Korsakoff syndrome is a chronic amnestic syndrome which follows Wernicke encephalopathy in which the main feature is anterograde amnesia, with possible confabulation. If left untreated, thiamine deficiency can eventually lead to neuronal death, and lesions can be identified on radiographic imaging and autopsy. 28 Vitamin deficiencies must be considered during the evaluation and treatment of all patients with a history of chronic alcohol use. Antidipsotropic Medications for Treatment of Alcohol Use Disorder Acamprosate appears to be one of the most effective medications for maintaining abstinence in alcohol use disorder. Acamprosate is thought to target GABA and N-methyl-D-aspartate glutamatergic receptor activity, thereby decreasing cravings and relapse. The individual must be alcohol free at initiation, and use is contraindicated in severe renal disease. Side effects include diarrhea and nausea. Dosing is weight based, and titration is not required. 29 Disulfiram is a second-line treatment to treat individuals who are dependent on alcohol but are motivated to discontinue use. Alcohol consumption results in increased serum acetaldehyde causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia.
These symptoms are known as disulfiram-alcohol reaction and discourage alcohol intake. Side effects include headache, skin rash, drowsiness, and metallic aftertaste; adverse reactions include hepatitis and peripheral neuropathy. 30 Naltrexone is considered first-line therapy for individuals with moderate or severe AUD and is an option for treatment of both alcohol and opioid dependence by the action of blocking the mu- receptor. Additionally, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress alcohol consumption. 31 It is prescribed in both oral and long-acting injectable forms. The therapeutic action of opioid receptor antagonism is to blunt the rewarding effects of alcohol. Side effects include mild nausea and vomiting and dizziness. Studies have supported doses of 50 mg/day of naltrexone significantly decreased the likelihood of a return to heavy drinking and, in some cases, resulted in abstinence. 32 Off-label use of topiramate, gabapentin, and baclofen has also assisted in treatment of AUD. Cognitive behavioral therapy (CBT) approaches have among the highest level of empirical support for the treatment of alcohol use disorders and show a small but statistically significant treatment effect over controls. 33
BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1. Sedatives, Hypnotics, and Anxiolytics Sedative, hypnotic, or anxiolytic use disorder is a substance use disorder characterized by repeated use of substances including benzodiazepines, benzodiazepine-like drugs (e.g., zolpidem, zaleplon), carbamates (e.g., glutethimide, meprobamate), barbiturates (e.g., phenobarbital, secobarbital), and barbiturate- like hypnotics (e.g., glutethimide, methaqualone) despite significant problems associated with their use. This class also includes all prescription sleeping medications and most prescription antianxiety medications. Nonbenzodiazepine antianxiety agents (e.g., buspirone, gepirone) are not typically included in this class because they are not associated with significant misuse. Anxiolytics are a class of medications aimed at treating patients with anxiety and panic disorders, but they have various other uses. Sedatives (hypnotics) are a class of drugs used in different situations ranging from treating insomnia to sedation for painful procedures.
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1
Mrs. Smith accompanies her husband Mr. Smith to an office visit to discuss some symptoms that she has recently noticed. During the interview Mrs. Smith admits to at least 1-2 glasses of wine each night; she uses this to help her relax and occasionally uses additional glasses to help her get to sleep. Recently, she expressed a desire to cut down on this habit but has had difficulty doing so. This habit is creating tension in their relationship, and Mr. Smith describes a few instances where Mrs. Smith has appeared shaky after attempting to abstain from alcohol use. She has sustained some minor injuries in the past due to falls after drinking alcohol. They are both seeking guidance on how to proceed.
1. Does Mrs. Smith meet any criteria for substance use disorder?
2. What therapies would be appropriate for treatment?
Mrs. Smith is brought back to see the physician by her husband and is now very anxious and nauseated. Her blood pressure is 175/95, her pulse is 125, and her respiratory rate is 22. She is diaphoretic and tremulous. She states that she continues to abstain from alcohol but now has a headache. Mr. Smith states she is more tremulous than before and is worried about what to do.
3. Are there clinical tools to guide you on the severity of her condition?
4. You calculate a CIWA score and find that Mrs. Smith has a CIWA score of 12. Do you think that Mrs. Smith should be referred to the hospital?
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