Foundation of Addiction Medicine 2019

Neurobiology of Withdrawal

• Low ethanol: glutamate binding to NMDAR:
Euphoria and Excitation

• Higher ethanol: Potentiates GABA effects:
Intoxication

• Prolonged alcohol use: downregulation of GABA
receptors and increased expression of NMDA
receptors with production of more glutamate

401

Contd…

• Abrupt cessation of chronic alcohol consumption:
glutamate-mediated CNS excitation: autonomic
overactivity and neuropsychiatric complications
such as delirium and seizures

• Increase in dopamine positively influences the
reward system

• Increase in dopamine levels during withdrawal:
autonomic hyperarousal and hallucinations

402

403

Alcohol Withdrawal Syndrome

Autonomic Motor Awareness Psychiatric
Symptoms Symptoms Symptoms Symptoms
Tachycardia Hand Tremor Insomnia Illusions
Agitation Delusions
Tachypnea Tremulousness
of body Irritability Hallucinations
Dilated Pupils Seizures Delirium Paranoid Ideas

Elevated Blood Ataxia Disorientation Anxiety
Pressure
Elevated Body Gait Affective
Temperature Disturbances instability
Diaphoresis Hyperreflexia Combativen4e04ss

Nausea/ Dysarthria

Timeline of Symptoms

Maudsley Prescribing Guidelines, 13th Ed

405

Timeline of Symptoms

Maudsley Prescribing Guidelines, 13th Ed

406

407

Risk Factors
• Severe alcohol dependence
• Self‐detoxification without medical input
• Multiple previous admissions for alcohol

withdrawal
• Concurrent medical illness
• Previous history of delirium tremens and alcohol

withdrawal seizures

408

Hallucinations in withdrawal

• Visual/ Auditory/ Tactile
• Lights too bright/ sounds too loud/ “pins and

needles”
• Visual hallucinations most common. Frequently

involves some animal
• Auditory: unformed sounds
• Tactile: bugs under the skin

409

Assessment

410

Short Alcohol Withdrawal Scale (SAWS)

Elholm et al, 2010 411

Outpatient withdrawal management

• Able to follow instructions
• Willing to commit to daily visits
• Has a supervising carer
• Treatment and contingency plan is agreed upon
• No h/o complicated withdrawal
• No h/o head injury (TBI)
• Not pregnant
• No unstable medical comorbidity

412

In-patient withdrawal management

• Severe alcohol dependence
• History of seizures or delirium tremens
• Extremes of ages
• Concurrent use of other substances (e.g. benzodiazepines)
• Co‐morbid mental or physical illness, learning disability or

cognitive impairment.
• Pregnant patient
• No social support
• History of failed OP detoxification

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Management (Detoxification)
• Benzodiazepines are the treatment of choice.
• Diazepam/ Chlordiazepoxide
• Lorazepam/ Oxazepam (deranged liver functions)
• Tapering dose of benzodiazepines over about 5-7

days, longer in case of complicated withdrawal
• Close monitoring of patients
• Don’t forget thiamine

414

Don’ts
• Do not start detoxification if blood alcohol

concentration is very high/ rising
• CONTRAINDICATED for ongoing use by people

with Alcohol Use Disorder (or any other kind of
Substance Use Disorder)
• DO NOT continue long-term benzodiazepines (>
10 days)

415

Detoxification Regimen
• Three types of detoxification regimes:
• Fixed dose reduction
• Variable dose reduction (Symptom-triggered)
• Front‐loading

416

417

418

Always Remember!
• Detoxification is the start and not the end of the

treatment
• Craving management and relapse prevention
• Psychosocial intervention: Enhancing social

support
• Managing vulnerabilities!

419

Thank you!

420

MANAGEMENT OF
COMPLICATED
ALCOHOL
WITHDRAWAL

DR JAYAKRISHNAN MENON T N
2ND YEAR DM RESIDENT IN ADDICTION PSYCHIATRY

421

Educational Objectives

● Able to diagnose Complicated alcohol
withdrawal

● Rule in and out from different other
comorbidities

● Evidence based management

422

A 35-year-old male with a history of alcohol use disorder is
involved in an accident and is hospitalized. Seventy-two hours
later, he tells the nurse that he hears the voice of his father telling
him to protect his mother, and he thinks he hears someone at his
door but no one is ever there. His vital signs show an elevated
blood pressure and tachycardia. What is the most likely
diagnosis? (zoom quiz)

1 .Post Traumatic Stress Disorder

2. Delirium Tremens

3. Severe Depression with Psychotic symptoms

4. Schizoaffective disorder

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ALCOHOL WITHDRAWAL -
CHRONOLOGY

424

WITHDRAWAL TIMELINE

2nd Person Tremulousness,
Auditory disorientation,
Hallucination agitation, visual
s most hallucinations
commonly

425

http://www.alltreatment.com/alcohol-withdrawal-timeli
ne

Diagnosis of Alcohol Withdrawal Syndrome
(DSM V, 2013)

A. Cessation of or reduction in alcohol intake, which has previously been
prolonged/heavy.

B. Criterion A, plus any 2 of the following symptoms developing within several
hours to a few days:

● Autonomic hyperactivity
● Worsening tremor
● Insomnia
● Vomiting and nausea
● Hallucinations
● Psychomotor agitation
● Anxiety
● Generalized tonic-clonic seizures.

C. The above symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The above symptoms are not attributable to other causes; for example, another
mental disorder, intoxication, or withdrawal from another substance.

Specify if hallucinations (usually visual or tactile) occur with intact reality testing, or if

auditory, visual, or tactile illusions occur in the absence of a delirium. 426

Alcohol Withdrawal
Delirium Tremens
(DTs)

427

DSM-5 diagnostic criteria for Delirium

Tremens

A. Decreased attention and awareness.

B. Disturbance in attention and awareness represents a change from the
normal level, and fluctuates in severity during the day.

C. Disturbance in memory, orientation, language, visuospatial ability, or
perception.

D. No evidence of coma or other evolving neurocognitive disorder severity
during the day.

E. History indicates that the disturbance is attributable to alcohol withdrawal.

American Psychiatric Association. Diagnostic and statistical manual of mental

disorders, 5th ed. (DSM-5). Washington, DC: American Psychiatric Publishing;

2013. 428

Who are vulnerable to have DT

● A history of sustained drinking

● A history of alcohol withdrawal seizures

● A history of DT

● Age greater than 30

● The presence of a concurrent illness

● The presence of significant alcohol withdrawal in

the presence of an elevated blood alcohol

concentration

● A longer period since the last drink (ie, patients

who present with alcohol withdrawal more than

two days after their last drink are more likely to

experience DT than those who present within two

days) Sutton LJ, Jutel A. Alcohol Withdrawal Syndrome in
Critically Ill Patients: Identification, Assessment, and
Management. Crit Care Nurse. 2016 Feb;36(1):28-38 429

Mortality

● In 20th Century the mortality was 37%

● With early diagnosis, improvement in

pharmacotherapy and supportive care it

is now estimated to <5%

● Cause for death: Arrhythmia,

pneumonia, comorbid medical illness,

old age, severe hepatitis etc

Saitz R, O'Malley SS. Pharmacotherapies for alcohol abuse: withdrawal and treatment. Medical 430
Clinics of North America. 1997 Jul 1;81(4):881-907.

DD’S DELIRIUM IN ALCOHOL
WITHDRAWAL

● Delirium Tremens (hyperactive delirium) 431
● Wernicke encephalopathy, Pellagra encephalopathy
● Metabolic encephalopathy – hyponatremia , hypoglycemia
● Head injury
● Infections – Both CNS and Systemic
● Stroke
● Hepatic encephalopathy
● Post ictal delirium
● Complications secondary to DM, HTN ; Poisoning

DD’S SEIZURE IN ALCOHOL
WITHDRAWAL

● Ask for semiology, number of episodes of seizures, h/o past episodes
● Withdrawal seizure
● Independent Seizure disorder
● Cortical venous thrombosis
● Other causes similar to that of delirium

432

Principles of Management

Treatment with
Benzodiazepine

1

Symptom

control and
Supportive care 2

Ruling out
3 Alternative

Diagnosis

433

MANAGEMENT

● Assume causality to be multifactorial and rule out other probable

conditions

● History to be taken with accuracy

● Symptoms follow typical timeline of alcohol withdrawal or not

● Past h/o DT, seizures are highly predictive of future episodes

● H/o jaundice, ascites, hematemesis, melena (h/o features of Portal

HTN)

● H/o fever, falls, h/o suggestive of raised ICT (headache, blurring of

vision, projectile vomiting), h/o multiple episodes of vomiting, h/o
cough

● H/o any other substance abuse viz h/o nicotine dependence (any h/o

s/o COPD – might lim0it our benzodiazepine dose), h/o

benzodiazepine dependence (worsen withdrawal symptoms) 434

MANAGEMENT

● Physical examination

● Vital signs – PR, BP, RR, Temperature

● General Examination – Jaundice, Pallor, Pedal oedema, Any

other stigmata of CLD, Any abrasions or bruises s/o fall, any
hyperpigmented scaly lesions on sun exposed ares and nape of
neck (for pellagra)

● Chest – Breath sounds, lung fields are clear, heart sounds

● Abdomen – Inspection (any ascites), on palpation presence of

any hepatosplenomegaly

● CNS – Pupils, DTR’s, Plantar reflex, Fundus (if possible), any

signs of meningeal irritation; For Wernicke Encephalopathy
(nystagmus, ataxia)

435

MANAGEMENT

● Investigations – GRBS, Complete Blood Count, LFT, RFT, SE
● PT INR (if there is jaundice)
● Chest X-Ray (If required)
● CT Brain (Plain and Contrast) – If there is any atypical presentation
● Repeat blood investigation as and when necessary

436

MANAGEMENT

● Keep patient NPO if in delirium
● Inj Thiamine 500mg in 100mL NS IV tid
● Inj Lorazepam / Inj Diazepam hourly in symptom triggered regimen

until PR < 100/mt, patient is drowsy

● PR, BP, sPO2, Chest, Level of arousal to be monitored hourly
● Give adequate fluids (dehydration can lead onto prolongation of

delirium)

● Inj. Pantoprazole, Antiemetic (Inj. Metoclopramide, Ondansetron)
● After resolution of delirium, dose of benzodiazepine required in first

24 hours may be converted to fixed dose regimen

437

MANAGEMENT

● For seizures where aetiology is alcohol withdrawal alone only

benzodiazepines are required

● Where independent seizures co-occur we may need to load an AED

parenterally and continue the same in long run

● Other management strategies are similar to that of delirium

438

Mahadeven and Chand, Primer for Treatment Alcohol and Tobacco Disorders 2016 439

Mahadeven and Chand, Primer for Treatment Alcohol and Tobacco Disorders 2016 440

THANK YOU

441

Alcohol induced Liver Disease
(ALD)

Dr. Sagar Garag MD Psychiatry 2nd yr

Karnataka Institute of Medical Sciences, Hubballi and Alumni of Foundation of
Addiction 2018, Project VKN ECHO, NIMHANS Digital Academy

Moderator Expert: Dr Lekhansh Shukla MD,

Asst Professor, Centre for Addiction Medicine, Dept of Psychiatry NIMHANS

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Educational Objective

• Spectrum of ALD
• Risk factors
• Types

- Fatty liver
- Hepatitis
- Cirrhosis
• Investigation
• Intervention

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Introduction

• Alcohol is the world's third largest risk factor
for disease burden.

• Role of alcohol is directly and indirectly
attributed to about 3.5 million deaths
worldwide each year.

• Most of the mortality attributed to alcohol is
secondary to cirrhosis.

• Top Modifiable factor as a cause of Death

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Definition of ALD as per ICD-10-CM Diagnostic criteria

K70

• A disorder caused by damage to the liver
parenchyma due to alcohol consumption. It
may present with an acute onset or follow a
chronic course, leading to cirrhosis.

• Includes all liver diseases associated with
alcoholism. It usually refers to the coexistence
of two or more sub-entities, i.e., alcoholic
fatty liver; alcoholic hepatitis; and alcoholic
cirrhosis.

445

Spectrum of Alcohol Liver Disease

Fatty liver Compensate Decompensated Alcohol Death and Liver
and Fibrosis d Cirrhosis Cirrhosis Hepatitis Transplant

Bajaj JS. Alcohol, liver disease and the gut microbiota. Nature Reviews Gastroenterology &
Hepatology. 2019 Jan 14:1.

446

Spectrum of ALD & Complications

447

Epidemiology

• 1 in 5 develops alcoholic hepatitis
• 1 in 4 develops cirrhosis.
• Chronic and excessive alcohol ingestion is a

major cause of liver disease and is responsible
for nearly 50% of the mortality from all
cirrhosis.

448

Risk Factors

• Risk factors

– Genetic Factors (eg, predilection to alcohol abuse,
gender)

– Environmental (eg, availability of alcohol, social
acceptability of alcohol use

– Concomitant hepatotoxic insults (eg, infections)

• More common 40 to 50 years old, obese patients,
and in women.

• Dose-dependent relation

449

Zoom Poll (anonymous)

If 100 people consuming alcohol regularly and
heavily, how many likely develop Cirrhosis
(around)
1. 80-100%
2. 70-80%
3. 30-60%
4. 10-20%

450