men >65, 7 per week, >4 per sitting)
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Alcohol withdrawal onset occurs 6-12 hours after last drink, with 90% having non-severe course; CIWA score \<10 at 24-48 hours indicates low risk of worsening symptoms
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Risk of seizures greatest at 12-24 hrs, occurring in ~3% of pts; risk of delirium greatest at 48-72 hrs, occurring in ~5%
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Risk assessment
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RF: prior seizures/delirium, co-substance use (especially benzodiazepines), no abstinent days in past month, presenting BAL >200, dysautonomia
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CIWA symptom-triggered protocol appropriate for pts at low risk of severe withdrawal
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For non-low risk pts, consider benzodiazepine/barbiturate load and standing taper;
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Indications for admission: prior severe withdrawal (withdrawal seizures or delirium), comorbidities (medical and psychiatric illness), pregnancy, significant impairment in social/occupational functioning, communication barriers, social barriers
Presentation¶
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Acute intoxication: disinhibition, slurred speech, ataxia, nystagmus
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Acute Withdrawal: nausea, vomiting, anxiety, agitation, audio-visual and tactile hallucinations, headache, diaphoresis, fine motor tremor while arms and fingers outstretched, autonomic hyperactivity
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Chronic heavy use: Sequelae of chronic liver disease & malnutrition, including thiamine deficiency
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Caine criteria for Wernicke’s encephalopathy:
- 2 or more: (1) malnutrition, (2) ataxia, (3) oculomotor abnormalities, (4) AMS
Evaluation¶
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Identify last use, quantity per day/week, other sedative-hypnotic use, history of withdrawal, social/occupational dysfunction, other toxic forms of alcohol compounds including methanol, ethylene glycol
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Acute Alcohol Withdrawal
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Labs: Blood alcohol level, urine toxicology (± ethyl glucuronide to detect use in prior 3 days), BMP, CBC, HFTs (AST:ALT elevation 2:1), CK and β - hCG
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CIWA score quantifies severity, though subject to inflation by subjective symptoms
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Management¶
Acute Alcohol Withdrawal¶
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Most patients are appropriate for diazepam-based protocols:
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CIWA-based symptom-triggered for low-risk patients
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Diazepam load + standing taper for non-low risk patients
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Substitute lorazepam for pts with hepatic impairment (risk of long-acting accumulation)
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Benzodiazepine resistance: likely due to poor cross-tolerance, these pts require phenobarbital load ( 8-12 mg/kg (up to 15 mg/kg) divided into 3 doses 3 hours apart)
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Add folate, multivitamin, and electrolyte repletion
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If >2 Caine criteria, treat empirically for Wernicke’s encephalopathy with high-dose IV thiamine (500 mg TID IV x 3-5 days)
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Consider Addiction Psychiatry consultation for complex presentations
Alcohol Use Disorder¶
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After withdrawal stabilization, engage pt in discussion around use and educate on connection between use and presenting medical problems
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All patients with AUD should be initiated on pharmacotherapy (MAUD) prior to discharge to mitigate risk of relapse, if consistent with patient’s goals
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Additional psychosocial treatments effective for AUD include 12-step groups (AA, SMART Recovery), cognitive behavioral therapy, sober living facilities, family therapy, contingency management, and IOP/residential facilities
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If patient does not have abstinence goal, reduced or controlled drinking may allow for harm reduction; naltrexone and topiramate have evidence for non-abstinence outcomes
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Pharmacologic Interventions:
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Naltrexone (cannot be on opioid agonist):
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Need 7-10 days since last opioid before starting
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25 mg x1 day, then titrate up to 50 mg daily; also available in q30d IM
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Monitor liver enzymes; AST/ALT must be \< 3-5x ULN
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Acamprosate (cannot be used in severe renal impairment)
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Head-to-head, inferior to naltrexone (see COMBINE trial)
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333 mg TID, titrating to 666 mg TID dosing
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Disulfiram
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Infrequently used outside of extreme motivation (e.g. professional under monitoring); would not use outside specialist care
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Must abstain from alcohol ~2 weeks after last dose, given risk of disulfiram-ethanol reaction (DER), which can be fatal depending upon disulfiram and ethanol doses
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Topiramate
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Not FDA-approved for AUD, but has significant supporting evidence
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Useful for individuals without abstinence goal
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Titrate slowly over 8 weeks to 200-300 mg/d
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Gabapentin
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Not FDA-approved for AUD, but with some evidence
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Useful for post-acute withdrawal anxiety, insomnia, or co-occurring neuropathy
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Titrate to 900-1800 mg/d divided into TID dosing, monitoring for sedation
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Risk of sedation/apnea if concomitant alcohol use
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