Alcohol Withdrawal

What medications might be prescribed to J.G. to assist him with sobriety? What would you discuss with J.G. concerning the treatment regimen, side effects and precautions of his medications

Acamprosate (Campral) should be initiated immediately after alcohol detoxification once J.G. has abstained from alcohol for 7 days. This is to help reduce the craving for alcohol. It is recommended therapy for 1 year. Common side effects include: GI upset, myalgia, headache, rash, syncope, palpitations, edema, and impotence. Diphenhydramine (Benadryl) 50 mg IM or IV is often prescribed as a GI decontaminant to reduce absorption of the toxic acetaldehydes. J.G. needs to be educated and aware that even small amounts of alcohol, such as those in mouthwash or cough syrup, can cause a reaction. Disulfiram (Antabuse) is aversive treatment used to prevent J.G. from resuming drinking. It is important to let J.G. know that reactions can occur with alcohol consumption and up to 14 days following the last drink. Reactions include flushing, sweating, headache, neck pain, palpitations, dyspnea, hyperventilation, tachycardia, hypotension, and nausea and vomiting. Serious side effects can include chest pain, difficulty breathing, severe hypotension, confusion, convulsions, or death. Prompt medical attention is necessary. In this case, it would be necessary to activate the emergency response system and transport J.G. to the ED within the hospital. If he is at home when this occurs, he needs to call 911.

List the criteria for alcohol use disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) and put an asterisk or star next to the ones J.G. demonstrates.

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) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect; b) A markedly diminished effect with continued use of the same amount of alcohol. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal); b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.*

What are the 2 most likely causes of J.G.'s symptoms

Alcohol withdrawal and blood loss from the GI bleed

What is the most likely time frame for someone to have withdrawal symptoms after abrupt cessation of alcohol

Anxiety, insomnia, nausea, and abdominal pain begins 8 hours after the last drink. High blood pressure, increased body temperature, unusual heart rate, and confusion begins 24-72 hours after the last drink. Hallucinations, fever, seizures, and agitation tends to begin 2-4 days after the last drink.

What lab tests might the physician order to assess for nutritional deficiencies or other medical problems J.G. is experiencing?

BMP, CBC, Albumin, Prealbumin, lipid panel, Urinalysis, Iron, Vitamin B12, Vitamin B1 Hepatitis screen Magnesium levels , thiamine, urine screen

Which data from your assessment of J.G. are of concern to you

Data that are concerning are temperature of 102.2, high blood pressure 174/98, pulse of 110, respiratory rate of 24, and a flushed appearance. Also, that J.G. admits to drinking a fifth of vodka daily and has had seizures while withdrawing from alcohol. However, tremors, anxiety, sweating, tachycardia, headache, and seizures are common signs of alcohol withdrawal.

Which of the previous lab results specifically reflects chronic alcohol ingestion

Gamma Glutamyl transferase (GTT) is an enzyme found in many organs, with the highest concentrations found in the liver. Elevated GGT can reflect chronic alcohol ingestion.

What chronic health problems are associated with alcoholism?

HTN, heart disease, stroke, liver disease, digestive problems, cancer of the breast/mouth/throat/esophagus/liver/colon

What types of information and referrals will be discussed with J.G. before his discharge from the hospital

He will need education regarding the side effects, long-term physical, or emotional effects (ex. depression) of alcohol use. If he has the resources, he should be referred to an intensive outpatient program for rehabilitation. Referral information about community-based mental health clinics, Alcoholics Anonymous, self- help groups, and halfway houses should also be provided, especially if he is unable to go to the intensive rehab. He should be referred to a dietitian to provide nutrition therapy to ensure proper caloric, vitamin, and mineral intake. Referral to a spiritual leader for J.G., if he so chooses, can be provided. Such as a pastor, rabbi, monk, etc.

What do the admission lab results indicate?

Hgb of 10.9 (12-16) low from blood loss from GI bleed Hct of 23% (42-52%) low from blood loss from GI bleed ALT 69 (7-56) increased due to liver damage from alcohol AST 111 (10-40) increased due to liver damage from alcohol GGT 75 (9-48) increased due to liver damage from alcohol ETOH 291- extremely elevated due to alcohol intoxication aPTT 35 seconds (21-35) and PT/INR 12 seconds (9.5-12) both high end of normal range

J.G. is referred to the local Alcoholics Anonymous (AA) program. What strategy can be implemented to increase his likelihood of attendance at these meetings?

It will be important to provide J.G. with a sponsor. A sponsor should be selected for J.G. before his discharge from the hospital. A sponsor is a person who is recovering from addiction, serves as a mentor, and can work with J.G. to provide support. They will also suggest ideas for managing cravings and coping with the issues that J.G. faces as he tries to stay sober. This person is the best help for him as they understand what he is going through more than anyone else.

What would be helpful for J.G.'s physician to know regarding J.G.'s substance use history

It would be important for the physician to know how much J.G has drank, how long he has been drinking, any effects he has related to his drinking, and types of withdrawal symptoms he has experienced. It would also be important to know any other substances J.G. uses or has used in the past. The physician would also like to know any history of complications such as seizures, while withdrawing from substance. In addition, current medical problems, current or past mental health treatment (e.g., for depression or anxiety) and any substance abuse treatment would be questions to ask J.G. as well.

Explain the rationale for each of the drugs used during acute alcohol withdrawal.

Thiamine (Vitamin B1)- this is given because alcoholics are deficient in B1 usually and this puts them at risk for Wernicke-Korsakoff Syndrome, cerebellar degeneration, and cardiovascular dysfunction. Beta Blockers- helps to resolve abnormal behavior and abnormal clinical characteristics more rapidly Benzodiazepines- help to reduce the impact of Alcohol Withdrawal Syndrome by helping to treat seizures, tremors, difficulty sleeping, nausea and vomiting Clonidine- helps with side effects of withdrawal Antiepileptic- these are prophylactic to prevent seizures from occurring

What medications are commonly prescribed for patients withdrawing from alcohol?

a. Thiamine, a B vitamin b. Beta blockers, such as propranolol d. Benzodiazepines, such as lorazepam (Ativan) e. Clonidine (Catapres), an alpha-adrenergic blocker g. Antiepileptic drugs, such as carbamazepine (Tegretol)

Based on the DSM-V criteria, how would you rate the severity of J.G.'s alcohol use?

d. Severe