Substance-Related Disorders

Question 1

Alcohol intoxication
Pt:
Tx:
Complications:

Answer 1

Pt:
Disinhibition
Depression: slurred speech, impaired judgement, somnolence
Ataxia, impaired attention/memory
Labile mood: erratic behavior, aggression

Tx:
Acute intoxication:
-observation 
Chronic pts/known alcohol-dependent pts
-IV thiamine and magnesium (prior to glucose administration) If glucose is given before thiamine, it may induce Korsakoff’s syndrome
-Multivitamins: B12 and Folate; IV fluids, dextrose 
Psychosis or severe aggression
-Haldol

Complications:

• Korsakoff syndrome: amnesia (retrograde and anterograde)
• Wernicke’s encephalopathy: Ataxia, confusion, oculomotor palsy-> due to thiamine/B1 deficiency)

Question 2

Alcohol Withdrawal
Pt:
Tx:

Answer 2

Pt:
Uncomplicated withdrawal: 6-24 hrs after last drink
-Increased CNS activity: tremors, anxiety, diaphoresis, palpitations, insomnia, GI (N/V/D)
-uncomplicated= no seizures, hallucinosis, delirium tremens

Withdrawal seizures: 6-48 hrs after last drink

• Usually generalized tonic-clonic type
• MC occurs as a single episode

Alcoholic Hallucinosis: 12-48hrs after last drink

• Visual auditory and or tactile hallucinations
• Pt has a clear sensorium and normal vital signs

Delirium Tremens: 2-5 days after last drink

• Delirium (altered sensorium), hallucinations, agitation
• Abnormal vital signs: tachycardia, HTN, fever; pt often diaphoretic

Tx:
IV benzodiazepines: Diazepam, lorazepam, chlordiazepoxide, oxazepam
Titrated until pt is slightly somnolent then gradually tapered
Lorazepam and oxazepam preferred in advanced cirrhosis or alcoholic hepatitis

IVF and supplementation
IV thiamine and Mg (prior to glucose)

Avoidance of medications that can lower seizure threshold
Bupropion 
Haldol 
Anticonvulsants
Clonidine
Beta blockers

Question 3

Alcohol Dependence
Dx
Tx

Answer 3

Dx:
Validated screening/assessment instrument: Alcohol use disorders identification tests (AUDIT)
CAGE- good for patients who are dependent (fails to identify pts who are at the at risk level)
-Cutdown
-Annoyed
-Guilt
-Eye opener (drink first thing in the morning)

Tx:

• Support: psychotherapy, AA, inpatient, residential rehabs
• Disulfiram (Antabuse)-> deterrent to alcohol use
• Naltrexone: opioid antagonist reduced alcohol craving and reduces alcohol-induced euphoria
• Gabapentin, topiramate
• Acamprosate 666mg TID