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ALCOHOLISM
Epidemiology
United States
• Alcohol use is the fourth leading cause of preventable death
in the United States (after smoking, high blood pressure, and
obesity). According to the CDC, excessive alcohol use led to
approximately 88,000 deaths in the United States from 2006
– 2010.
• The economic costs of excessive alcohol consumption in 2010
were estimated at $249 billion, or $2.05 a drink.
Turkey
• In a review of 7249 autopsies in the Morgue Department of
Istanbul, in 1994–1996, alcohol was detected in 21.9% of all
traffic accident cases, and 56.2% of these cases were drivers.
• Of the 30 485 calls reported to the Drug and Poison
Information Center in Izmir, Turkey between 1993 and 2002,
996 (3.3%) cases were that of alcohol poisoning.
• The rate of alcoholic psychosis incidence per 100 000
population was 0.04 in both 1997 and 1998.
• The number of alcohol-related road traffic accidents per 100
000 population was 4.35 in 2000 and 3.59 in 2001.
Diagnosis
• The diagnosis of an alcohol problem is best made by the
history. Laboratory tests have a sensitivity of no better than
50%, and physical examination is helpful only after the
consequences of alcoholism are apparent. Early diagnosis
based on a careful history can prevent such consequences.
Physicians should use terms such as "person with an alcohol
problem" rather than "alcoholic" or "addict," which are
commonly used but demeaning shorthand terms.
Screening
- THE AUDIT
- THE CAGE
- DSM-5
• The AUDIT (alcohol use disorders identification test) is the
best test for screening because it detects hazardous drinking
and alcohol abuse. Furthermore, it has a greater sensitivity in
populations with a lower prevalence of alcoholism. One study
suggested that questions 1, 2, 4, 5, and 10 were nearly as
effective as the entire questionnaire. If confirmed, AUDIT
would be easier to administer.
• The AUDIT can be administered as a paper-and-pencil test,
but the CAGE questionnaire should be administered face to
face.
• The CAGE ([need to] cut down [on drinking], annoyance, guilt
[about drinking], [need for] eye-opener) questionnaire is the
best-known and most-studied short screening test for alcohol
problems.
• The CAGE questions should be given face-to-face (not as a
paper and pencil test) and should be asked before questions
on quantity and frequency (the sensitivity of the questions
drops if quantity questions precede them).
The following 4 questions make up the CAGE questionnaire:
• Have you ever felt the need to cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady
your nerves or get rid of a hangover?
 Patients who answer affirmatively to 2 questions are 7 times
more likely to be alcohol dependent than the general
population.
DSM-5 criteria are as follows:
• A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by 2 or more of the following,
occurring at any time in the same 12-month period:
• Alcohol is often taken in larger amounts or over a longer period than was
intended.
• There is a persistent desire or unsuccessful efforts to cut down or control
alcohol use.
• A great deal of time is spent in activities necessary to obtain alcohol, use
alcohol, or recover from its effects.
• Craving, or a strong desire or urge to use alcohol.
• Recurrent alcohol use resulting in a failure to fulfill major role obligations
at work, school, or home.
• Continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of alcohol.
• Important social, occupational, or recreational activities are given up or
reduced because of alcohol use.
• Recurrent alcohol use in situations in which it is physically hazardous.
• 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 alcohol.
 Tolerance, as defined by either of the following:
• A need for markedly increased amounts of alcohol to achieve
intoxication or desired effect.
• A markedly diminished effect with continued use of the same
amount of alcohol.
 Withdrawal, as manifested by either of the following:
• The characteristic withdrawal syndrome for alcohol
• Alcohol (or a closely related substance, such as a benzodiazepine) is
taken to relieve or avoid withdrawal symptoms.
 Specify if the Alcohol Use Disorder is:
• Mild - Presence of 2–3 symptoms
• Moderate - Presence of 4–5 symptoms
• Severe - Presence of 6 or more symptoms
 Specify if the Alcohol Use Disorder is:
• In early remission - The individual who had once met criteria for
Alcohol Use Disorder has not met criteria for more than 3 months
and less than 12 months (does not count the presence of cravings)
• In sustained remission - The individual who had once met criteria
for Alcohol Use Disorder has not met criteria for more than 12
months (does not count the presence of cravings)
Physical
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The following are signs and symptoms of alcohol withdrawal:
Nausea and vomiting
Diaphoresis
Agitation and anxiety
Headache
Tremor
Seizures
Visual and auditory hallucinations: Many patients who are not
disoriented, and who therefore do not have delirium tremens,
have hallucinations.
 The following are signs of delirium tremens (ie, alcohol
withdrawal delirium):
• Tachycardia and hypertension
• Temperature elevation
• Delirium
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The following are signs of chronic alcoholism:
Gynecomastia
Spider angiomata
Dupuytren contractures (also may be congenital)
Testicular atrophy
Enlarged or shrunken liver
Enlarged spleen
Causes
Psychological studies
• Behavioral models explain alcohol abuse in terms of learning
theory. Through operant conditioning, the reinforcing
elements of alcohol use become habitual.
• Cognitive models explain alcohol abuse in terms of “automatic
thoughts,” which precede the person’s more identifiable
feelings about alcohol. For example, an automatic thought
might be “I deserve a drink because I’ve had a rough day."
• Psychoanalytic models explain alcohol abuse in terms of ego
defenses and intrapsychic conflicts. The alcohol serves as a
way to escape the uncomfortable internal conflict.
Differential Diagnoses
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Anxiety Disorder
Bipolar Affective Disorder
Depression
Dysthymic Disorder
Insomnia
Panic Disorder
Social Phobia
Biomarkers
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Indirect alcohol biomarkers include
aspartate aminotransferase (AST),
alanine aminotransferase (ALT),
gamma glutamyltransferase (GGT),
mean corpuscular volume (MCV)
carbohydrate-deficient transferrin (CDT)
 Direct alcohol biomarkers include
• alcohol itself
• ethyl glucuronide (EtG).
Medical Care
 Treatment of alcoholism involves the following:
• Brief physician advice makes a difference.
• While a trial period of controlled drinking with careful follow-up might be
appropriate for a diagnosis of alcohol abuse, this approach increases a physician's
professional liability. Complete abstinence is the only treatment for alcohol
dependence. Emphasize that the most common error is underestimating the
amount of help that will be needed to stop drinking. The differential diagnosis
between alcohol abuse and dependence can be a difficult judgment call.
• Hospitalize patients if they have a history of delirium tremens or if they have
significant comorbidity. Consider inpatient treatment if the patient has poor social
support, significant psychiatric problems, or a history of relapse after treatment.
• Strongly recommend AA.
• Encourage hospitalized patients to call AA from the hospital. AA will send someone
to talk to them if the patient makes the contact. Patients need to attend meetings
regularly (daily at first) and for a sufficient length of time (usually 2 y or more)
because recovery is a difficult and lengthy process.
• In the beginning of treatment, and perhaps ongoing, patients should remove
alcohol from their homes and avoid bars and other establishments where strong
pressures to drink may influence successful abstinence.
• If the patient has an antisocial personality (ie, severe problems with family, peers,
school, and police before age 15 y and before the onset of alcohol problems),
recovery is less likely. If the patient has primary depression, anxiety disorder, or
another potentially contributory disorder (the other disorder must antedate the
problems with alcohol or it must be a significant problem during long periods of
sobriety), treat this primary problem aggressively.
Medication
• Glutamate receptor blockers - Acamprosate (Campral)
Mechanism of action is unknown, but it enhances GABA
transmission and inhibits glutamate transmission. Compared
with placebo, reduces drinking frequency and effectively
increases abstinence in patients with alcoholism.
• Aldehyde dehydrogenase inhibitors - Disulfiram (Antabuse)
Disulfiram inhibits aldehyde dehydrogenase, and, as a result,
acetaldehyde accumulates. This leads to nausea, hypotension,
and flushing if a person drinks alcohol while taking disulfiram.
• Opiate antagonists - Naltrexone (ReVia, Vivitrol)
Alcohol has been shown to bind to opiate receptors in the
brain. Studies show that blocking opiate receptors decreases
cravings for alcohol.
History
• Cannabis, also known as marijuana among several other
names, is a preparation of the Cannabis sativa plant intended
for use as a psychoactive drug or medicine. The main
psychoactive part of cannabis is tetrahydrocannabinol (THC);
one of 483 known compounds in the plant, including at least
65 other cannabinoids. Cannabis can be used by smoking,
vaporization, within food, or as an extract.
• Cannabis is mostly used recreationally or as a medicinal drug.
It may also be used for religious or spiritual purposes. In 2013,
between 128 and 232 million people used cannabis (2.7% to
4.9% of the global population between the ages of 15 and
65).In 2015, 43% of Americans had used cannabis, which
increased to 51% in 2016. This makes it the most commonly
used illegal drug both in the world and the United States.
• Synthetic cannabinoids are a class of chemicals that are
different from the cannabinoids found in cannabis but which
also bind to cannabinoid receptors. They are often marketed
as designer drugs or sold in products with claims that they
give the effects of cannabis. When these chemicals are
sprayed or otherwise soaked into a plant or other base
material the blend is sometimes misleadingly referred to
as synthetic marijuana. These synthetic marijuana products
are sold for recreational drug use.
• There are several psychoactive artificial cannabinoid families
(e.g. AM-xxx, HU-xxx, JWH-xxx, CP xx) that are sprayed onto
plant matter that is then sold under brand names
like K2 and Spice (In Turkey, Bonzai) both of which are now
often used as generic terms used for any synthetic cannabis
product.
• Synthetic cannabinoids are made in the lab and are more
powerful than natural ones. There is no upper limit to the
psychoactive effects of these compounds, and the potency
can vary greatly, which means it’s easier to experience
harmful reaction with synthetic cannabinoids. Ingestion of
synthetic marijuana can lead to toxic side effects like seizures,
hallucinations and convulsions, and can cause extremely
severe reactions, including ischemic stroke.
• Although there’s no official study on the effects of synthetic
cannabinoids on humans, there are reports describing
harmful effects such as hypertension, tachycardia, vomiting,
agitation, myocardial infarction, panic attacks, blurred vision
and psychoses.
Cannabis intoxication
 Defined by DSM-5, as the following:
• Recent use of cannabis
• Clinically significant problematic behavioral or psychological
changes (eg, impaired motor coordination, euphoria, anxiety,
sensation of slowed time, impaired judgment, social
withdrawal) that developed during, or shortly after, cannabis
use
• At least 2 of the following signs, developing within 2 hours of
cannabis use:Conjunctival injection
o Increased appetite
o Dry mouth
o Tachycardia
• Symptoms not due to a general medical condition and not
better accounted for by another mental disorder
Cannabis use disorder
 DSM-5 as the following:
• A problematic pattern of cannabis use leading to clinically significant
impairment or distress, as manifested by at least 2 of the following,
occurring within a 12-month period:
o Cannabis is often taken in larger amounts or over a longer period than was
intended.
o There is a persistent desire or unsuccessful efforts to cut down or control
cannabis use.
o A great deal of time is spent in activities necessary to obtain cannabis, use
cannabis, or recover from its effects.
o Craving, or a strong desire or urge to use cannabis.
o Recurrent cannabis use resulting in a failure to fulfill major role obligations
at work, school, or home.
o Continued cannabis use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of cannabis.
o Important social, occupational, or recreational activities are given up or
reduced because of cannabis use.
o Recurrent cannabis use in situations in which it is physically hazardous.
o Cannabis 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 cannabis.
• Tolerance, as defined by either a (1) need for markedly increased
cannabis to achieve intoxication or desired effect or (2) markedly
diminished effect with continued use of the same amount of the
substance.
• Withdrawal, as manifested by either (1) the characteristic
withdrawal syndrome for cannabis or (2) cannabis is taken to relieve
or avoid withdrawal symptoms
 Clinicians are instructed to specify the following:
• In early remission - After full criteria for cannabis use disorder were
previously met, none of the criteria for cannabis use disorder has
been met for at least 3 months but for less than 12 months (with an
exception provided for craving).
• In sustained remission - After full criteria for cannabis use disorder
were previously met, none of the criteria for cannabis use disorder
has been met at any time during a period of 12 months or longer
(with an exception provided for craving).
Cannabis withdrawal
 DSM-5 provided criteria for cannabis withdrawal defined as follows:
• Cessation of cannabis use that has been heavy and prolonged (ie, usually
daily or almost daily use over a period of at least a few months).
• Three or more of the following signs and symptoms develop within
approximately 1 week after cessation of heavy, prolonged use:
o Irritability, anger or aggression
o Nervousness or anxiety
o Sleep difficulty (ie, insomnia, disturbing dreams)
o Decreased appetite or weight loss
o Restlessness
o Depressed mood
o At least one of the following physical symptoms causing significant
discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or
headache
Physical and psychological
manifestations
 A thorough mental status examination is an integral component of every
patient assessment. Key mental status findings associated with cannabis
use, cannabis-induced, and cannabis-related disorders include the
following:
o Mood: Acute use may be associated with feelings of euphoria,
uncontrollable laughter, increased appetite, and difficulty concentrating.
In chronic use or withdrawal, patients may report a depressed mood
characterized by apathy, lack of motivation, irritability, loss of interest in
typical activities, difficulty concentrating, and possibly isolation.
o Affect: Acutely, affect may span the spectrum from euphoric to anxious. In
chronic use, affect may be constricted or flat.
o Thought process and content: As in any mental status examination,
assessing the patient for the presence of suicidality or homicidality and
taking appropriate action is critical. Patients may demonstrate flight of
ideas, loose associations, and, in some cases, delusions and hallucinations.
o Cognition: In both acute and chronic use, difficulty concentrating and
memory impairment are common.
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Physical signs and symptoms associated with cannabis use are particularly relevant to the diagnosis of
cannabis intoxication. Clinicians are advised to identify at least 2 or more of the following physical
symptoms, occurring within 2 hours of cannabis use, as defined by DSM-5 criteria:
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
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Other adverse physical and psychological manifestations associated with marijuana abuse are as follows:
Sweating
Headaches
Restlessness
Forgetfulness
Visual distortions
Lack of concentration
Paranoia
Mood changes
Perceptual changes
Feeling impersonal
Panic disorder
Amotivational syndrome
Delusions
Psychosis
Differential Diagnoses
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Alcohol-Related Psychosis
Allergic and Environmental Asthma
Amphetamine-Related Psychiatric Disorders
Anxiety Disorders
Atrial Tachycardia
Benzodiazepine Toxicity
Brief Psychotic Disorder
Delirium
Depression
Hallucinogen Use
Panic Disorder
Primary Hypersomnia
Sedative, Hypnotic, Anxiolytic Use Disorders
Substance-Induced Mood Disorder
Laboratory Studies
 Urine testing
• Cannabinoids can be detected in the urine for as many as 21
days after use in persons chronically using marijuana, because
these lipid-soluble metabolites are slowly released from fat
cells into the blood; however, 1-5 days is the normal urinepositive period.
 Blood testing
• Blood samples may be used to measure quantitative levels of
cannabinoids. Serial monitoring of tetrahydrocannabinol
(THC)–COOH to creatinine ratios can distinguish between
recent use and residual excretion. To assess the extent of
cannabis use, determination of free and bound THC-COOH
can be useful.
 Hair analysis
 Saliva testing
Treatment
 Acute intoxication of cannabis usually resolves
unremarkably within 4-6 hours and is best managed by
the following measures:
• Frequent reassurance and maintenance of a
nonthreatening environment
• Minimal stimuli
• Use of a specifically assigned nurse to calm the patient
• Judicious use of benzodiazepines when significant anxiety
is present
Medication
• Short-term, low-dose benzodiazepines for treatment of
significant anxiety associated with acute intoxication has been
used. Clinicians are advised to use caution when
administering benzodiazepines for the treatment of cannabisinduced anxiety, as the anxiety will invariable resolve with no
medication over a short period.
 Anxiolytics - Lorazepam (Ativan)
• These agents depress all levels of CNS, which, in turn, reduces
anxiety symptoms.
• Amphetamine (contracted from alpha-methylphenethylamine) is
a potent central nervous system (CNS) stimulant that is used in the
treatment of attention deficit hyperactivity
disorder (ADHD), narcolepsy, and obesity. Amphetamine was
discovered in 1887 and exists as
two enantiomers: levoamphetamine and dextroamphetamine.
• Historically, it has been used to treat nasal congestion and
depression. Amphetamine is also used as an athletic performance
enhancer and cognitive enhancer, and recreationally as
an aphrodisiac and euphoriant. It is a prescription drug in many
countries, and unauthorized possession and distribution of
amphetamine are often tightly controlled due to the significant
health risks associated with recreational use.
• The substance 3,4-methylenedioxymethamphetamine (MDMA) is a
popular recreational stimulant commonly referred to as ecstasy.
MDMA has the desired effects of euphoria, high energy, and social
disinhibition lasting 3-6 hours. The drug is often consumed in
dance clubs, where users dance vigorously for long periods. The
drug sometimes causes toxicity and dehydration, as well as severe
hyperthermia.
History
• Amphetamine-related psychiatric disorders can be confused
with psychiatric disorders caused by organic, medical,
neurologic, and/or psychological etiologies. The causes of
amphetamine-related psychiatric disorders usually can be
determined by assessing the patient's history and the family's
genealogy.
 Psychiatric history
• Two issues are emphasized:
o Determine whether a psychiatric disorder or symptoms ever
occurred when the patient was not exposed to
amphetamines.
o Determine whether the patient ever had a psychiatric
disorder or symptoms similar to the present symptoms in
relation to any other drug or medication.
 Recent history
• The patient's history of amphetamine abuse is the most important factor
and is determined by asking the following questions:
o When did the patient's amphetamine use start?
o How often does the patient use amphetamines?
o How much does he or she use?
o Is the patient currently intoxicated or in withdrawal from amphetamines?
o Does the patient frequently attend rave parties?
o Has the patient recently increased his or her amphetamine use or started
to binge?
 Substance abuse history
• Potentially abused substances include the following:
o Alcohol
o Marijuana
o Cocaine
o Lysergic acid diethylamide (LSD)
o OTC sympathomimetics
o Steroids
 Family history
• A family history of a psychiatric disorder may suggest a primary psychiatric
disorder. A diagnosis of amphetamine-related psychiatric disorder might
still be possible if the patient has no family history of psychiatric disorder.
DSM criteria for intoxication and
withdrawal
 The DSM-5 criteria for stimulant withdrawal are as follows:
• A. Cessation of (or reduction in) prolonged amphetamine-type
substance, cocaine, or other stimulant use.
• B. Dysphoric mood and two (or more) of the following physiologic
changes developing within a few hours to several days after
Criterion A:
o Fatigue
o Vivid, unpleasant dreams
o Insomnia or hypersomnia
o Increased appetite
o Psychomotor retardation or agitation
• The signs or symptoms are not attributable to another general
medical condition, and are not better explained by another mental
disorder, including intoxication or withdrawal from another
substance.
• Delirium is not a condition observed during amphetamine
withdrawal.
 The DSM-5 criteria for stimulant intoxication are as follows:
• A. Recent ues of an amphetamine-type substance, cocaine or other
stimulant.
• B. Clinically significant problematic behavioral or psychological changes
(e.g., euphoria or affective blunting; changes in sociability; hypervigilance;
interpersonal sensitivity; anxiety, tension, or anger; stereotyped
behaviors; impaired judgment) that develop during, or shortly after, use of
a stimulant.
• C. Two (or more) of the following signs or symptoms, developing during, or
shortly after, stimulant use:
o Tachycardia or bradycardia
o Pupillary dilatation
o Elevated or lowered blood pressure
o Perspiration or chills
o Nausea or vomiting
o Evidence of weight loss
o Psychomotor agitation or retardation
o Muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias
o Confusion, seizures, dyskinesias, dystonias, or coma
• 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.
Physical and psychological
manifestations
• Mental status examination should emphasize delusions, hallucinations,
suicide, homicide, orientation, insight and judgment, and affect. The
mental status examination can be very different for intoxication and
psychosis.
 A mental status expected for a patient with amphetamine intoxication is
as follows:
o Appearance and behavior: Unusually friendly, scattered eye contact,
buccal oral gyrations, excoriations on extremities and face from picking at
skin, overly talkative and verbally intrusive
o Speech: Increased rate
o Thought process: Tangential, circumstantial over inclusive and disinhibited
o Thought content: Paranoid; no suicidal or homicidal thoughts
o Mood: Anxious, hypomanic
o Affect: Anxious and tense
o Insight and judgment: Poor
o Orientation: Alert to person, place, and purpose; perspective of time is
disorganized
 A mental status expected for a patient with amphetamine psychosis is as follows:
o Appearance and behavior: Disheveled, suspicious, paranoid, difficult to engage,
and poor eye contact
o Speech: Decreased and rapid
o Thought process: Guarded and internally preoccupied
o Thought content: Paranoid; possible auditory hallucinations; no suicidal or
homicidal thoughts
o Mood: Anxious
o Affect: Paranoid and fearful
o Insight and judgment: Poor
o Orientation: Has no concept of purpose, though understands place and person;
perspective of time is disorganized.
 A mental status for a patient withdrawing form amphetamines is as follows:
o Appearance and behavior: Disheveled, psychomotor slowing, poor eye contact,
pale appearance to skin
o Speech: Decreased tone and volume
o Thought processes: Decreased content, guarded
o Thought content: No auditory, visual hallucinations; suicidal thoughts present, but
no homicidal thoughts
o Mood: depressed
o Affect: Flat and withdrawn
o Insight and judgment: Poor
o Orientation: Oriented to person, place, and purpose
Differential Diagnoses
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Cannabis-Related Disorders
Cocaine-Related Psychiatric Disorders
Delirium
Depression
Hallucinogen Use
Hyperthyroidism
Hypothyroidism
Inhalant-Related Psychiatric Disorders
Insomnia
Opioid Abuse
Phencyclidine (PCP)-Related Psychiatric Disorders
Schizophrenia
Toxicity, Heroin
Toxicity, Mushroom
Wernicke-Korsakoff Syndrome
Laboratory Studies
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Laboratory evaluation should include the following tests:
Finger-stick blood glucose test
CBC determination
Determination of electrolyte levels, including magnesium, amylase,
albumin, total protein, uric acid, BUN, alkaline phosphatase, and
bilirubin levels
Urinalysis
Stat urine or serum toxicology screening to exclude acetaminophen,
tricyclic antidepressants, aspirin, and other potential toxins:
Individuals who abuse drugs may ingest a substance called Urine
Luck, or pyridinium chlorochromate (PCC), to produce invalid results
on urine drug screens. PCC alters the results for cannabis and
opiates but elevates levels of amphetamines.
Blood test for an alcohol level if the patient appears intoxicated
HIV and rapid plasma reagin (RPR) tests
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Other Tests
Perform ECG to evaluate for cardiac involvement.
Perform EEG if a seizure disorder is considered possible.
Use of the brief psychotic rating scale (BPRS), Beck Depression
Scale, violence and suicide assessment, and other measures
may be helpful.
• If persistent psychiatric conditions are noted,
neuropsychological testing can be beneficial to assess levels of
psychosocial and neurologic function to guide treatment and
to assess the need for placement.
• Results of projective testing, such as the Rorschach test and
the Thematic Apperception Test, can help in clarifying thought
disorders.
• During amphetamine intoxication, the Mini-Mental State
Examination (MMSE) can be helpful in measuring cognitive
change.
Treatment
 The excretion of amphetamines can be accelerated by the use of
ammonium chloride, given either IV or orally (PO).
• Amphetamine intoxication can be treated with ammonium chloride,
often found in OTC expectorants, such as ammonium chloride
(Quelidrine), baby cough syrup, Romilar, and P-V-Tussin.
• The recommended dose to acidify the urine is ammonium chloride
500 mg every 2-3 hours.
• The ingredients in OTC cough syrups vary, and the clinician should
become familiar with 1 or 2 stock items for use in the emergency
department.
• Ammonium chloride (Quelidrine), an OTC expectorant, can be used
in the absence of liver or kidney failure.
• Administer IV fluids to provide adequate hydration.
Medication
 Antipsychotics - Haloperidol (Haldol)
• Clinicians should select a high-potency antipsychotic that
is available in tablet, liquid, and IM forms for
administration in emergency situations. Antipsychotics
help control psychotic symptoms and provide rapid
tranquilization of the agitated and psychotic patient.
 Benzodiazepines - Lorazepam (Ativan)
• These drugs are primarily used to sedate agitated
patients. Availability in PO, IV, and IM forms allowing the
drug to be used in emergency situations. Caution must
be used in the violent, aggressive patient because
benzodiazepines may cause disinhibition.
 Beta-blockers - Propranolol (Inderal)
• Propranolol (Inderal) is useful in patients who are agitated, anxious,
and hyperarousable because of amphetamines. They are
temporarily used until the amphetamine is eliminated from the
patient's system. For some patients, anxiety can be prolonged, and
nonaddictive beta-blockers may be helpful.
 Expectorants - Ammonium chloride (Quelidrine)
• Expectorants are used to acidify the urine and increase
amphetamine excretion when intoxication from amphetamines has
resulted in psychiatric and medical complications. These agents are
available in PO form, and the patient must be able to swallow or
receive a nasogastric tube.
 Adsorbents - Activated charcoal suspension (Actidose-aqua, InstAqua, Liquid-Char)
• These agents, given through a nasogastric tube into the stomach,
absorb intentionally and accidentally ingested substances to
prevent their further absorption into the systemic circulation.
References
• American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition. Washington, DC: American
Psychiatric Association; 2013. DSM-5
• Substance Abuse and Mental Health Services Administration.
Results from the 2013 National Survey on Drug Use and Health:
Summary of National Findings.
• CDC. Alcohol-Related Disease Impact (ARDI). Centers for Disease
Control and Prevention. Available at
http://nccd.cdc.gov/DPH_ARDI/default/default.aspx. Accessed:
March 4, 2016.
• World Health Organization. Global status report on alcohol and
health. 2014. Available at
http://www.who.int/substance_abuse/publications/global_alcohol_
report/msb_gsr_2014_1.pdf?ua=1.
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