The preoperative consult: An introduction

1
Substance-use disorders A whirlwind tour
Anthony Worsham, MD Best Practices Division of
Hospital Medicine Department of Internal
Medicine University of New Mexico Health Sciences
Center Wednesday, June 19, 2013
2
The dose makes the poison
What is it that is not a poison? All things are
poison and nothing is without poison. Solely, the
dose determines that a thing is not a
poison. --Paracelsus (14931541), the Renaissance
Father of Toxicology, in his Third Defense
Erickson TB, The approach to the patient with an
unknown overdose, Emerg Med Clin N Am 25 (2007)
249281 http//en.wikipedia.org/wiki/Paracelsus
3

• The publication of The Core Competencies
  represents the first attempt to define the
  specialty of Hospital Medicine.
• Purpose
• The Core Competencies provide a framework for
  professional and curricular development based on
  a shared understanding of the essential
  knowledge, skills and attitudes expected of
  physicians working as hospitalists.

4
Core CompetenciesClinical Conditions

• Acute Coronary Syndrome
• Acute Renal Failure
• Alcohol and Drug Withdrawal
• Asthma
• Cardiac Arrhythmia
• Cellulitis
• Chronic Obstructive Pulmonary Disease
• Community Acquired Pneumonia
• Congestive Heart Failure

• Delirium and Dementia
• Diabetes Mellitus
• Gastrointestinal Bleed
• Hospital-Acquired Pneumonia
• Pain Management
• Perioperative Medicine
• Sepsis Syndrome
• Stroke
• Urinary Tract Infection
• Venous Thromboembolism

5
Alcohol and Drug WithdrawalCore Competency
Knowledge

• Hospitalists should be able to
• Describe the effects of drug and alcohol
  withdrawal on medical illness and the effects of
  medical illness on substance withdrawal.
• Recognize the complications from substance use
  and dependency.
• Distinguish alcohol or drug withdrawal from other
  causes of delirium.
• Describe the indicated tests required to evaluate
  alcohol or drug withdrawal.
• Identify patients at increased risk for drug and
  alcohol withdrawal using current diagnostic
  criteria for withdrawal.
• Explain indications, contraindications and
  mechanisms of action of pharmacologic agents used
  to treat acute alcohol and drug withdrawal.
• Identify local trends in illicit drug use.
• Determine the best setting within the hospital to
  initiate, monitor, evaluate and treat patients
  with drug or alcohol withdrawal.
• Explain patient characteristics that on admission
  portend poor prognosis.
• Explain goals for hospital discharge, including
  specific measures of clinical stability for safe
  care transition.

The Core Competencies in Hospital Medicine A
Framework for Curriculum Development. Journal of
Hospital Medicine. Volume 1, Issue S1, pages 67,
2006.
6
Alcohol and Drug WithdrawalCore Competency
Skills

• Hospitalists should be able to
• Elicit a thorough and relevant history, with
  emphasis on substance use.
• Recognize the symptoms and signs of alcohol and
  drug withdrawal, including prescription and OTC
  drugs.
• Differentiate delirium tremens from other alcohol
  withdrawal syndromes.
• Assess for common co-morbidities in patients with
  a history of alcohol and drug use.
• Perform a rapid, efficient and targeted physical
  examination to assess alcohol or drug withdrawal
  and determine life-threatening co-morbidities.
• Apply DSM-IV Diagnostic Criteria for Alcohol
  Withdrawal.
• Formulate a treatment plan, tailored to the
  individual patient, which may include appropriate
  pharmacologic agents and dosing, route of
  administration, and nutritional supplementation.
• Integrate existing literature and federal
  regulations into the management of patients with
  opioid withdrawal syndromes. for patients who are
  undergoing existing treatment for opioid
  dependency, communicate with outpatient treatment
  centers and integrate dosing regimens into care
  management.
• Manage withdrawal syndromes in patients with
  concomitant medical or surgical issues.
• Determine need for the use of restraints to
  ensure patient safety.
• Reassure, reorient, and frequently monitor the
  patient in a calm environment.
• Assess patients with suspected alcohol or drug
  withdrawal in a timely manner, identify the level
  of care required, and manage or co-manage the
  patient with the primary requesting service.

The Core Competencies in Hospital Medicine A
Framework for Curriculum Development. Journal of
Hospital Medicine. Volume 1, Issue S1, pages 67,
2006.
7
Alcohol and drug withdrawalCore competency
Attitudes

• Hospitalists should be able to
• Use the acute hospitalization as an opportunity
  to counsel patients about abstinence, recovery
  and the medical risks of drug and alcohol use.
• Communicate with patients and families to explain
  goals of care plan, discharge instructions and
  management after release from hospital.
• Appreciate the indications for specialty
  consultations.
• Initiate prevention measures prior to discharge,
  including alcohol and drug cessation measures.
• Manage the hospitalized patient with substance
  use in a non-judgmental manner.
• Employ a multidisciplinary approach, which may
  include psychiatry, pharmacy, nursing and social
  services, in the treatment of patients with
  substance use or dependency.
• Establish and maintain an open dialogue with
  patients and families regarding care goals and
  limitations.
• Appreciate and document the value of appropriate
  treatment in reducing mortality, duration of
  delirium, time required to control agitation,
  adequate control of delirium, treatment of
  complications, and cost.
• Facilitate discharge planning early in the
  hospitalization, including communicating with the
  primary care provider and presenting the patient
  with contact information for follow-up care,
  support and rehabilitation.
• Utilize evidence based national recommendations
  to guide diagnosis, monitoring and treatment of
  withdrawal symptoms.

The Core Competencies in Hospital Medicine A
Framework for Curriculum Development. Journal of
Hospital Medicine. Volume 1, Issue S1, pages 67,
2006.
8
Alcohol and drug withdrawalCore competency
System Organization and Improvement

• To improve efficiency and quality within their
  organizations, Hospitalists should
• Lead, coordinate or participate in the
  development and promotion of guidelines and/or
  pathways that facilitate efficient and timely
  evaluation and treatment of patients with alcohol
  and drug withdrawal.
• Promote the development and use of evidence based
  guidelines and protocols for the treatment of
  withdrawal syndromes.
• Advocate for hospital resources to improve the
  care of patients with substance withdrawal, and
  the environment in which the care is delivered.
• Lead, coordinate or participate in
  multidisciplinary teams, which may include
  psychiatry, to improve patient safety and
  management strategies for patients with substance
  abuse.

The Core Competencies in Hospital Medicine A
Framework for Curriculum Development. Journal of
Hospital Medicine. Volume 1, Issue S1, pages 67,
2006.
9
(No Transcript)
10
Camí J, Farré M, Drug Addiction, N Engl J Med,
2003349975-86.
11
Renner JA, Ward EN, Drug Addition, Massachusetts
General Hospital Comprehensive Clinical Psychiatry
12
Identify local trends in illicit drug use
New Mexico Department of Health . New Mexico
Substance Abuse Epidemiology Profile July
2011.http//nmhealth.org/erd/SubstanceAbuse/20112
0New20Mexico20Substance20Abuse20Epidemiology2
0Profile.pdf
13

• 49 Prescription opioids(i.e.,methadone,oxycodone,
  morphine)
• 36 heroin
• 31 cocaine
• 29 tranquilizers/musclerelaxants
• 16 antidepressants
• median age of unintentional drug overdose
  43.7years

14
(No Transcript)
15
Elicit a thorough and relevant history, with
emphasis on substance use

• Obtain all prescription bottles and other
  containers when possible. Perform a pill count.
  Be sure that the bottles contain the medications
  listed. Identify any unknown tablets.
• Contact the prescribing physician(s) or the
  pharmacy as listed on the bottles to determine
  previous overdoses or other medications that the
  patient may have available.
• Identify underlying medical and psychiatric
  disorders and medication allergies. Review past
  medical records.
• Talk to the patients family and friends in the
  emergency department. If necessary, call the
  patients home to ask questions of others. The
  persons providing the important elements of the
  history should be identified in the chart.
• Search the patients belongings for drugs or drug
  paraphernalia. A single pill hidden in a pocket,
  for example, may provide the most important clue
  to the diagnosis.
• Have family members (or the police) search the
  patients home, including the medicine cabinet,
  clothes drawers, closets, and garage such
  searches may also provide clues that make the
  diagnosis. This has the added benefit of
  involving the family in the patients care.
• Always look for track marks on the patient.
  Consider body packing or body stuffing.

Kulig K, Ling LJ, General Approach to the
Poisoned Patient. Rosen's Emergency Medicine, 7th
ed., 2009.
16
Approach to the poisoned patient
Erickson TB, The approach to the patient with an
unknown overdose, Emerg Med Clin N Am 25 (2007)
249281
17
(No Transcript)
18
Ford MD, Acute Poisoning, Goldman's Cecil
Medicine, 24th ed., 2011.
19
Recognize the symptoms and signs of alcohol and
drug withdrawal

• Toxidrome a constellation of signs and symptoms
  characteristic of a class of drugs

20
Shannon MW, A General Approach to Poisoning,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
21
Cholinergic syndromeMnemonics

• DUMBBELS
• Defecation
• Urination
• Miosis
• Bronchorrhea
• Bronchoconstriction
• Emesis
• Lacrimation
• Salivation

• SLUDGE
• Salivation
• Lacrimation
• Urination
• Defecation
• Gastrointestinal dysfunction
• Emesis

22
Describe the indicated tests required to evaluate
alcohol or drug withdrawal
Bast RP et al, Limited Utility of Routine Drug
Screening in Trauma Patients, Southern Medical
Journal, 2000, 397-399.
23
Limited utility of tox screens?

• Diagnostic and management decisions are made
  before toxicologic test results are returned.
• Benign diagnostic intervention may preclude the
  need for these tests (e.g., response to naloxone
  in opiate intoxication
• Few specific interventions or antidotal therapies
  depend on toxicologic test outcomes.
• The incidence of overall morbidity is low (less
  than 1) in the setting of optimal patient
  management, including decontamination and
  supportive therapy.
• Toxicity is often apparent on presentation.
• There is a lack of rapid commercial assays for
  somedrugs commonly involved in emergency room
  evaluations (e.g. oxycodone, ketamine, GHB).

Shannon MW, A General Approach to Poisoning,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
24
ED Triage Protocol Tox-SI-OD
25
ED Triage Protocol Tox-SI-OD
26
ED AMS-Withdrawal
27
ED AMS-Withdrawal
28
Describe the indicated tests required to evaluate
alcohol or drug withdrawal
Osterloh JD, Haller CA, Laboratory Diagnoses and
Drug Screening, Haddad and Winchester's Clinical
Management of Poisoning and Drug Overdose, 4th
ed., 2007.
29
Moeller KE, Urine Drug Screening Practical Guide
for Clinicians, Mayo Clin Proc. 200883(1)66-76
30
Quantification of Toxins
Shannon MW, A General Approach to Poisoning,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed., 2007.
31
Osmolar Gap
Levine M et al, Toxicology in the ICU Part 1
General Overview and Approach to Treatment Chest
2011 140( 3 ) 795 806
32
Poisoning pearls

• Protracted coughing with hydrocarbon ingestions
• Inability to swallow or drooling with caustic
  ingestions
• Hematemesis with iron ingestions
• Intractable seizures with isoniazid overdose
• Loss of consciousness with carbon monoxide

33
Guidelines for In-Hospital Disposition ICU

• Need for intubation
• Seizures
• Unresponsiveness to verbal stimuli
• Arterial carbon dioxide pressure greater than 45
  mm Hg
• Cardiac conduction or rhythm disturbances (any
  rhythm except sinus arrhythmia)
• Close monitoring of vital signs during antidotal
  therapy or elimination procedures
• The need for continuous monitoring
• QRS interval greater than 0.10 second, in cases
  of tricyclic antidepressant poisoning
• Systolic blood pressure less than 80 mm Hg
• Hypoxia, hypercarbia, acid-base imbalance, or
  metabolic abnormalities
• Extremes of temperature
• Progressive deterioration or significant
  underlying medical disorders
• Suicidality

Mofenson HC et al, Medical Toxicology, Physical
and Chemical Injuries, Bope Kellerman Conn's
Current Therapy 2013
34
Diagnostic algorithm usingthe size of the pupils
Ford MD, Acute Poisoning, Goldman's Cecil
Medicine, 24th ed., 2011.
35
Apply DSM-IV Diagnostic Criteria for Alcohol
Withdrawal
36
Highlights of Changes from DSM-IV-TR to DSM-5

• DSM-5 does not separate the diagnoses of
  substance abuse and dependence as in DSM-IV.
  Rather, criteria are provided for substance use
  disorder, accompanied by criteria for
  intoxication, withdrawal, substance/medication-ind
  uced disorders, and unspecified substance-induced
  disorders, where relevant.
• The DSM-5 substance use disorder criteria are
  nearly identical to the DSM-IV substance abuse
  and dependence criteria combined into a single
  list, with two exceptions.
• The DSM-IV recurrent legal problems criterion for
  substance abuse has been deleted from DSM-5, and
  a new criterion, craving or a strong desire or
  urge to use a substance, has been added.
• In addition, the threshold for substance use
  disorder diagnosis in DSM-5 is set at two or more
  criteria, in contrast to a threshold of one or
  more criteria for a diagnosis of DSM-IV substance
  abuse and three or more for DSM-IV substance
  dependence.
• Cannabis withdrawal is new for DSM-5, as is
  caffeine withdrawal (which was in DSM-IV Appendix
  B, Criteria Sets and Axes Provided for Further
  Study).

American Psychiatric Association. Highlight of
Changes from DSM-IV-TR to DSM-5.
http//www.dsm5.org/Documents/changes20from20dsm
-iv-tr20to20dsm-5.pdf
37
Highlight of Changes from DSM-IV-TR to DSM-5

• Of note, the criteria for DSM-5 tobacco use
  disorder are the same as those for other
  substance use disorders. By contrast, DSM-IV did
  not have a category for tobacco abuse, so the
  criteria in DSM-5 that are from DSM-IV abuse are
  new for tobacco in DSM-5.
• Severity of the DSM-5 substance use disorders is
  based on the number of criteria endorsed 23
  criteria indicate a mild disorder 45 criteria,
  a moderate disorder and 6 or more, a severe
  disorder.
• The DSM-IV specifier for a physiological subtype
  has been eliminated in DSM-5, as has the DSM-IV
  diagnosis of polysubstance dependence.
• Early remission from a DSM-5 substance use
  disorder is defined as at least 3 but less than
  12 months without substance use disorder criteria
  (except craving), and sustained remission is
  defined as at least 12 months without criteria
  (except craving).
• Additional new DSM-5 specifiers include in a
  controlled environment and on maintenance
  therapy as the situation warrants.

American Psychiatric Association. Highlight of
Changes from DSM-IV-TR to DSM-5.
http//www.dsm5.org/Documents/changes20from20dsm
-iv-tr20to20dsm-5.pdf
38
Substance-related disordersDSM-5 classification

• Substance use disorders
• Substance-induced disorders
• Substance intoxication
• Substance withdrawal
• Substance/medication-induced mental disorders
• Other substance-induced disorders
• Unspecified substance-related disorder

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
39
Substance-related disorders10 classes of drugs

• alcohol
• caffeine
• cannabis
• hallucinogens
• PCP
• other hallucinogens
• Inhalants
• opioids

• sedatives, hypnotics, and anxiolytics
• stimulants (amphetamine-type substances, cocaine,
  and other stimulants)
• tobacco
• other (or unknown) substances

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
40
Abuse versus dependenceDSM IV-TR

• Alcohol abuse
• A. A maladaptive pattern of drinking, leading to
  clinically significant impairment or distress, as
  manifested by at least one of the following
  occurring within a 12-month period
• Recurrent use of alcohol resulting in a failure
  to fulfill major role obligations at work,
  school, or home (e.g., repeated absences or poor
  work performance related to alcohol use
  alcohol-related absences, suspensions, or
  expulsions from school neglect of children or
  household)
• Recurrent alcohol use in situations in which it
  is physically hazardous (e.g., driving an
  automobile or operating a machine when impaired
  by alcohol use)
• Recurrent alcohol-related legal problems (e.g.,
  arrests for alcohol-related disorderly conduct)
• Continued alcohol use despite having persistent
  or recurrent social or interpersonal problems
  caused or exacerbated by the effects of alcohol
  (e.g., arguments with spouse about consequences
  of intoxication).
• B. Never met criteria for alcohol dependence.

• Alcohol dependence
• A. A maladaptive pattern of drinking, leading to
  clinically significant impairment or distress, as
  manifested by three or more of the following
  occurring at any time in the same 12-month
  period
• Need for markedly increased amounts of alcohol to
  achieve intoxication or desired effect or
  markedly diminished effect with continued use of
  the same amount of alcohol
• The characteristic withdrawal syndrome for
  alcohol or drinking (or using a closely related
  substance) to relieve or avoid withdrawal
  symptoms
• Drinking in larger amounts or over a longer
  period than intended.
• Persistent desire or one or more unsuccessful
  efforts to cut down or control drinking
• Important social, occupational, or recreational
  activities given up or reduced because of
  drinking
• A great deal of time spent in activities
  necessary to obtain, to use, or to recover from
  the effects of drinking
• Continued drinking despite knowledge of having a
  persistent or recurrent physical or psychological
  problem that is likely to be caused or
  exacerbated by drinking.
• B. No duration criterion separately specified,
  but several dependence criteria must occur
  repeatedly as specified by duration qualifiers
  associated with criteria (e.g., persistent,
  continued).

American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental
disorders (4th ed., text rev.).
41
Substance-use disordersDiagnostic criteria

• Criteria A
• Impaired control (Criteria 1-4)
• Social impairment (Criteria 5-7)
• Risky use (Criteria 8-9)
• Pharmacological criteria (Criteria 10-11)

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
42
Substance use disorderDiagnostic criteria

• A. A problematic pattern of __ use leading to
  clinically significant impairment or distress, as
  manifested by at least two or the following,
  occuring within a 12-month period

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
43
Substance use disorderDiagnostic criteria

• 1. __ is often taken in larger amounts or over a
  longer period than was intended.
• 2. There is a persistent desire or unsuccessful
  efforts to cut down or control __ use.
• 3. A great deal of time in spent in activities
  necessary to obtain __, use __, or recover from
  its effects.
• 4. Craving, or a strong desire or urge to use __.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
44
Substance use disorderDiagnostic criteria

• 5. Recurrent __ use resulting in a failure to
  fulfill major role obligations at work, school,
  or home
• 6. Continued __ use despite having persistent or
  recurrent social or interpersonal problems caused
  or exacerbated by the effects of __.
• 7. Important social, occupational, or
  recreational activities are given up or reduced
  because of __ use.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
45
Substance use disorderDiagnostic criteria

• 8. Recurrent __ use in situations in which it is
  physically hazardous.
• 9. Alcohol use is continued despite knowledge of
  having a persistent or recurrent physical or
  psychological problem that is likely to have been
  caused or exacerbated by __.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
46
Substance use disorderDiagnostic criteria

• 10. Tolerance, as defined by either of the
  following
• a. A need for markedly increased amounts of __ to
  achieve intoxication or desired effect.
• b. A markedly diminished effect with continued
  use of the same amount of __.
• 11. Withdrawal, as manifested by either of the
  following
• a. The characteristic withdrawal syndrome for __
• b. __ (or a closely related substance) is taken
  to relieve or avoid withdrawal symptoms.

47
Substance use disordersDiagnostic criteria

• Specifiers
• In early remission no criteria met at least 3
  months but less than 12 months
• In sustained remission no criteria met for 12
  months or longer
• In a controlled environment
• Severity
• Mild presence of 2-3 symptoms
• Moderate presence of 4-5 symptoms
• Severe presence of 6 or more symptoms

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
48
Substance IntoxicationDiagnostic Criteria

• A. Recent ingestion of __.
• B. Clinically significant problematic behavioral
  or psychological changes (e.g., __) that
  developed during, or shortly after, __ use.
• C. (or more) of the following signs of symptoms
  developing during, or shortly after, __ use
• D. The signs or symptoms are not attributable to
  another medical condition and are not better
  explained by another mental disorder, including
  intoxication with another substance.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
49
Substance withdrawalDiagnostic Criteria

• A. Cessation of (or reduction in) __ use that has
  been heavy and prolonged.
• B. (or more) of the following signs and
  symptoms developing within __ after Criteria A.
• C. The signs or symptoms in Criteria B cause
  clinically significant distress or impairment in
  social, occupational, or other important areas of
  functioning.
• D. The signs or symptoms are not attributable to
  another medical condition, and are not better
  explained by another mental disorder, including
  intoxication or withdrawal from another
  substance.
• Specifier with perceptual disturbance.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
50
Permutations

• 10 substances x 5 conditions 50
• Exceptions
• No caffeine intoxication disorder
• No hallucinogen or inhalant withdrawal disorders
• Hallucinogen persisting perception disorder
• No tobacco intoxication disorder
• Gambling disorder

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
51
Alcohol

• Intoxication
• B. Inappropriate sexual or aggressive behavior,
  mood lability, impaired judgment
• C. 1 or more of
• Slurred speech
• Incoordination
• Unsteady gait
• Nystagmus
• Impairment in attention or memory
• Stupor or coma

• Withdrawal (2 within hrs-days)
• Autonomic hyperactivity
• E.g., sweating or pulse rate gt100 bpm
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory
  hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Generalized tonic-clonic seizures

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
52
Alcohol BAC and effects
Kelly JF, Renner JA, Alcohol-Related Disorders,
Massachusetts General Hospital Comprehensive
Clinical Psychiatry
53
Alcohol withdrawal time course

• 4 classic categories withdrawal tremulousness,
• hallucinations, seizures, and DT

ALCOHOL ABUSE AND DEPENDENCE PATRICK G. OCONNOR
54
(No Transcript)
55
OConnor PG, Alcohol Abuse And Dependence,
Goldman L, Ausiello D, eds. Cecil Medicine. 23rd
ed. Philadelphia, Pa Saunders Elsevier
2007chap 31.
56
CAGE questionnaire

• 1.Have you ever felt you needed to Cut down on
  your drinking?
• 2.Have people Annoyed you by criticizing your
  drinking?
• 3.Have you ever felt Guilty about drinking?
• 4.Have you ever felt you needed a drink first
  thing in the morning (Eye-opener) to steady your
  nerves or to get rid of a hangover?
• CAGE test scores gt2 is positive
• Excessive drinking specificity 76, sensitivity
  of 93
• alcoholism specificity of 77, sensitivity of 91

Kitchens JM (1994). "Does this patient have an
alcohol problem?". JAMA 272 (22)17827.
57
(No Transcript)
58
Alcohol withdrawal syndrome admission management
goals

• 1. Monitor course of syndrome, ensuring patient
  safety
• 2. Use methods to abort progression and treat
  symptoms
• 3. Manage comorbid medical, surgical,
  toxicologic, and psychiatric problems
• 4. Anticipate need for intensive care monitoring
  and therapy
• 5. Ensure multidisciplinary approach to
  management, including preparation for
  rehabilitation

Carlson RW et al, Alcohol Withdrawal Syndrome,
Crit Care Clin 28 (2012) 549585
59
Objectives for alcohol withdrawal services

• To interrupt a pattern of heavy and regular
  alcohol use
• To alleviate withdrawal symptoms
• To prevent severe withdrawal complications
• Facilitate linkages to ongoing treatment for
  alcohol dependence.
• To get help with any other problems
• N.B. Successful completion of alcohol withdrawal
  does not prevent recurrent alcohol consumption
  and additional interventions are needed to
  achieve long-term
• Australian Alcohol Guidelines.

60
Admission studies for patients with moderate to
severe alcohol withdrawal syndrome

• 1. Complete blood cell count
• 2. Baseline metabolic panel with serum
  electrolytes (including magnesium), glucose,
  renal
• function tests
• 3. Blood alcohol, and urine and blood toxicology
  studies
• 4. Serum calcium, phosphate, lipase, CPK activity
• 5. Liver function tests, including INR and serum
  AST, ALT, bilirubin, ammonia
• 6. Chest radiograph
• 7. Electrocardiogram, cardiac biomarkers,
  echocardiogram
• 8. Urinalysis
• 9. Arterial blood gas analysis
• 10. Blood, urine, and sputum cultures
• Abbreviations ALT, alanine aminotransferase
  AST, aspartate aminotransferase CPK, creatine
• phosphokinase INR, international normalized
  ratio.
• a Laboratory, imaging, and clinical evaluations
  must be individualized.

Carlson RW et al, Alcohol Withdrawal Syndrome,
Crit Care Clin 28 (2012) 549585
61
Alcohol labs

• Blood alcohol level

Alcohol-use disorders Marc A Schuckit, Lancet
2009 373 492501
62
Alcohol treatment medications
OConnor PG, Alcohol Abuse And Dependence,
Goldman L, Ausiello D, eds. Cecil Medicine. 23rd
ed. Philadelphia, Pa Saunders Elsevier
2007chap 31.
63
UNM CIWA protocol
64
Risk factors for severe course of AWS, including
seizures and delirium

• 1. Prior episodes of AWS requiring
  detoxification, including seizures or delirium
  (kindling)
• 2. Grade 2 severity or higher on presentation
  (CIWA-Ar Score gt10)
• 3. Advanced age
• 4. Acute or chronic comorbid conditions,
  including alcoholic liver disease,
  co-intoxications,
• trauma, infections, sepsis
• 5. Detectable blood alcohol level on admission
• 6. Use of eye opener, high daily intake of
  alcohol, or number of drinking days/month
• 7. Abnormal liver function (serum aspartate
  aminotransferase activity gt80 U/L)
• 8. Prior benzodiazepine use
• 9. Male sex
• Abbreviation CIWA-Ar, Clinical Institute of
  Withdrawal Assessment for Alcohol, revised.

Carlson RW et al, Alcohol Withdrawal Syndrome,
Crit Care Clin 28 (2012) 549585
65
Potential indications for ICU management

• 1. Advanced Stage 2 or greater alcohol withdrawal
  syndrome
• 2. Critical comorbid conditions including
  trauma severe sepsis respiratory failure acute
  respiratory distress syndrome hemodynamic
  instability gastrointestinal bleeding hepatic
  failure pancreatitis rhabdomyolysis
  co-intoxication coagulopathies acute CNS
  process cardiac arrhythmias, ischemia, or
  congestive failure severe fluid or electrolyte
  defects renal failure persistent fever or
  complex acid-base defects
• 3. Escalating intravenous bolus or
  continuous-infusion sedation therapy
• 4. Persistent fever gt39 C

Carlson RW et al, Alcohol Withdrawal Syndrome,
Crit Care Clin 28 (2012) 549585
66
DeliriumDiagnostic Criteria

1. A disturbance in attention (i.e., reduced ability
   to direct, focus, sustain, and shift attention)
   and awareness (reduced orientation to the
   environment).
2. The disturbance develops over a short period of
   time (usually hours to a few days), represents a
   change from baseline attention and awareness, and
   tends to fluctuate in severity during the course
   of a day.
3. An additional disturbance in cognition (e.g.,
   memory deficit, disorientation, language,
   visuospatial ability, or perception).
4. The disturbances in Criteria A or C are not
   better explained by another preexisting,
   established, or evolving neurocognitive disorder
   and do not occur in the context of a severely
   reduced level of arousal, such as coma.
5. There is evidence from the history, physical
   examination, or laboratory findings that the
   disturbance is a direct physiological consequence
   of another medical condition, substance
   intoxication or withdrawal (i.e., due to a drug
   of abuse or to a medication), or exposure to a
   toxin, or is due to multiple etiologies.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
67
DeliriumDiagnostic criteria

• Specifiers
• Substance intoxication delirium Substance
  withdrawal delirium
• Medication-induced delirium Delirium due to
  multiple etiologies
• Delirium due to another medical condition
• Acute lasting a few hours or days
• Persistent lasting weeks or months

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
68
Differentiate delirium tremens from other alcohol
withdrawal syndromes

• 5 of patients with alcohol withdrawal
• Constellation of symptoms confusion,
  hallucinations, fever (with or without evidence
  of infection), and autonomic hyperresponsiveness
  with hypertension and profound tachycardia
• Suspect in any agitated patient withdrawing from
  alcohol with BP gt140/90 mm Hg, HR gt 100/min, T
  gt 101 Fahrenheit
• Mortality 5-15

Erwin WE et al, Delirium tremens, Southern
Medical Journal (May 1998, 915), 425-432.
69
Acetaminophen metabolism Salhanick SD,
Shannon MW, Acetaminophen, Haddad and
Winchester's Clinical Management of Poisoning and
Drug Overdose, 4th ed., 2007.
70
Algorithm showing current recommendations for
N-acetylcysteine (NAC) treatment of acetaminophen
overdose. Chun LJ et al, Acetaminophen
Hepatotoxicity and Acute Liver Failure, J Clin
Gastroenterol 200943342349.
71
Caffeine

• Intoxication (5 or more of)
• Restlessness
• Nervousness
• Excitement
• Insomnia
• Flushed face
• Diuresis
• Gastrointestinal disturbance
• Muscle twitching
• Rambling flow of thought and speech
• Tachycardia or cardiac arrhythmia
• Periods of inexhaustibility
• Psychomotor agitation

• Withdrawal (3 or more within 24 hr of)
• Headache
• Marked fatigue or drowsiness
• Dysphoric mood, depressed mood, or irritability
• Difficulty concentrating
• Flu-like symptoms (nausea, vomiting, or muscle
  pain/stiffness)

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
72
Cannabis

• Intoxication
• B. Impaired motor coordination, euphoria,
  anxiety, sensation of slowed time, impaired
  judgment, social withdrawal
• C. 2 or more within 2 hrs of
• Conjunctival injection
• Increased appetite
• Dry mouth
• tachycardia

• Withdrawal (3 or more within 1 wk)
• Irritability, anger, or aggression
• Nervousness or anxiety
• Sleep difficulty (e.g., insomnia, disturbing
  dreams)
• Decreased appetite or weight loss
• Restlessness
• Depressed mood
• At least one of the following physical symptoms
  causing significant discomfort abdominal pain,
  shakiness/tremors, sweating, fever, chills, or
  headache

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
73
Synthetic marijuanaSpice and K2

• Synthetic marijuana (often known as K2 or
  Spice)consists of plant material that has been
  laced with substances (synthetic cannabinoids)
  that users claim mimics ?9-tetrahydrocannabinol(TH
  C), the primary psychoactive active ingredient in
  marijuana, and are marketed toward young people
  as a legal high.
• According to data from the 2011 Monitoring the
  Future survey of youth drug-use trends, 11.4
  percent of 12th graders used Spice or K2 in the
  past year, making it the second most commonly
  used illicit drug among seniors.
• The effects of synthetic marijuana include
  agitation, extreme nervousness, nausea, vomiting,
  tachycardia (fast, racing heartbeat), elevated
  blood pressure, tremors and seizures,
  hallucinations, and dilated pupils.

White House, Office of National Drug Control
Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath
Salts, etc.), http//www.whitehouse.gov/ondcp/ondc
p-fact-sheets/synthetic-drugs-k2-spice-bath-salts
74
Proposed Clinical Criteria forCannabinoid
Hyperemesis

• Essential for diagnosis
• Long-term cannabis use
• Major features
• Severe cyclic nausea and vomiting
• Resolution with cannabis cessation
• Relief of symptoms with hot showers or baths
• Abdominal pain, epigastric or periumbilical
• Weekly use of marijuana
• Supportive features
• Age less than 50 y
• Weight loss of gt5 kg
• Morning predominance of symptoms
• Normal bowel habits
• Negative laboratory, radiographic, and endoscopic
  test results

Simonetto DA et al, Cannabinoid Hyperemesis A
Case Series of 98 Patients, Mayo Clin Proc.
201287(2)114-119
75
Hallucinogens

• PCP Intoxication
• B. belligerence, assaultiveness, impulsiveness,
  unpredictability, psychomotor agitation, impaired
  judgment
• C. 2 or more within 1 hr
• Vertical or horizontal nystagmus
• Hypertension or tachycardia
• Numbness or diminished responsiveness to pain
• Ataxia
• Dysarthria
• Muscle rigidity
• Seizures or coma
• hyperacusis

• Other hallucinogen intoxication
• B. Marked anxiety or depression, ideas of
  reference, fear of losing ones mind, paranoid
  ideation, impaired judgment
• C. 2 or more of
• Pupillary dilation
• Tachycardia
• Sweating
• Palpitations
• Blurring of vision
• Tremors
• incoordination

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
76
Jimson weedDatura stramonium

• Contains anticholinergics atropine and
  scopolamine and is hallucinogenic
• Symptoms of toxicity usually occur within 30-60
  minutes after ingestion and may continue for
  24-48 hours because the alkaloids delay
  gastrointestinal motility.
• Ingestion of Jimson weed manifests as classic
  atropine poisoning. Initial manifestations
  include dry mucous membranes, thirst, difficulty
  swallowing and speaking, blurred vision, and
  photophobia, and may be followed by hyperthermia,
  confusion, agitation, combative behavior,
  hallucinations typically involving insects,
  urinary retention, seizures, and coma.
• Treatment consists of supportive care,
  gastrointestinal decontamination (i.e., emesis
  and/or activated charcoal), and physostigmine in
  severe cases.

Epidemiologic Notes and Reports Jimson Weed
Poisoning -- Texas, New York, and California,
1994. MMWR (1995) 44(03)41-44.
https//en.wikipedia.org/wiki/Datura_stramonium
77
Inhalant Intoxication

• B. belligerence, assaultiveness, apathy, impaired
  judgment
• C. 2 or more of
• Dizziness
• Nystagmus
• Incoordination
• Slurred speech
• Unsteady gait
• Lethargy

• Depressed reflexes
• Psychomotor retardation
• Tremor
• Generalized muscle weakness
• Blurred vision or diplopia
• Stupor or coma
• Euphoria

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
78
Opioids

• Intoxication
• B. Initial euphoria followed by apathy,
  dysphoria, psychomotor agitation or retardation,
  impaired judgment
• C. Pupillary constriction (or pupillary dilation
  due to anoxia from severe overdose) 1 or more
  of
• Drowsiness or coma
• Slurred speech
• Impairment in attention or memory

• Withdrawal (3 within min-days)
• Dysphoric mood
• Nausea or vomiting
• Muscle aches
• Lacrimation or rhinorrhea
• Pupillary dilation, piloerection, or sweating
• Diarrhea
• Yawning
• Fever
• insomnia

79
Management of injecting drug users admitted to
hospital Paul S Haber, Abdullah Demirkol, Kezia
Lange, Bridin Murnion, Lancet 2009 374 128493
80
Sedative-, Hypnotic-, or Anxiolytic-related
disorders

• Intoxication
• B. Inappropriate sexual or aggressive behavior,
  mood lability, impaired judgment
• C. 1 or more of
• Slurred speech
• Incoordination
• Unsteady gait
• Nystagmus
• Impairment in cognition (e.g., attention, memory)
• Stupor or coma

• Withdrawal (2 within hrs-few days)
• Autonomic hyperactivity (e.g., sweating or pulse
  greater than 100 bpm)
• Hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile, or auditory
  hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Grand mal seizures

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
81
Stimulants

• Intoxication
• B. Euphoria or affective blunting changes in
  sociability hyperviligance interpersonal
  sensitivity anxiety, tension, or anger
  stereotyped behaviors impaired judgment
• C. 2 or more of
• Tachycardia or bradycardia
• Pupillary dilation
• Elevated or lowered blood pressure
• Perspiration or chills
• Nausea or vomiting
• Evidence of weight loss
• Psychomotor agitation or retardation
• Muscular weakness, respiratory depression, chest
  pain, or cardiac arrhythmias
• Confusion, seizures, dyskinesias, dystonias, or
  coma

• Withdrawal
• Dysphoric mood 2 within few hours-days
• Fatigue
• Vivid, unpleasant dreams
• Insomnia or hypersomnia
• Increased appetite
• Psychomotor retardation or agitation

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
82
Bath salts

• Bath salts contain manmade chemicals related to
  amphetamines that often consist of
  methylenedioxypyrovalerone (MDPV), mephedrone,
  and methylone, also known as substituted
  cathinones.
• Similar to the adverse effects of cocaine, LSD
  and methamphetamine, bath salt use is associated
  with increased heart rate and blood pressure,
  extreme paranoia, hallucinations, and violent
  behavior, which causes users to harm themselves
  or others.

White House, Office of National Drug Control
Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath
Salts, etc.), http//www.whitehouse.gov/ondcp/ondc
p-fact-sheets/synthetic-drugs-k2-spice-bath-salts
83
Amphetamine effects
Albertson TE et al, Amphetamines and derivatives,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed.200
84
Faces of Meth
Faces of Meth, Multnomah County Sheriffs Office,
http//www.facesofmeth.us/
85
Albertson TE et al, Amphetamines and derivatives,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed.200
86
Amphetamine treatment algorithm
Albertson TE et al, Amphetamines and derivatives,
Haddad and Winchester's Clinical Management of
Poisoning and Drug Overdose, 4th ed.200
87
Tobacco Withdrawal

• Cessation followed within 24 hours by four (or
  more) of the following signs or symptoms
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Increased appetite
• Depressed mood
• insomnia

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
88
Other (or Unknown) Substances

• Anabolic steroids
• Nonsteroidal anti-inflammatory drugs
• Cortisol
• Antiparkinsonian medications
• Antihistamines
• Nitrous oxide
• Amyl-, butyl-, or isobutyl-nitrites
• Betel nut
• Kava
• Cathinones (e.g., khât)

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
89
Substance/medication-induced mental disorders

• The disorder represents a clinically significant
  presentation of a relevant mental disorder.
• There is evidence from the history, physical
  examination, or laboratory findings of both of
  the following
• The disorder developed during or within 1 month
  of a substance intoxication or withdrawal or
  taking a medication and
• The involved substance/medication is capable of
  producing the mental disorder.
• The disorder is not better explained by an
  independent mental disorder (i.e., one that is
  not substance- or medication-induced). Such
  evidence of an independent mental disorder could
  include the following
• The disorder preceded the onset of severe
  intoxication or withdrawal or exposure to the
  medication or
• The full mental disorder persisted for a
  substantial period of time (e.g., at least 1
  month) after the cessation of acute withdrawal or
  severe intoxication or taking the medication.
  This criterion does not apply to
  substance-induced neurocognitive disorders or
  hallucinogen persisting perception disorder,
  which persist beyond the cessation of acute
  intoxication or withdrawal.
• The disorder does not occur exclusively during
  the course of a delirium.
• The disorder causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
90
Substance/medication-induced mental disorders

• Psychotic disorders
• Bipolar disorders
• Depressive disorders
• Anxiety disorders
• Obsessive-compulsive and related disorders
• Sleep disorders
• Sexual dysfunctions

American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed.).
91
Discussion Action Items

• Which labs are needed for patients with overdose?
  Do all such patients need to be admitted? If not,
  when is it safe to discharge them?
• Do all alcohol withdrawal patients need to be
  admitted? If not, when, to where, and with what
  medications (if any)?