Acute detox for alcohol (incl other substances )

Question 1

Mr MS, a 45-year-old man, arrives at the emergency department after experiencing acute chest pain, severe tremors, and confusion. On examination, his vitals reveal a heart rate of 138 bpm and a blood pressure of 190/100 mmHg. The patient is agitated, with tremors making it difficult to hold objects. He reports seeing “strange shadows” in the room, He also complains of sweating profusely and feeling nauseated.He admits that he has been drinking heavily for over 20 years, typically consuming 6-8 bottles of beer daily, with occasional shots of whiskey in the evenings. Recently, he decided to cut back on his alcohol intake after his doctor warned him about the risk of worsening his high blood pressure. However, despite his intentions, he struggled to reduce his drinking, often finding himself craving alcohol and giving in to those urges. He stopped drinking abruptly three days ago, hoping to make a change. He acknowledges that his drinking has caused problems at home, with his wife frequently complaining about his behaviour when he drinks, but he has continued to drink despite these issues.

• What is the diagnosis of the patient’s condition and name the DSM-5 criteria that are being met? (6 marks)

Answer 1

diagnosis: Alcohol Withdrawal

DSM5:
Criteria A: Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
Criteria B: Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol:
* Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
* Increased hand tremor.
* Nausea or vomiting.
* Transient visual, tactile, or auditory hallucinations or illusions.
* Anxiety
* Psychomotor agitation.
Criteria C: The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criteria 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

Question 2

Provide 2 psychosocial management plans for the patient to aid in alcohol use reduction. Discuss each management plan in 1 sentence. (4 Marks)

Answer 2

• Motivational Interviewing: Interviewing techniques to enhance the patient’s readiness and commitment to change. Ultimately the patient is empowered to make the change in behaviour.
• Support Groups: Engage in peer-support programs like Alcoholics Anonymous (AA) for ongoing emotional and psychological support.

Question 3

Explain why patients may experience signs and symptoms such as agitation, tachycardia, and tremor when they suddenly reduce alcohol intake after prolonged use. (1 mark)

Answer 3

Patients may experience these symptoms because alcohol has an inhibitory effect on the central nervous system (CNS). When alcohol intake is suddenly reduced after prolonged use, this inhibitory effect is removed, leading to CNS excitation. This results in signs and symptoms of alcohol withdrawal

Question 4

Discuss the approach to managing patients presenting with alcohol withdrawal, including the assessment of disease severity, risk stratification, and appropriate pharmacological treatment options. (6 marks)

Answer 4

• Use a standardized tool like the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scale to assess the severity of withdrawal symptoms. (1 mark)
• Determine the risk of severe withdrawal symptoms and complications. Patients are categorised based on their symptom severity and risk factors for complications. (1 mark)
• Patients with minimal to mild symptoms and low risk for complications can be discharged home with oral medications. For mild withdrawal, anticonvulsants such as gabapentin or carbamazepine are preferred. (1 mark)
• For patients with moderate withdrawal symptoms and low risk of complications, oral benzodiazepines can be prescribed. (1 mark)
• Patients with moderate to severe withdrawal features or significant risk factors for complications should be admitted to the hospital for close monitoring. These patients should receive intravenous benzodiazepine therapy. (1 mark)
• In severe cases, patients may require ICU admission and treatment with phenobarbital. Additionally, thiamine should be administered to prevent or treat Wernicke encephalopathy. (1 mark)

Question 5

Name 4 other substances of abuse (2 marks)

Answer 5

Benzodiazepines, Stimulants (Cocaine/Amphetamines), Cannabis, Opioids.

Question 6

What is the antidote for benzodiazepine intoxication (1 mark)

Answer 6

Flumazenil