Patients should be monitored for signs of metabolic acidosis or hyponatremia. 171 Phenobarbital can be used as an alternative to benzodiazepines, but is not preferred due to the need for close monitoring. Adjunctive antipsychotic agents can be used if delirium and hallucinations are not controlled by benzodiazepines; antipsychotics should not be used as monotherapy due to the risk of lowering the seizure threshold and increasing the risk of withdrawal seizures. Second generation antipsychotics such as risperidone or quetiapine are preferred because they have less of an effect on the seizure threshold when compared to first generation agents. Haloperidol has also been successfully used in the management of delirium. 171 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 7. Long-Term Management of Alcohol Use Disorder Treatment of alcohol use disorder should be a collaborative process between the patient and their provider. Including the patient’s family or support system can also be helpful if the patient gives permission to include them. Treatment goals should be established prior to initiating therapy and
can range from reducing alcohol use, to eliminating drinking in high-risk situations, to complete abstinence. Defining goals at the beginning of therapy is associated with improved treatment outcomes. 204 When possible, treatment for alcohol use disorder should be started concurrently with withdrawal treatment if cognitive status allows. 171 Patient preference plays a significant role in choosing therapy; some patients prefer non- pharmacological therapy, while others prefer the use of medications. Offering all available options to patients can help ensure treatment plans are developed based on patient preferences and potentially improve adherence. 204 Pharmacotherapy for patients with moderate to severe alcohol use disorder who have a goal of abstinence or reduced consumption of alcohol and want to initiate medication treatment should begin with naltrexone or acamprosate. These medications can also be considered in patients with mild alcohol use disorder if the patient prefers medication therapy. 204 Disulfiram can be offered to motivated patients with alcohol use disorder who have a clear goal of achieving abstinence. It is contraindicated in patients who are active alcohol users, so patients
must understand the risks of consuming alcohol while taking disulfiram. Topiramate or gabapentin can also be offered as second line agents in patients who wish to reduce or eliminate alcohol consumption, those who have not responded to naltrexone and acamprosate, or who prefer to use these agents. 204 Psychosocial interventions are recommended for all patients with alcohol use disorder. These can include alcohol counseling, motivational interviewing, couples or family therapy, social services, or participation in a mutual help group such as Alcoholics Anonymous. Psychosocial interventions can be effective to treat alcohol use disorder, but when used as monotherapy, as many as 70% of patients return to heavy drinking. Selection of psychosocial interventions should be made on a patient-specific basis. 212
Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow. Case Study 7
Bill is a 48 year old combat veteran who is admitted to the hospital after a fall. He is treated for a broken leg in the emergency room, but his wife notes that her husband is a heavy drinker and that his last drink was over 24 hours ago. She says that Bill has withdrawn from alcohol several times in the past and experienced seizures and delirium on several occasions. Bill is very agitated and anxious, has a terrible headache and a tremor, and is sweating and vomiting. He also appears to be hallucinating – he is experiencing auditory and visual disturbances. The nurse administers a CIWA-AR scale and he scores a 23. 1. Which of the following is NOT a risk factor for severe or complicated withdrawal that should be considered when developing a treatment plan for Bill?
A. Age of 48 years B. Long history of regular, heavy alcohol use C. Numerous prior episodes of withdrawal D. Prior history of alcohol withdrawal seizures or delirium
Answer: A. Age of 48 years is not a risk factor for severe or complicated withdrawal; age over 65 years is a risk factor. Other risk factors include: • Prior history of alcohol withdrawal seizures or delirium • Medical or surgical comorbidities, especially traumatic brain injury
• Numerous prior episodes of withdrawal • Long history of regular, heavy alcohol use
• Seizures or significant autonomic hyperactivity during the current withdrawal episode • Dependence on medications that enhance GABA such as benzodiazepines or barbiturates • Use of other addictive substances in conjunction with alcohol • Signs and symptoms of withdrawal in conjunction with a positive blood alcohol concentration • Moderate to severe co-occurring psychiatric disorder
2. Bill begins to experience delirium symptoms while he is withdrawing from alcohol in the hospital and is admitted to the ICU. Which of the following is recommended as first-line therapy for the treatment of alcohol withdrawal delirium?
A. Carbamazepine B. Phenobarbital C. Benzodiazepines D. Valproic acid
Answer: C. Benzodiazepines are recommended as first-line treatment for alcohol withdrawal delirium. Administration of intravenous benzodiazepines to achieve light sedation where the patient is awake but tends to fall asleep unless stimulated is recommended to help control agitation and maintain patient safety.
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