Download Opioid Dependence During Pregnancy

AUD in General Hospitals
 High
Prevalence
 25%
Lifetime abuse or dependence
 35% Trauma surgical patients
 20% Burn patients
 Very
costly
 $166
Billion/yr: ↓work, ↑crime, ↓health
 Comorbid AUD ↑ stay and cost
© AMSP 2012
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↑ Medical Complications
Alcohol
↓
interacts with meds
General health
Poor
nutrition
© AMSP 2012
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This Lecture Reviews:
 Definitions
 Screening/evaluation
 Medical/psych
complications,
comorbidity and Rx
 Interventions
in the hospital
© AMSP 2012
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Definitions

Standard Drink (~10 grams alcohol)
 12 oz. Beer
 5 oz. Wine
 1.5oz. Hard liquor (80 proof)

Hazardous Drinking
 Men: >14 drinks/wk or >4 drinks/sitting
 Women: >7 drinks/wk or >3 drinks/sitting
© AMSP 2012
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Abuse & Dependence

Abuse 1+ of:
Failure in roles
 Hazardous use
 Social/interpersonal
problems
 Legal problems

(Not alc dependent)
© AMSP 2012

Dependence 3+ of:
Tolerance
 Withdrawal
 Unable to ↓ or quit
 Longer than intended
 ↑ Time find/use
 ↓ Important activities
 Despite consequences

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This Lecture Reviews
 Definitions
 Screening/evaluation
 Medical/psych
complications,
comorbidity, and Rx
 Interventions
in the hospital
© AMSP 2012
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Screening/Evaluation
 Often
undetected by MDs
 Reasons
include:
Inadequate
training
Misperceptions/stereotyping
Uncertain about what to do
© AMSP 2012
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Psychiatric Consultation
 Ask
why refer
 Review
records/labs/etc.
 Review
all meds
 Interview/examine
patient
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Psychiatric Consultation
 Interview
 Order
collateral
diagnostic tests
 Formulate
 Discuss
assessment & plan
w/ referring clinician
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Taking AUD History
Current/past
patterns of use
Usual
drinks/day
Binge pattern
Periods of abstinence
History of treatment
Withdrawal
Family history
© AMSP 2012
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Screening/Evaluation
 Alc
Use Disorders Identification Test
10 questions, scored 0-4
≥8 = hazardous drinking (Sens=98%)
≥10 = alc dependence (Sens=99%)
 Short Michigan Alcohol Screening Test
13 questions, self-administered
Accuracy=25 item MAST (Sens 90%)
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Screening/Evaluation
 Lab
markers
 Gamma-glutamyltransferase
 Aspartate
& Alanine Aminotransferase
 Carbohydrate
 Mean
deficient transferrin
Corpuscular Volume
© AMSP 2012
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Lab Markers 1 (GGT)

Gamma-glutamyltransferase





↑ With heavy drinking
↑ In: heart disease, kidney disease, preg
GGT >35
-Heavy drinking
-↑ Before liver damage
-Sensitivity for heavy drinking ~75%
GGT >50 may indicate liver damage
Normalizes ~5 weeks of abstinence
© AMSP 2012
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Lab Markers 2 (LFT)

Liver enzymes: AST and ALT
 ALT in liver, AST in many tissues
 ↑ In high use AND liver damage
 Absolute value &ratio important
-AST (14-38 U/L normal range)
-ALT (15-48 U/L normal range)
-AST:ALT ratio >2 suggestive of alcohol
 Less sensitive than GGT
© AMSP 2012
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Lab Markers 3 (CDT)

Carbohydrate deficient transferrin
 Transferrin=protein; transports iron
 Abnormal form produced in ↑ drinking
 CDT >20 g/l indicates heavy drinking
 Few other conditions ↑
 Sensitivity & specificity ~75% (=GGT)
 Normalizes ~1 month of abstinence
© AMSP 2012
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Lab Markers 4 (MCV)
 Mean

Corpuscular Volume
Size of red cells (nl =80-100u)
↑
By heavy drinking
 >90u
suggests heavy drinking
 MCV
↑ in other conditions
© AMSP 2012
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Screening/Evaluation

Signs and symptoms
 Irregular
heart rhythm
 Enlarged tender liver (alc hepatitis)
 Hard small liver (cirrhosis- in 20% of AUD)
 Ascites (abdom. cavity fluid in liver failure)
 Jaundice (yellow skin/eyes in liver failure)
 Tremor (hangover or withdrawal)
 Hyperactive reflexes/↑ pulse/ etc.
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© AMSP 2012
This Lecture Reviews
 Definitions
 Screening/evaluation
 Medical/psych
complications,
comorbidity, and Rx
 Interventions
in the hospital
© AMSP 2012
19
Alcohol Withdrawal


Cessation or ↓ heavy use
2+ w/in hrs:

Tremor (hands, arms, legs, tongue)

↑ Pulse

Insomnia

Agitation (restlessness/agitation/aggression)

Anxiety

Visual/tactile/auditory hallucinations (rare)

Grand mal seizure (rare)
© AMSP 2012
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Alcohol Withdrawal
 6-8
hours after last drink
 Declining
BAC (not at zero)
 Symptoms
 R/O
→ distress/↓ functioning
general medical or mental dx
 Delirium
Tremens (DT’s) (rare)
© AMSP 2012
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Delirium Tremens (DT’s)

Seen in ~5% AUD

Disorientation (confusion)

Fluctuating consciousness

Hyperactivity/excitation

↑ Pulse, bp, temp, etc.
© AMSP 2012
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Delirium Tremens (DT’s)
 Hallucinations
 Can
be fatal if med problems
 Onset
↑
48-96 hours after last drink
Risk prior episodes/med probs
 R/O
other causes
© AMSP 2012
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Withdrawal Tx
 Benzodiazepines
(e.g. diazepam [Valium])
Correct transmitter problems
Day 1: give enough to ↓ symptoms
↓ Dose ~20% day 1 dose each day
↑ Dose if symp ↑; ↓ dose next day
 Anticonvulsants
not needed
© AMSP 2012
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Clinical Case
 80
y/o female
 ↑BP, 3 days s/p hip surgery
 Keeps trying to get out of bed
 Confused
 Agitated
 ↑ BP and bilateral hand tremor
 Dx: EtOH withdrawal delirium (DT)
© AMSP 2012
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Clinical Case
 Review
criteria for DT’s
 Symptom
onset at 72 hours
 Confusion
 Psychomotor
↑
agitation
Blood pressure/pulse/etc.
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Clinical Case
 Rx
recommendations:
1:1
observation
Folate
 R/O
1mg/d, thiamine 100mg/d
other causes
 Benzodiazepine
© AMSP 2012
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Benzodiazepine Rx


Chlordiazepoxide (Librium);diazepam (Valium)

Longer half-life=smoother withdrawal

Better seizure protection

But can over-sedate elderly and liver impaired
Lorazepam (Ativan)=better choice in this pt

Shorter half-life = ↓ risk of oversedation

↓ Risk if liver prob; not metabolized in liver
© AMSP 2012
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Wernicke Encephalopathy
 Cause:
↓ thiamine (Vit B1)
 Emergency:
untreated →20% death
 Triad:
Confusion, ataxia (incoordination),
ophthalmoplegia (eye muscle paralysis)
 Rx:
IV thiamine (to optimize absorption)
© AMSP 2012
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Korsakoff’s Syndrome

Impaired memory in alert, responsive pt

Limited insight to memory loss

Confabulation -- makes up stories

Retrograde & anterograde memory loss
© AMSP 2012
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Psychiatric Disorders: MDE
 Co-morbid
major depression

Gen pop major depressive episode (MDE) ~15%

AUD slightly ↑ even when not drinking

MDE unrelated to drinking
-Alcohol ↑ depressive symptoms
-Alcohol intoxication/withdrawal ↑ suicidal ideation
© AMSP 2012
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Psychiatric Disorders: AID
 Alcohol
induced: severe intoxication →
temporary MDE in ~30%
 Causal
relationship--psychiatric disorder
not predating AUD
 Treatment
= abstinence (≠ meds)
 Depression
↓↓ in 2 d to 4 wks abstinence
© AMSP 2012
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Psychiatric Disorders: Psychosis
 Psychosis – Hallucinations
 Delirium
(e.g. post surgery, DT’s) --usually
disappear as delirium resolves
 ~3%
AUD during severe intoxication
-No delirium
-Alcohol-induced psychosis
-Disappears 2 d to 4 wks without meds
-Antipsychotics (e.g. risperidone) control symp
© AMSP 2012
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This Lecture Reviews
 Definitions
 Screening/evaluation
 Medical/psych
complications,
comorbidity, and Rx
 Interventions
in the hospital
© AMSP 2012
34
Interventions
 Brief
intervention for heavy drinkers
 Non-dependent
 Goal:
 ~10
(e.g.regular >3 drks/d)
early intervention & prevention
min educ. or MotivationaI Interviewing
 Delivered
by MD/staff
© AMSP 2012
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Motivational Interviewing (MI)
 Behavior
change (e.g. taking meds)
 Change: process with multiple steps
 Stage of change model
 Collaboration (not confrontation)
 ↑ Pt’s motivation
 Respect pt’s own decision
© AMSP 2012
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Stages of Change Model
 Precontemplative Contemplative
 Preparation
 Action
not a problem
– considers change
- makes plans
- changes behavior
 Maintenance
- sustains change
© AMSP 2012
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Motivational Interviewing
 General
principles:
Empathy
Discuss
ambivalence to change
Skillful listening
Point out behavior contrast to goals
Roll with resistance
Support self-efficacy
© AMSP 2012
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Clinical Case
 45
year old male high school principal
 3rd admission for alcoholic pancreatitis
 Given AUD treatment options in past
 No follow up
 Now: marital discord, job lay-off, etc.
 Admits alcohol a problem
© AMSP 2012
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Clinical Case
Stage of change: contemplative
 Express empathy for situation/stressors
 Discuss barriers to change
 Discuss goals vs behavior
 Support ability to change if desired
 Result: pt takes initiative
 Stage : contemplation→preparation

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Treatment
 All
options work to:
Change thinking about AUD
-Chronic disorder
-Can be managed
Help
prevent relapse
-Recognize triggers
-Avoid high risk situations
-Cope with cravings
© AMSP 2012
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Referral Option 1
 Inpatient/residential
rehabilitation
 Lessons/support
in 24 hr milieu
 Typically 14-28 days
 Learn through group discussions
 Intensive
Outpatient Treatment (IOP)
 Groups
multiple days of week
 Provided in “real world” setting
© AMSP 2012
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Referral Option 2
 Outpatient
treatment
 Substance
or mental health Rx provider
 Provided in variety of settings
 Self-help
groups (AA)
 Introduced
in rehab or IOP
 Requires only desire to stop drinking
 Change through working “12 steps”
© AMSP 2012
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Medications
 Naltrexone
(ReVia or Vivitrol)
 Oral
(50mg/d) or injectable (380mg/mo)
 Opioid receptor antagonist
 ↓Cravings
 Acamprosate
(Campral)
 Oral
(~2g/d)
 NMDA receptor antagonist
 ↓ Post-withdrawal symptoms
 Rx
3-6 months
 ~15% improvement
© AMSP 2012
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Conclusions

AUD important issue in general hospital

Effective screening and evaluation

Multiple medical/psychiatric complications

Effective interventions for Rx and referral
© AMSP 2012
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