ALCOHOL:ALCOHOL:Withdrawal & DependenceBy: Zarifah Adilah

Interns 2014

0Alcohol use disorders are common lethal conditions that often masquerade as other psychiatric syndromes. 

0An understanding of the effects of alcohol and the clinical importance of alcohol-related disorders is essential for the practice of psychiatry.

ALCOHOL WITHDRAWAL

Diagnosis

4 Stages of Alcohol Withdrawal

Treatment

Benzodiazepines (BZDs)0First line agent, best efficacy, safety and cost

0 ↑ GABAAR function0 ↓Seizures: ~ 90%0 ↓ Delirium: ~ 70%

0Choices of BZDs:0 Long half-life (chlordiazepoxide, diazepam):

0 ↓ Seizures: ~ 58% 0 ↓ Distress (“smoother detox”)

0 Shorter half-life (lorazepam, oxazepam)0 ↓ Oversedation0 Safer in elderly / liver impairment

0Treatment should allow:i. Individualization

ii.Rapid appropriate dosing

Carbamazepine and ValproateEffective in:

0 Mild to moderate AW / protracted AW0 ↓ distress and faster return to work0 No abuse potential / alcohol interactions0 No toxicity in 7-day trials

Limitations:0 Not better than BZDs 0 ↑ Side effects0 ↑ Cost0 Limited data in AW seizures/delirium

OTHER DRUGS

0 Antipsychotics:0 ↑ seizures, ↓ agitation

0 β-Adrenergic antagonists and clonidine:0 ↓ Autonomic activity, may hide impending seizures

0 Magnesium:0 ↓ levels in AW, supplement does not ↓ severity

0 Ethyl Alcohol:0 No evidence of efficacy, toxic + expensive

Nonpharmacological Treatment

0 Quiet environment

0 Nutrition and hydration: Oral thiamine (prevents Wernicke-Korsakoff) / folic acid Oral fluids / electrolytes

0 Orientation to reality

0 Brief interventions / motivate to change

ALCOHOL DEPENDENCE

In 1964 a WHO Expert Committee introduced the term ‘dependence’ to replace the terms ‘addiction’ and ‘habituation’. 

Definition (ICD-10): 0a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value.

Diagnostic guidelines (ICD-10)≥3 Criterias

1.a strong desire or sense of compulsion to take the

substance;

2.difficulties in controlling substance-taking behaviour in

terms of its onset, termination, or levels of use;

3.a physiological withdrawal state when substance use has

ceased or been reduced;

4. evidence of tolerance;

5. progressive neglect of alternative pleasures

or interests;

6. persisting with substance use despite clear

evidence of overtly harmful consequences

The diagnosis of the dependence syndrome may be further specified by the following five-character codes:

0F1x.20 Currently abstinent

0F1x.21 Currently abstinent, but in a protected environment (e.g. in hospital, in a therapeutic community, in prison, etc.)

0F1x.22 Currently on a clinically supervised maintenance or replacement regime [controlled dependence] (e.g. with methadone; nicotine gum or nicotine patch)

0F1x.23 Currently abstinent, but receiving treatment with aversive or blocking drugs

(e.g. naltrexone or disulfiram)

0F1x.24 Currently using the substance [active dependence]

0F1x.25 Continuous use

0F1x.26 Episodic use [dipsomani]

Medications for Alcohol Dependence

0Approved oral medications

-Naltrexone

-Acamprosate

-Disulfiram

TREATMENT AND REHABILITATION

3 General Steps:1. intervention, 2. detoxification, 3. rehabilitation.

InterventionThe goal= confrontationto break through feelings of denial and help the patient recognize the adverse consequences likely to occur if the disorder is not treated. Process that aimed at maximizing the motivation for treatment and continued abstinence.

Detoxification0The essential first step: thorough physical examination. 0The second step: • rest, • adequate nutrition, and multiple vitamins, especially

those containing thiamine.

Rehabilitation03 major components:

1. continued efforts to increase and maintain high levels of motivation for abstinence,

2. work to help the patient readjust to a lifestyle free of alcohol,

3. relapse prevention.

Thank You