back to basics! substance abuse/drug addiction/withdrawal march 19, 2012 dr. gabrielle cyr pgy-3...
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Back to basics!Substance abuse/drug addiction/withdrawal
March 19, 2012Dr. Gabrielle Cyr
PGY-3 resident, psychiatryUniversity of Ottawa
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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
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Why do we care?
• Anybody can be affected (++ common)
• All specialties of medicine
• Major psychosocial/functionnal impacts
• Potentially lethal
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Basics of addiction
• Genetic vulnerability
• Environmental factors– Low socioeconomic status– Chaotic background– Etc…
• Repeated use
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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
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Substances
• Depressants– Alcohol– Benzodiazepines– Barbiturates– Opioids
• Stimulants– Amphetamines– Cocaine– Cannabis– Hallucinogens (MDMA, LSD, Psilocybin, Mescaline)
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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.)
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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
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Physical examination
• Cognition/LOC/Orientation
• Signs of intoxication (toxidromes)/withdrawal– Vitals– Skin (signs of liver failure, needle marks, etc.)– Pupils– Etc.
• +/- complete physical exam
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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
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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
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Standard drinks…
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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
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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%
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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)
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Potentially deadly withdrawals…
• Alcohol
• Benzodiazepines/Barbiturates
• GHB…
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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
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Stages of change
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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
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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
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Alcohol/benzo withdrawal management
• Non medical detoxification/residential treatment– Patient intoxicated/mild withdrawal– Can take own medication– Medically stable– Short stay only
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Residential treatment (Ottawa)
• Empathy House
• Serenity House
• Sobriety House
• VESTA
• Maison Fraternité
• The ROMHC Meadow Creek
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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
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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
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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
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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)
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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
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Opiate withdrawal
• Nausea/vomiting, diarrhea, sweating, lacrimation• Piloerection• Pupillary dilatation• Myalgias• Dysphoric mood, insomnia, anxiety
• Not life threatening, but uncomfortable
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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)
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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
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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
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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
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Nicotine…
• Varenicline (Champix)– Some studies have showmn exacerbation of
pre-existing psychiatric conditions – so monitor
– Usually treat for 3 months
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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
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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