Alcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice

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1 Dr IM Joubert

2 Alcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice for any reason had either an at-risk pattern of alcohol use or an alcohol related health problem

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4 It is important to note that alcohol contributes and leads to a wide range of medical problems and is also a significant contributor to trauma Alcohol use history is important in all patients In trauma patients exclude head injury before ascribing unusual behaviour to alcohol withdrawal but conversely keep alcohol withdrawal in mind for all patients with an altered mental status of unknown aetiology

5 High likelihood in following patients: Alcohol-related reason for admission Regular use >80g/day in males, >60g/day in females >30 years of alcohol use <10 days since last drink History of alcohol dependence/previous withdrawal

6 Range from mild withdrawal to severe withdrawal and delirium tremens Start within 6 to 24 hours of last drink, peak over hours Subside over a few days but mood and sleep disturbance may persist for weeks Seizures can occur early in course usually of short duration and self-limiting but may progress to status epilepticus

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8 History of previous severe withdrawal Use of >150mg alcohol per day Presence of other illness/injury History of head injury Use of other psychotropic drugs Patients at risk for severe withdrawal should be closely monitored and receive early and aggressive treatment ideally in high care setting

9 Agitation Restlessness Gross tremor Disorientation and mental confusion Fluctuating level of consciousness Fluid and electrolyte imbalances Sweating and pyrexia Visual hallucinations Paranoia

10 Identify and treat underlying medical conditions Control behaviour Prevent injuries High dose benzodiazepines (not > 100mg/hour or 250mg in 8 hours)

11 Result of thiamine deficiency Life threatening condition Global confusional state Ocular disturbances: horizontal nystagmus, opthalmoplegia, CN VI palsy with diplopia Ataxia Treatment: Thiamine 300mg IVI for 3-5 days, then mg po dly All withdrawal patients should receive Thiamine 300mg IVI stat on presentation

12 Benzodiazepines Treatment of choice Reduce withdrawal severity and incidence of seizures and delirium Good safety profile Usually long-acting but can give short-acting in cases of liver disease Given for short period of time due to potential for abuse Dosing: Fixed dose, loading dose followed by fixed dose or symptom triggered therapy

13 Symptom-triggered therapy requires close monitoring, not ideal except in dedicated detoxification centre Fixed dose in mild withdrawal Day mg qid Day mg qid Day mg tds Day 4 10mg bd Day 5 5mg bd

14 Loading dose therapy is indicated in cases of a high level of dependency or a patient at high risk for severe withdrawal Loading dose of 10-20mg diazepam every 2-4 hours until light sedation achieved, then then 10mg 4-6hourly, wean slowly over next 5 days

15 Anticonvulsants: Phenytoin has no benefit Valproate and Carbamazepine increase seizure threshold Thiamine: 300mg IVI stat, then 100mg dly for 7 days Antipsychotics/sedatives: Phenothiazines/Haloperidol decrease symptoms but less effective than benzos adjunct in severe withdrawal with perceptual disturbances, can decrease seizure threshold

16 ß-blockers and clonidine reduce autonomic manifestations, ß-blockers may mask symptoms of early withdrawal or impending delirium Symptomatic treatment Metoclopramide for nausea and vomiting Buscopan for abdominal cramps Immodium for diarrhoea Paracetamol for headaches and muscle pain if no liver damage

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18 Nicotine and other tobacco components may interact with and affect action and metabolism of certain medication e.g. clozapine and olanzepine upon cessation of smoking patients may develop drug side-effects - consider revising dosages After smoking cessation caffeine is absorbed more readily increased caffeine levels increase restlessness and sleep disturbance

19 Start hours after last cigarette, peak in hours, decline and resolve within 2 4 weeks Dysphoric or depressed mood Insomnia Irritability, frustration or anger Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

20 Nicotine replacement therapy Available as patches, gum, inhalers and lozenges, gel Dosage depends on amount of cigarettes smoked before stopping Combinations may be used in patients with high nicotine tolerance

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22 Schuckit MA. Alcohol and Alcoholism in Kasper BL, Braunwald E et al (eds), Harrison s Principles of Internal Medicine, 16 th ed, McGraw Hill, New York, 2006, p Burns DM. Nicotine Addiction in Kasper BL, Braunwald E et al (eds), Harrison s Principles of Internal Medicine, 16 th ed, McGraw Hill, New York, 2006, p Kosten TR, O Connor PG. Management of drug and alcohol withdrawal. N Eng J Med 2003;348(18): Eyer F et al. Alcohol Alcohol 2011;46(4): McKeown N. Withdrawal Syndromes. Available from URL: overview#showall NorthWestern Mental Health. Alcohol and Other Drug Withdrawal Practice Guidelines. Australian Alcohol and Drug Abuse Management Guidelines

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