TreaT
Alcohol Use Disorder
Medications for Alcohol Cravings
Naltrexone 50mg PO qDay #30 tabs, no refills
OR
Naltrexone 380mg IM
(monthly injection)
Contraindicated if active opioid use, planned surgery, acute liver injury (AST or ALT >250), significant cirrhosis, or pregnancy.
Naltrexone is NOT an opioid. Naltrexone is an opioid-receptor antagonist!
Refer
To
treaTment
Perform motivational interviewing with the patient. Listen for something the patient says that is positive toward change and repeat it back.
Consult social worker for assistance. Some patients may benefit from and desire to go to more intensive treatment such as Tarzana Treatment Center. After hours, still send a Consult. CSW will follow up next day.
Any patient started on medication for addiction treatment (e.g. Naltrexone) should be referred back to their PCP.
Any DHS patient without a PCP should be NERF'd and referred to the Bridge program.
Benzo's vs Phenobarb
Treat
Alcohol WithDrawal
Alcohol Withdrawal Severity
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Severity of alcohol withdrawal can be measured using the CIWA-Ar criteria
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Any patient experiencing alcohol withdrawal should be considered to have an alcohol use disorder. Discussion with the patient about their motivation for treatment should occur.
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Consult Social Work for any patient with alcohol withdrawal.
CIWA-Ar
Mild Withdrawal
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Patients experiencing mild withdrawal symptoms (CIWA < 8), with no history of withdrawal seizures, hallucinations, or delirium tremens may be treated in the ED with oral medications.
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Options include Chlordiazepoxide (Librium) 50-100 mg PO with discharge prescription for chlordiazepoxide.
Moderate to Severe Withdrawal
Phenorbarbital
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As a monotherapy 130mg IV over 3mins for mild withdrawal or 260 mg iV over 5mins for moderate-severe withdrawal.
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Titrate additional dosages as needed: 130mg q 15mins or 260 mg q 30min IV up to max 1040mg IV in 24 hours.
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For severe withdrawal, consider 5mg/kg (rate 60mg/min)
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Hold for SBP <110, RR <8, excessive sedation.
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The decision to admit or discharge any patient with alcohol withdrawal is based on a variety of factors. All patients receiving phenobarbital, especially those receiving more than 10mg/kg, should be re-evaluated by the provider prior to any disposition decision.
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Current inpatient CIWA protocols for alcohol withdrawal using benzodiazepines are acceptable to use after ED treatment initiation with phenobarbital.
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Contraindications:
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Allergy to Phenobarbital
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OR
Lorazepam
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Patients should receive 2-4 mg IV lorazepam over 1-2 minutes.
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Onset of action 5-20 mins IV.
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Patients should be reassessed every 15-20 mins and the previous dose should be doubled if control is not achieved (4 mg IV then 8 mg IV then 16 mg IV).
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If patients improve, but do not have resolution of the symptoms, the same dose can be administered, whereas if very little improvement is noted, the dose should be doubled.
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Patients who receive more than 30mg of lorazepam (2 mg IV then 4 mg IV then 8 mg IV then 16 mg iV) without significant improvement of symptoms should be switched to phenobarbital. Such patients should be considered to be exhibiting severe withdrawal.
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For severe withdrawal, titrating benzo’s to achieve a state of somnolence with arousal to minimal stimulation is a reasonable goal.
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Contraindications
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Allergy to Lorazepam
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OR
Diazepam
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Patients should receive 10 mg IV diazepam over 1-2 minutes.
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Onset of action 1-5 mins IV.
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Patients should be reassessed every 5-10 minutes, and the previous dose doubled if control is not achieved (10 mg IV then 20 mg IV then 40 mg IV).
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If patients improve, but do not have resolution of the symptoms, the same dose can be administered, whereas if very little improvement is noted, the dose should be doubled.
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Patients who receive more than 150 mg of diazepam (10 mg IV then 20 mg IV then 40 mg IV then and then 80 mg iV) without significant improvement of symptoms should be switched to phenobarbital (see below). Such patients should be considered to be exhibiting severe withdrawal.
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Contraindications:
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Allergy to Diazepam
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AND
Discharge Medication for Post-Acute Withdrawal Management
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Patients who stop drinking often feel post-acute withdrawal symptoms for weeks to months - insomnia, restlessness, irritability. If not treated, these symptoms and the continued cravings, often cause many patients to start drinking again.
Chlordiazepoxide (LIbrium) taper prescription (benzodiazepine)
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Traditionally prescribed upon discharge. Long-acting benzo with more addiction potential, more dangerous when combined with alcohol, and more likely diverted.
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Librium taper prescription can be found in Cerner prescriptions
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Day 1: 50mg q6
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Day 2: 25mg q6h
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Day 3: 25mg q12h
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Day 4: 25mg at night then off
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Rx: 15 (fifteen ) 25mg tabs
OR
Gabapentin prescription
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RECOMMENDED BY DHS SUBSTANCE USE DISORDER WORKGROUP: Less sedating and less abuse potential than Librium. May offer additional decrease in cravings. May offer less relapse compared to Librium discharge prescription. Typically prescribed for months or longer as the brain heals. PCP can continue the prescription. Safe even if patient stops cold turkey.
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NOTE: GABAPENTIN SHOULD NEVER BE USED AS A SOLE AGENT FOR ACUTE WITHDRAWAL in the ED; Patient must receive benzo or phenobarbital in the ED.
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Gabapentin 600mg PO TID # 90 tabs
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Inform patient that dizziness may occur; if so, decrease dose to 300mg PO TID for a few days then increase back up to 600mg.
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Contraindications
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Cleared renally, dose adjusted if CrCl <60. Shared decision making with the patient.
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CrCl 30-59 mL/min, gabapentin max 600 mg BID
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CrCl 15-29 mL/min, gabapentin 600 mg once a day
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CrCl <15 mL/min, gabapentin 300 mg once a day
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CrCl <7.5 max 100 mg once a day
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Allergy to Gabapentin
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Pregnant Patients – the literature is in support of the use of gabapentin in pregnant patients for alcohol use disorder. The risk of fetal alcohol syndrome is high in pregnant women with alcohol use disorder. ANY PREGNANT PATIENT WITH AUD is considered a HIGH RISK PATIENT, CONTACT OBGYN during the ED visit to help coordinate follow-up.
TreaT
Alcohol Use Disorder
INITIATING MEDS FOR ADDICTION TREATMENT (MAT)
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For patients who are motivated to get treatment for their disease, initiating treatment in the ED with medications that have been shown to be effective is appropriate.
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Social Work can help gauge severity of disease and determine if outpatient medication treatment will suffice or if more intensive care such as residential treatment would be better.
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Although some patients may benefit from more intensive care, they may not be ready. Important that we "meet the patient where they are at". They may just want to start with medications.
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Harm Reduction supports the use of less drugs, less alcohol. Patients may not completely abstain from alcohol. That's OK! Patients who experience a significant decrease in cravings and overall drinking should be considered a success.
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For patients NOT interested in treatment, patient handout Alcohol Use Information can offer tips on ways for patients to drink less.
REFER BACK TO PCP
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Refer any patient started on MAT back to their PCP.
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Patients without a PCP may be NERF'd and referred to the Bridge Program.
Message pool V. Figueroa for any patient started on Naltrexone.
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Patients may not completely abstain from alcohol. That's OK! Patients who experience a significant decrease in cravings and overall drinking should be considered a success.
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PCPs or rehab services will re-evaluate the effectiveness of the treatment in deciding whether or not to continue the treatment. Patients who have seen a decrease in cravings with resultant decrease in alcohol use can be continued on these medications.
WHAT IS NALTREXONE?
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Naltrexone is an opioid receptor antagonist. Alcohol induces an endogenous opioid surge, resulting in a dopamine surge, both resulting in alcohol's pleasurable effects on the brain. Naltrexone blocks this pathway resulting in less cravings for alcohol.
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Naltrexone is not an opioid. Does not require an x-waiver.
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Naltrexone is safe! Will not make the patient "sick" if the patient continues to drink.
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OVMC participates in the manufacturer's (Alkermes) programs for free dosages for our patients.
Naltrexone 50mg PO q day #30 tabs, no refills OR Naltrexone 380mg IM
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Contraindications to Naltrexone
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ANY CHRONIC OPIOID USE!! (pills, heroin, methadone or buprenorphine) for chronic pain or opioid use disorder. Patients should be off short acting opioids for up to a week, and off methadone for up to two weeks to avoid precipitating withdrawal. (Opioids only given in the ED such as morphine or Norco is not a contraindication to Nalrexone)
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Buprenorphine ED initiation
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Planned surgery/anesthesia in the next 30 days (IM naltrexone contraindicated, can prescribe oral formula with instructions to stop the medication 1 day before the surgery)
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Acute liver injury with AST or ALT >250
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Decompensated cirrhosis (Childs Pugh Class 3)
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Pregnancy
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Allergy to naltrexone
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Side Effects from Naltrexone (1/2 tablet - 25mg - for first 3 days can decrease nausea)
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Headache
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Nausea
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Local site reaction to IM formulation
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Mild-moderate flu-like symptoms for one week usually seen with IM formulation (recommend OTC medications such as acetaminophen or ibuprofen as needed
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Note – if the patient’s ability to continue oral medication after discharge is questionable (e.g. residential treatment or correctional facility rules), then IM Naltrexone should be offered.
AND
Thiamine 100mg tabs, 1 tab daily, #14 PLUS
MVI with folate 1mg tabs, 1 tab daily, #14
Refer to Treatment
CONSULT TO SOCIAL WORK:
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Consult Social Worker for help with evaluation and referral to treatment.
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Social work will help determine what level of treatment the patient needs and desires.
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Important that we meet the patient where they are at.
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Most patients with a substance use disorder are ambivalent - want to change yet don't want to change.
ASAM Criteria for Substance Use Disorder Treatment
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1: Acute intoxication and/or withdrawal potential
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2: Medical conditions and complications
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3. Emotional, behavioral and cognitive conditions and complications
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4. Readiness to change
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5. Relapse, continued use or continued problem potential
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6. Recovery/living environment
