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WHAT’S INSIDE
ALL COURSES SATISFY GENERAL HOURS REQUIREMENT Addiction Medicine Part 2: Alcohol 1 [2 contact hours] Alcohol use disorder is a serious national health problem in the United States. It is estimated that more than 14 million American adults had an alcohol use disorder in 2019, as well as 414,000 adolescents aged 12 to 17. There is a clear need for improvement in the treatment of alcohol use disorder; this course serves to review the recognition, diagnosis, and treatment of alcohol use disorder and alco- hol withdrawal. Educating Patients: Creating Teaching Moments in Practice 11 [4 contact hours] Effective education is essential to help patients and family gain knowledge. All healthcare professionals (HCPs) can identify teaching opportunities to assess and provide effective education. The purpose of this course is to provide HCPs with current evidence-based information to help them learn and apply skills and practice for effective patient and family teaching in a variety of settings. Heart Failure: Evidence Review and Management 29 [2 contact hours] Heart failure is a complex clinical syndrome associated with increasing morbidity, mortality, and economic burden. Despite evidence supporting guideline-directed therapy and management for reduction of morbidity and mortality, these medications are still underprescribed. According to the CHAMP-HF registry, among eligible patients, only 22% were prescribed essential heart failure medications per guideline recommendations ((Greene et al., 2018). Healthcare providers have an essential role in improving outcomes with heart failure by bridging the gap between guideline-directed recommendations and actual clinical practice. The learning outcomes of this activity will help clinicians understand this healthcare gap by reviewing the current evidence-based pharmacotherapy recommendations for HF treatment through analyzing clinical trials and guidelines. Mental Health Concerns for the Older Adult 40 [6 contact hours] The healthcare worker meeting mental health needs will be able to view the older adult within the context of aging theo- ries and identify interpersonal connection, biopsychosocial elements, and the assessment and treatment for common mental health problems in the older adult. The target audience is any healthcare worker who will assess, intervene, or treat mental health needs of an older adult cli- ent. Registered nurses, mental health technicians, mental health providers, case managers, and primary care healthcare workers can benefit from the perspective provided by this course. Monitoring Techniques for Optimal Diabetes Management and Control 67 [2 contact hours] The purpose of this course is to assist in the successful management of diabetes, including blood glucose monitoring (BGM) and the ability of persons with diabetes to monitor the effectiveness of their diabetes treatment plan to understand better the interre- lationships of food, activity, and medication-taking. In addition, BGM data can alert the person to hypoglycemia and hyperglycemia, inspiring lifestyle modifications that may help people with diabetes achieve their A1C goals. Diabetes technology has resulted in many improvements in blood glucose meters. Continuing advances in BGM have led to the development of continuous glucose monitoring (CGM) systems that enable people with diabetes to optimize glycemic stability and improve the quality of their lives. This course reviews the features and function- ality of BGM with glucometers and CGMs in line with the 2022 American Diabetes Association (ADA) evidence-based guidelines integrated into clinical practice. Pharmacological Management: Type 2 Diabetes in Children, 2nd Edition 80 [3 contact hours] This course will outline the risk factors, pathophysiology, and diagnostic criteria of type 2 diabetes. Goals of management, treatment options, and psychosocial barriers will also be addressed to guide successful multidisciplinary care of these patients. Prescribing Controlled Substances Safely: A DEA Requirement 94 [8 contact hours] Nurse Practitioners (NPs), Physician Assistants (PAs), Pharmacists, and Dentists care for patients with disorders in many healthcare settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must understand federal and state requirements for all controlled sub- stances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/vaping. However, the focus is on clinical safety considerations when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. Shingles Disease Process and Vaccination for Pharmacists 132 [1 contact hour ] Shingles causes a characteristic rash typically localized in one area of the body. Serious complications, which often depend on the rash location, can arise, such as pain that persists after the rash has cleared and even vision or hearing loss. Treatment typically focuses on antiviral therapy and symptom control. Shingles can be prevented through vaccination, which is recommended for adults over 50 since the immune system weakens with age. This course serves to review the disease process of shingles and the use of vaccinations to prevent shingles. The Complications of Chronic Kidney Disease, Second Edition 138 [2 contact hours] This course serves as a review of chronic kidney disease (CKD) and the medications used to prevent adverse effects of CKD and slow disease progression.
i ©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
PHARMACY CONTINUING EDUCATION
Book code: RPUS3024
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal? Licenses Expire
Mandatory Subjects and Hours
Varies depending on state
See state requirement chart on the following pages.
How much will it cost? If you are only completing individual courses in this book, enter the code that corresponds to the course below online.
COURSE TITLE
HOURS
PRICE
COURSE CODE
Addiction Medicine Part 2: Alcohol
2
$14.95
RPUS02AA
Educating Patients: Creating Teaching Moments in Practice
4
$24.95
RPUS04TP
Heart Failure: Evidence Review and Management
2
$14.95
RPUS02HM
6
$34.95
RPUS06MH
Mental Health Concerns for the Older Adult
Monitoring Techniques for Optimal Diabetes Management and Control
2
$14.95
RPUS02DC
Pharmacological Management: Type 2 Diabetes in Children, 2nd Edition
3
$19.95
RPUS03TT
Prescribing Controlled Substances Safely: A DEA Requirement
8
$79.95
RPUS08DR
Shingles Disease Process and Vaccination for Pharmacists
1
$9.95
RPUS01SH
The Complications of Chronic Kidney Disease, Second Edition
2
$14.95
RPUS02CK
Best Value - Save $94.55 - All 30 Hours
30
$135.00
RPUS3024
How do I complete this course and receive my certificate of completion? See the inside back cover for step by step instructions to complete and receive your certificate. Are you approved by ACPE? Colibri Healthcare, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. (Provider #0607) Are my contact hours reported to my state board? Yes, we report your hours electronically to CPE Monitor as early as within 10 business days after course completion and no later than 60 days after the event. CPE Monitor is a national online continuing pharmacy education (CPE) tracking service that will authenticate and store data for completed CPE units and allow you to easily track your ACPE-accredited CPE units electronically. It is a collaborative effort between the National Association of Boards of Pharmacy® (NABP®), the Accredited Council for Pharmacy Education (ACPE), and accredited continuing pharmacy education (CPE) providers. Keep your certificate in a safe place for your records. Please provide your license #, date of birth, and NABP ID. This is necessary to report your completion. Missing information can delay reporting and result in additional fees after 60-days of completion. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Pharmacy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 1-888-666-9053, Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.
Browse our entire library to select your own courses, go to EliteLearning.com/Pharmacy. You may also read and complete the courses in this book online.
ii
Book code: RPUS3024
PHARMACY CONTINUING EDUCATION
STATE BY STATE REQUIREMENT GUIDE
STATE
HOURS ALLOWED BY HOME-STUDY
TOTAL HOURS REQUIRED (NOTE: CE Rules can change. Always check your state board for the most up-to-date informa- tion.)
24 30 30 18 30 24 10 30 30
Alabama Alaska Arizona Arkansas California Colorado
30 6 hrs must be live each year.
30 All hours allowed by correspondence.
30 3 hours opioid-related; All hours allowed by correspondence. 30 12 hrs live drug therapy/patient care; 12 hrs ACPE approved. 30 1 hour cultural competency; All hours allowed by correspondence.
24 All hours allowed by correspondence.
Connecticut
15 1 hr of Pharmacy/Drug Law; not less than 5 hrs live presentation. 30 2 hours Medication Safety/Errors; 2 hours Controlled Substances. 40 2 hours HIV, 2 hours Medication/Dispensing Errors, 2 hours on cultural competency focused on patients or clients who identify as LGBTQ, 4 hours in designated public health priority topics. 30 2 hrs Prevention of Medical Errors; 2 hrs Validation of Prescriptions for Con- trolled Substances, 1 hr HIV first time renewal only.
Delaware District of Columbia
20
Florida
30 30 15 30 30 30 30 15
Georgia Hawaii
30 All hours allowed by correspondence. 30 All hours allowed by correspondence. 15 All hours allowed by correspondence.
Idaho Illinois
30 1 hour sexual harassment prevention, 1 hour implicit bias awareness, All hours allowed by correspondence.
Indiana
30 All hours allowed by correspondence.
Iowa
30 15 hrs ACPE-approved activities in Drug Therapy; 2 hrs Pharmacy Law; 2 hrs Dealing with Patient/Medication Safety can be ACPE approved or not. 30 1 hour Board-provided training, All hours allowed by correspondence. 15 1 hour opioid epidemic or opioid use disorder, All hours allowed by correspondence. 15 Either 15 hours each year, 3 hours must be live OR 20 hours each year if no live hours taken. All other hours may be completed by correspondence.
Kansas
Kentucky
12
Louisiana
15 28 30 20 30 13 30 10 30 29 10 20
Maine
15 2 hrs ACPE/board-approved Drug Administration. 30 1 hr Preventing Medication Errors; 2 hrs live. 40 4 hrs Pharmacy Law per biennium; 15 hours live each year.
Maryland
Massachusetts
Michigan
30 1 hour Pain Management, 1 hour Pharmacy Ethics and Law, 1 hour Implicit Bias training each year (in addition to required 30 hours), 10 hours must be live.
Minnesota Mississippi Missouri Montana Nebraska
30 All hours allowed by correspondence.
15 2 hours opioid abuse and prevention, 2 hours must be obtained by live seminar or webcast.
30 All hours allowed by correspondence. 15 5 hrs in approved group setting. 30 All hours allowed by correspondence.
Nevada
30 1 hour Law through a Board-provided program or by attending a full day of a board meeting, All other hours allowed by correspondence.
New Hampshire
30 10 hours must be earned in a live setting.
New Jersey
30 3 hours in pharmacy law, 1 hour in opioid drug topics, 10 hours must be earned in a live setting.
NOTE: CE Rules can change. Always check your state board for the most up-to-date information.
iii
Book code: RPUS3021C
PHARMACY CONTINUING EDUCATION
STATE
HOURS ALLOWED BY HOME-STUDY
TOTAL HOURS REQUIRED (NOTE: CE Rules can change. Always check your state board for the most up-to-date informa- tion.) 30 10 hrs live; 2 hrs Pharmacy Law; 2 hrs Patient Safety. 2 hrs Safe Use of Opioids. 45 3 hour Reducing Medication & Prescription Errors, 3 hours Pharmaceutical Com- pounding, 23 hours must be learned in a live setting.
20 23 10 15 30 15 30
New Mexico
New York
North Carolina North Dakota
15 5 hrs must be contact activity.
15 All hours allowed by correspondence.
Ohio
30 2 hours Medication Errors/Patient Safety, 2 hours Jurisprudence or Law, All hours allowed by correspondence.
Oklahoma
15 All hours allowed by correspondence.
Oregon
30 2 hours Pharmacy Law, 2 hours Patient Safety/Medication Error Prevention, 2 hours Cultural Competency, 1 hour Pain Management (through Oregon Health Authority), All hours allowed by correspondence. 30 2 hours Patient Safety, 2 hours Pain Management, 2 hours Immunizations for licensees with authorization, 2 hours Child Abuse for licensees who are mandated reporters, All hours allowed by correspondence.
30
Pennsylvania
10
Rhode Island South Carolina
15 1 hour Law, 5 hours must be live
9
15 1 hour Approved Procedures for Monitoring Controlled Substances, 7.5 hours must be on drug therapy or patient management, 6 hours must be live.
12 15 30
South Dakota
12 All hours allowed by correspondence. 30 15 hrs ACPE-approved live courses.
Tennessee
Texas
30 1 hour Texas Pharmacy Laws/Rules, 1 TX HHSC-approved course on Human trafficking, All hours allowed by correspondence. 30 12 hrs live, 15 hrs must be in Drug Therapy or Patient Management, 1 hr Phar- macy Law or Ethics. 30 20 hours allowed by correspondence. Professionals who prescribe or dispense controlled substances must complete 2 hrs regarding controlled substances. 15 2 hours Medications for Opioid Use Disorder (for 2023 renewals), 3 hours must be live. 15 All hours allowed by correspondence. 3 hr Suicide Prevention and Awareness Training (one time requirement at first renewal).
18
Utah
20
Vermont
12
Virginia
15
Washington
24 30 12
West Virginia
30 2 hours Drug Diversion Training, 6 hours must be live.
Wisconsin Wyoming
30 All hours allowed by correspondence.
12 1.5 hours Responsible prescribing of controlled substances, All hours allowed by correspondence.
NOTE: CE Rules can change. Always check your state board for the most up-to-date information.
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Book code: RPUS3021C
PHARMACY CONTINUING EDUCATION
Chapter 1: Addiction Medicine Part 2: Alcohol 2 Contact Hours
By: Katie Blair, PharmD, RPh Author Disclosure : Katie Blair and Colibri Healthcare, LLC do not have any actual or potential conflicts of interest in relation to this lesson. Universal Activity Number (UAN) : 0607-0000-22-039-H01-P Activity Type : Knowledge-based Initial Release Date : October 21, 2022 Expiration Date : October 21, 2025 Target Audience: Pharmacists in a community-based setting. To Obtain Credit: A minimum test score of 75 percent is needed to obtain a credit. Please submit your answers either by mail, fax, or online at EliteLearning.com/Book Questions regarding statements of credit and other customer ser- vice issues should be directed to 1-888-666-9053. This lesson is $14.95. Learning objectives After reading this monograph, pharmacists should be able to: Summarize the complications associated with alcohol use, including inebriation, withdrawal, and long term complications. Introduction Alcohol is one of the most widely used intoxicants in the world. In 2020, the National Survey on Drug Use and Health found that 50 percent of adults had used alcohol in the past month, and 22.2 percent reported drinking five or more drinks on one oc - casion in the past month (Substance Abuse and Mental Health Services Administration, 2021). The use of alcohol occurs on a spectrum, ranging from occasional drinking to regular, heavy use. Alcohol use disorder (AUD) is a medical condition characterized by an inability to control alcohol use despite adverse consequenc- es (National Institute on Alcohol Abuse and Alcoholism, 2021). Alcohol use disorder is a serious national health problem in the U.S. It is estimated that more than 14 million American adults and 414,000 adolescents (ages 12 to 17 years) had an AUD in 2019 (National Institute on Alcohol Abuse and Alcoholism, 2021). There are over 95,000 deaths every year that are directly attributed to
Colibri Healthcare, LLC is accredited by the Accredi- tation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. Partici- pants of the session who complete the evaluation and provide accurate NABP e-Profile information will have their credit for 2 contact hours (0.2 CEU) submit-
ted to CPE Monitor as early as within 10 business days after course completion and no later than 60 days after the event. Please know that if accurate e-Profile information is not provided within 60 days of the event, credit cannot be claimed after that time. The participant is accountable for verifying the accurate posting of CE credit to their CPE Monitor account within 60 days.
Describe current best practices for the treatment of alcohol withdrawal. Explain the screening, diagnosis and treatment of alcohol use disorder, including pharmacological and non- pharmacological treatment options. alcohol use, and the economic cost of alcohol use is astounding: Excessive alcohol use in the U.S. is said to cost nearly $250 billion annually. The majority of these costs (77 percent) are associated with binge drinking, that is drinking four or more alcoholic bev- erages per occasion for women, or five or more drinks for men (Centers for Disease Control and Prevention, 2019). In the U.S., AUD has a lifetime prevalence of approximately 29 percent. Despite the high prevalence and common complica- tions, alcohol use disorder is undertreated. Less than 10 percent of patients with a diagnosis in the past 12 months receive any treatment, and only around 6 percent of patients receive evi- dence-based care (Reus et al., 2018). There is a clear need for improvement in the treatment of this common condition, and this course serves to review the recognition, diagnosis, and treatment of alcohol use disorder.
SHORT- AND LONG-TERM EFFECTS OF ALCOHOL
Inebriation Alcohol is a central nervous system (CNS) depressant, causing decreased reaction time, motor coordination, and mental perfor- mance. After ingestion, it is swiftly absorbed into the bloodstream through the stomach and small intestine. From there, it is slowly metabolized by the liver. A healthy liver typically metabolizes one standard drink per hour, which is equivalent to 12 oz of 4 percent beer, 1.5 oz of 80-proof liquor, or 5 oz of table wine. The remain- ing alcohol continues to flow through the bloodstream until the liver is able to process it (UC Santa Cruz, 2019). The amount of alcohol present in the bloodstream determines the intensity of its effect on the body. Blood alcohol concentra- tion, or the percent of alcohol in the bloodstream, increases as more drinks are consumed. Blood alcohol levels of 0.08 percent or higher are associated with mild balance, speech, and vision im- pairment. This concentration marks the legal threshold of driving under the influence in most states. Between 0.1 and 0.15 percent, motor coordination and balance are significantly affected, speech may be slurred, and major loss of balance can occur. Concentra-
tions of 0.16 to 0.3 percent indicate severe intoxication, causing symptoms such as confusion, nausea, vomiting, and needing assis- tance walking. Blood alcohol concentrations of 0.35 to 0.4 percent are associated with a loss of consciousness, and over 0.4 percent can cause a coma and increase the likelihood of death by respira- tory failure (Stanford University, 2021; UC Santa Cruz, 2019). A number of factors can impact a person’s response to alcohol consumption. The presence of food in the stomach can slow the absorption of alcohol; blood alcohol concentrations can be up to three times higher in a person with an empty stomach when compared to someone who ate a meal before drinking. In addi- tion, up to 50 percent of people of Asian descent are less able to metabolize alcohol because of an inactive liver enzyme (alcohol dehydrogenase) needed for metabolism, resulting in more rap- id intoxication, flushing, dizziness, nausea, headache, and rapid heartbeat with alcohol use. Gender can also significantly impact the effects of alcohol.
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Book Code: RPUS3024
Page 1
Women have less body water than men to dilute alcohol as well as lower quantities of the liver enzymes needed to metabolize alco- Case study 1 Jane is a 21-year-old Japanese exchange student at the local university. She is brought to the emergency department by her roommate after an evening gathering of friends at their home. Her roommate states that Jane has been in and out of conscious- ness, and she presents with confusion, slurred speech, poor bal- ance, and memory loss. Her blood alcohol level is tested and found to be 0.14 percent. Jane’s roommate is confused because she thought Jane had fewer than two drinks that evening. The friends had a large meal together before they started drinking, and they were playing board games when Jane started to appear very intoxicated. Jane’s roommate hasn’t known Jane long, since they just moved in together the previous month, and she says she had never seen Jane drink prior to this evening. Jane’s roommate is concerned Withdrawal Approximately 8 to 12 hours after consuming alcohol, the body’s reaction to poisoning and withdrawal from alcohol, known as a hangover, begins. This reaction varies in severity based on the amount of alcohol consumed as well as individual factors and can include headache, nausea, vomiting, fatigue, and depression. While there are a number of home remedies thought to help pre- vent or relieve hangovers, limiting the consumption of alcohol is the only effective remedy. Eating a full meal before drinking alco- hol and alternating alcoholic drinks with nonalcoholic drinks can limit absorption (UC Santa Cruz, 2019). Heavy drinkers who suddenly decrease or stop consuming alco- hol may experience alcohol withdrawal. Alcohol withdrawal symp- toms typically peak within 24 to 72 hours of the last drink and can continue for weeks. Common symptoms include irritability, anxi- ety, depression, mood swings, nightmares, fatigue, and confu- sion. Other symptoms such as rapid heart rate, sweating, tremor, insomnia, loss of appetite, nausea and vomiting can occur. Severe withdrawal can cause agitation, seizures, hallucinations, and se- vere confusion (Dugdale, 2021). Complications The unhealthy use of alcohol can cause a number of medical and psychiatric complications, with higher use resulting in more profound effects. Health conditions associated with excessive alcohol use include (Edelman & Fiellin, 2016): ● Cirrhosis ● Hypertension ● Stroke
hol, and the effects of estrogen can slow down the rate of alcohol elimination from the body (UC Santa Cruz, 2019).
that maybe Jane took other drugs or was drinking more in her room where other people wouldn’t see her. Jane was given a drug screen, which came back negative for the 10 most commonly abused drugs. Self-Assessment Quiz Question #1 Which of the following factors is most likely to influence Jane’s blood alcohol concentration? a. Eating a large meal prior to drinking. b. Jane’s age. c. Jane’s ethnicity. d. Jane’s living situation. Patients at risk of developing complicated alcohol withdrawal should be closely monitored. Seizures can occur within 8 to 48 hours after stopping or reducing alcohol use, with risk peaking at approximately 24 hours. An impending seizure can produce signs such as high blood pressure, increased heart rate, tremors, fever, or overactive reflexes, though seizures can occur without warning. Patients who have experienced one alcohol withdrawal seizure are at a higher risk of having another seizure or progress- ing to alcohol withdrawal delirium (American Society of Addiction Medicine, 2020). An acute state of confusion with impaired cognition, known as delirium, can occur during alcohol withdrawal. It is associated with increased morbidity and mortality, longer hospital stays, and in- creased utilization of health services. Prevention and early recog- nition are especially important in delirium management. Factors known to increase the risk of delirium include cognitive, visual, or hearing impairments; immobility; dehydration; and sleep depriva- tion (American Society of Addiction Medicine, 2020). at a particularly high risk of experiencing adverse effects from medication– alcohol interactions (Edelman & Fiellin, 2016). Unhealthy alcohol use can also cause a number of social and men- tal health consequences. Depression is highly correlated with al- cohol use disorders. Accidents such as falls, burns, and firearm injuries are more common among heavy drinkers, as is unsafe sex, intimate partner violence, homicide, and suicide (Edelman & Fiel- lin, 2016). Alcoholic Liver Disease Alcoholic liver disease covers a spectrum of liver disorders, beginning with steatosis, or fat accumulation in the liver; progressing to hepatitis, or inflammation of the liver cells; and ending with cirrhosis, or irreversible damage to the liver (Patel & Mueller, 2022). Signs and symptoms of liver disease include (American Society of Addiction Medicine, 2020): ● Edema ● Jaundice ● Dark-colored urine ● Itchy skin ● Pale, bloody, or tar-colored stool ● Chronic fatigue ● Confusion ● Nausea or vomiting Heavy alcohol users can present with alcoholic liver disease be- tween 40 and 50 years of age. Liver disease can be progressive, and between 10 to 20 percent of patients with alcoholic hepatitis progress to cirrhosis each year. The management of alcoholic liver disease can vary depending on the extent of disease. Alcohol ces- sation is highly recommended for patients with alcoholic liver dis-
● Cardiomyopathy ● Hypogonadism ● Gastroesophageal reflux ● Osteoporosis ● Sexual dysfunction ● Chronic pancreatitis ● Brain atrophy ● Seizures ● Arrhythmias
Malnourishment is a significant issue associated with chronic al - cohol use, resulting in deficiencies in vitamins A, B, and C; mag - nesium; folic acid; carnitine; selenium; zinc; antioxidants; and essential fatty acids. Moderate alcohol use has been associated with a higher risk of certain types of cancer, including those of the esophagus, larynx, mouth, liver, colon, and breast. Alcohol use is also associated with a higher risk of developing diabetes and acquiring HIV, and it complicates disease state management because of the effects on medication adherence (Edelman & Fiel- lin, 2016). Alcohol interacts with a number of prescription medications, in- cluding opioids, anticoagulants, anxiolytics, sedatives, and anti- convulsants. Elderly patients and patients with polypharmacy are
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Book Code: RPUS3024
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ease. Patients may also require laboratory or diagnostic studies, nutritional support, regular screening for liver cancer, and treat- ment of complications or coexisting infections. A number of com- plications can arise from alcoholic liver disease, including variceal bleeding, ascites, peritonitis, renal failure, and encephalopathy (Patel & Mueller, 2022). Pancreatitis Long-term alcohol use causes between 17 and 25 percent of cases of acute pancreatitis worldwide. This inflammatory condi - tion affecting the pancreas causes acute abdominal pain, nausea, vomiting, anorexia, and high lipase levels. Severe cases can pres- ent with sepsis, acute respiratory distress syndrome, or shock. Acute pancreatitis often requires hospitalization and management with IV fluids, electrolyte replacement, analgesics, and antiemet - ics (Klochkov et al., 2022). Between 40 to 70 percent of cases of chronic pancreatitis are caused by chronic alcohol use. Patients who experience recurrent Screening/assessment Alcohol use should be assessed in all patients routinely, especially those presenting with symptoms of alcohol abuse or any of the above comorbidities. When assessing a patient with suspected unhealthy alcohol use, ask about the following (Tetrault & O’Connor, 2021): ● Past and current use of alcohol and any prior treatment ● Family history of issues related to alcohol and treatment ● Details on the quantity and frequency of use ● Symptoms and behaviors associated with the following: ○ Alcohol use disorder criteria ○ Medical comorbidities ○ Behavioral complications ○ Psychiatric complications ○ Use of other substances A physical examination should be conducted to assess for fea- tures of unhealthy alcohol use. Patients may come to appoint- ments smelling of alcohol or actively under the influence of al - cohol, as noted by slurred speech, incoordination, dehydration, flushing, confusion, aggression, nausea, or vomiting. Signs of alcohol withdrawal include tremor, agitation, or clouded senses. Patients with advanced liver disease may present with hepatic en- largement, splenic enlargement, or yellowing skin or eyes (Tet- rault & O’Connor, 2021). Laboratory evaluation can test for abnormalities related to heavy, repeated alcohol use or liver disease. Assessment of liver en- zymes, including aspartate aminotransferase (AST), alanine ami- notransferase (ALT), bilirubin, and albumin, can indicate liver dam- age. Hemoglobin and complete blood count can determine the Diagnosis The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) created a new diagnosis of AUD that replaced alcohol abuse and alcohol dependence, which were described in the DSM-IV. AUD is diagnosed when patients experience a problematic pattern of alcohol use that leads to clinically significant distress or impairment, including at least two of the following characteristics within a 12-month period (American Psychiatric Association, 2013): ● Patients experience a persistent desire or unsuccessful efforts to cut down or control use. ● Alcohol is taken in larger amounts or for longer durations than intended. ● A significant amount of time is spent on activities related to obtaining, using, or recovering from alcohol. ● Patients have cravings or strong urges to use alcohol. ● Recurrent alcohol use results in a failure to fulfill significant obligations at school, work, or home. ● There is continued use of alcohol despite recurrent or persis- tent interpersonal or social issues caused or exacerbated by the effects of alcohol.
cases of acute pancreatitis are significantly more likely to progress to chronic pancreatitis, in which the inflammation of the pancreas worsens over time, leads to permanent damage, and increases the patient’s risk of pancreatic cancer. Chronic pancreatitis can cause the pancreas to work less efficiently, leading to poor fat absorption, steatorrhea, and diabetes. Complications of chronic pancreatitis can be local effects on the pancreas such as necrosis and pseudocysts, as well as systemic complications such as sep- sis, pleural effusion, bacteremia, and shock (Klochkov et al., 2022). Self-Assessment Quiz Question #2 A number of complications can arise from alcoholic liver dis- ease, including all of the following EXCEPT: a. Variceal bleeding. b. Ascites. c. Heart failure. d. Encephalopathy. presence of anemia or blood dyscrasias associated with heavy alcohol use or liver disease (Tetrault & O’Connor, 2021). Patients with suspected alcohol withdrawal should have a similar assessment, with a focus on assessing recent or current withdrawal symptoms, history of prior withdrawal, and urine drug testing to rule out other substance use. The Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-Ar), developed in the 1980s, is a standardized evaluation tool that can be used to assess the severity of withdrawal symptoms. It can help clinicians determine the need for medically supervised withdrawal and is commonly used to guide the treatment of alcohol withdrawal symptoms. The severity of alcohol withdrawal symptoms assessed include the following (American Society of Patients are scored based on symptom severity and classified as having mild withdrawal (fewer than 10 points), moderate with- drawal (10 to 18 points), and severe withdrawal (more than 19 points) (American Society of Addiction Medicine, 2020). ● Important recreational, social, or occupational activities are reduced or given up because of alcohol use. ● There is recurring alcohol use in physically hazardous situa- tions. ● There is continued alcohol use despite knowing of persistent physical or psychological problems caused or exacerbated by alcohol. ● Tolerance develops, as defined by either a need for signifi - cantly increased amounts of alcohol to achieve intoxication or desired effects, or a decreased effect with continued use of the same amount of alcohol. ● Withdrawal occurs, as manifested by either classic withdrawal symptoms or the need to use alcohol or other depressants to relieve or avoid withdrawal symptoms. Alcohol withdrawal can be life threatening and may require intensive or inpatient care. Diagnostic criteria for alcohol withdrawal include the following (American Psychiatric Association, 2013): ● Reduction in or cessation of alcohol use that was prolonged and heavy Addiction Medicine, 2020): ● Nausea and vomiting ● Headache ● Paroxysmal sweats ● Auditory disturbances ● Anxiety ● Visual disturbances ● Agitation ● Tactile disturbances ● Tremor ● Orientation and clouded senses
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Book Code: RPUS3024
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● Two or more of the following symptoms that develop within a few hours to a few days after alcohol reduction or cessation: ○ Increased hand tremor ○ Nausea or vomiting ○ Autonomic hyperactivity ○ Insomnia ○ Anxiety ○ Generalized tonic-clonic seizures Risk factors for alcohol use disorder Risk factors for alcohol use disorder in a person’s lifetime include the following (Tetrault & O’Connor, 2021):
○ Transient hallucinations that are visual, auditory, or tac- tile ○ Psychomotor agitation ● Significant distress or impairment in important areas of social or occupational functioning caused by the above symptoms ● Symptoms not attributable to another medical condition, mental disorder, intoxication, or withdrawal from another substance ● Significant disability ● Mood disorders, such as major depression or bipolar disorder ● Other substance use disorders ● Personality disorders such as antisocial or borderline personality disorder
● Age 18 to 29 ● Male gender ● White and Native American ethnicities
TREATMENT OF WITHDRAWAL
Alcohol withdrawal treatment is typically dependent on the sever- ity of withdrawal and should be tailored to the patient’s specific needs. Patients experiencing mild alcohol withdrawal, or those with a CIWA-Ar score of less than 10, can be treated in the out- patient setting with supportive care, or with supportive care and pharmacotherapy. Appropriate medications include carbamaze- pine or gabapentin. Benzodiazepines may be considered if the patient is at risk of developing new or worsening symptoms while away from the treatment center (American Society of Addiction Medicine, 2020). Patients experiencing moderate alcohol withdrawal, or those with a CIWA-Ar score between 10 and 18, can be treated in the outpa- tient setting and should receive pharmacotherapy. Benzodiazepines are considered first-line treatment in these pa - tients, though carbamazepine, gabapentin, or phenobarbital can be used as alternatives for patients with contraindications to ben- zodiazepines. If needed, benzodiazepines can be given with ad- junctive carbamazepine, gabapentin, or valproic acid (American Society of Addiction Medicine, 2020). Severe, uncomplicated cases of alcohol withdrawal, or those with a CIWA-Ar score greater than 19, should be treated with pharma- cotherapy. These patients can be treated in a higher- level am- bulatory setting, such as a treatment program, that has regular monitoring available in the event of escalation, or in higher levels of care if necessary. Benzodiazepines should be used as firs- line therapy for these patients. Phenobarbital, carbamazepine or ga- bapentin may be used as an alternative. Adjunctive therapy with carbamazepine, gabapentin, or valproic acid is also appropriate (American Society of Addiction Medicine, 2020). For patients who have uncontrolled symptoms in the ambulatory setting, medication adherence should first be verified. If the pa - tient is taking medication as prescribed, providers should con- sider increasing the dose. If providers are concerned about inad- equate monitoring or oversedation, they can consider switching Supportive care and nutrition Once comorbidities and alternative substance withdrawal have been excluded, the treatment of alcohol withdrawal is focused on alleviating symptoms and correcting metabolic abnormali- ties. Supportive care, such as IV fluids, nutritional supplementa - tion, and frequent clinical reassessment, is a core component of withdrawal treatment. Patients should be educated on expecta- tions over the course of withdrawal, including common symptoms and how they will be treated. In the outpatient setting, education should be provided about monitoring for more severe withdrawal. Patients should also know that safe withdrawal treatment may re- quire transfer to a higher level of care if the ambulatory setting is not safe or effective for the patient (American Society of Addiction Medicine, 2020).
medications, adding an adjunctive medication, or reassessing the level of care (American Society of Addiction Medicine, 2020). Providers should consider the patient’s risk for severe or complicated withdrawal when determining a treatment plan, as these patients may require closer management or inpatient hospitalization. Risk factors for severe or complicated withdrawal include (American Society of Addiction Medicine, 2020): ● Prior history of alcohol withdrawal seizures or delirium ● Medical or surgical comorbidities, especially traumatic brain injury ● Numerous prior episodes of withdrawal ● Age over 65 years ● Long history of regular, heavy alcohol use ● Seizures or significant autonomic hyperactivity during the cur - rent withdrawal episode ● Dependence on medications that enhance gamma-aminobu- tyric acid (GABA) such as benzodiazepines or barbiturates ● Use of other addictive substances in conjunction with alcohol ● Signs and symptoms of withdrawal in conjunction with a posi- tive blood alcohol concentration ● Moderate to severe co-occurring psychiatric disorder The risk of severe or complicated withdrawal is higher in patients with multiple risk factors. Providers can generally use CIWA-Ar scores to assess for the risk of severe or complicated withdrawal. Patients with a CIWA-Ar score of 10 or greater or those experi- encing at least moderate alcohol withdrawal on presentation are at a higher risk of severe or complicated withdrawal. Other tools such as The ASAM Criteria Risk Assessment Matrix, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), or the Luebeck Alcohol-Withdrawal Risk Scale (LARS) can help assess a patient’s risk of severe or complicated alcohol withdrawal as well as poten- tial complications of withdrawal (American Society of Addiction Medicine, 2020). Patients experiencing withdrawal should be placed in a low-stimu- lation, reassuring environment that is calm and quiet. Dehydrated patients should receive IV fluids until they are euvolemic. Thia - mine and glucose should be given to treat or prevent Wernicke’s encephalopathy, an acute neurological condition caused by thia- mine deficiency and characterized by ataxia, ocular abnormalities, and confusion. Multivitamins with folate should be initiated, and electrolyte disturbances such as magnesium, potassium, glucose, and phosphate should be corrected. Depending on the sever- ity, nutritional supplementation may need to be intravenous for at least the first day or two for aspiration prevention, as well as impaired gastrointestinal absorption in patients who chronically abuse alcohol (American Society of Addiction Medicine, 2020; Hoffman & Weinhouse, 2021).
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Book Code: RPUS3024
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Self-Assessment Quiz Question #3 Which of the following should be given to patients withdrawing from alcohol to treat or prevent Wernicke’s encephalopathy? a. Lorazepam. b. Thiamine. c. Folate. d. Magnesium. Medications Benzodiazepines Benzodiazepines are a mainstay of alcohol withdrawal treatment. They are useful for preventing withdrawal symptoms from becom- ing more severe, preventing seizures and delirium, and treating psychomotor agitation. Longer-acting agents such as diazepam and chlordiazepoxide are preferable, as their longer action and less frequent need for redosing reduces the chance of seizures or recurrent withdrawal. Patients with severe liver disease are at a higher risk of benzodiazepine accumulation because of reduced metabolism. These patients should be treated with lorazepam because of its shorter half-life, or oxazepam because of the lack of active metabolites, which prevents prolonged oversedation. IV administration is often required for patients in severe withdrawal, who cannot tolerate oral administration, or who are unconscious. Doses vary greatly and should be patient-specific. Patients should be monitored for signs of oversedation and respiratory depres- sion (American Society of Addiction Medicine, 2020). Benzodiazepines are Schedule IV controlled substances that carry a risk of misuse or diversion. This risk can be mitigated by order- ing the minimum amount needed to achieve stability and hold the patient over until their next appointment. Benzodiazepines should be discontinued once alcohol withdrawal treatment is complete. Patients and caregivers should be educated on the risks of combining alcohol with benzodiazepines, the risks of driv- ing or using heavy machinery while taking benzodiazepines, and the interaction between benzodiazepines and other CNS depres- sants. Patients at a high risk of benzodiazepine abuse or diversion can be prescribed alternative medications or referred for inpatient management, depending on the severity of their case (American Society of Addiction Medicine, 2020). For patients in hospitals or treatment centers, the preferred dosing method is symptom- triggered dosing administered by trained staff. In this method, patients are given medication only when experiencing significant symptoms of withdrawal, as noted by a symptom severity scale such as the CIWA-Ar, and doses are based on symptom severity. Withdrawal symptoms can be moni- tored using the CIWA-Ar scale every 1 to 4 hours initially, and can be extended to every 4 to 8 hours once the patient has been stabilized. Symptom-triggered treatment allows for individualized dosing based on real-time severity of symptoms, reducing the risk of over- or undertreatment. Patients may require large doses of benzodiazepines initially, with reduced doses over time. Studies have shown that symptom-triggered dosing reduces treatment duration and length of inpatient stay compared to fixed-dose schedules (American Society of Addiction Medicine, 2020). Fixed dosing is commonly used in ambulatory settings. This meth- od allows for set amounts of benzodiazepines to be administered at regular intervals, and the dose and/or frequency is gradually tapered according to a set schedule. Fixed dosing is easier for patients to self- administer, though it is also easier to over- or underestimate the dose needed, leading to oversedation or sub- optimal symptom control. Patients on fixed-dose schedules still require frequent monitoring and should be reassessed regularly to determine if dosage changes are necessary (American Society of Addiction Medicine, 2020). Front loading with benzodiazepines is recommended for patients in severe alcohol withdrawal (CIWA-Ar scores greater than 19). Front loading involves giving a moderate or high dose of a long-
acting benzodiazepine to ensure withdrawal symptoms are rap- idly controlled. Studies have shown that front loading reduces the risk of withdrawal seizures, shortens treatment duration, and reduces the duration of delirium. Patients receiving front-loaded doses should be closely monitored for respiratory depression and signs of oversedation, as these side effects occur more frequently with this type of dosing regimen (American Society of Addiction Medicine, 2020). Phenobarbital Patients who have a contraindication to benzodiazepine use and are experiencing moderate to severe withdrawal, or are at risk of developing severe or complicated withdrawal, may be treated with phenobarbital. Phenobarbital was the first medication used to successfully treat alcohol withdrawal, and its use for this indica- tion began in the 1920s. Because of the risk of toxicity when used in high doses or in combination with alcohol, phenobarbital is best administered by providers experienced with its use who are able to closely monitor the patient. Phenobarbital has a narrow therapeutic index, which can create challenges in dosing it ap- propriately. It can cause respiratory depression and oversedation when used at high doses. Its dosing can also be complicated by its long half-life of up to 7 days, and its metabolism by the liver, which can be impaired in patients who chronically abuse alcohol. Phenobarbital is associ- ated with a number of other side effects, including hypotension, pulmonary edema, bradycardia, bradypnea, hypothermia, acute renal failure, and Steven–Johnson syndrome. When the effective use of benzodiazepines for the treatment of al- cohol withdrawal was initiated in the 1960s, the use of phenobarbi- tal fell out of favor (American Society of Addiction Medicine, 2020). Anticonvulsants Anticonvulsants such as carbamazepine, gabapentin, or valproic acid can be used as adjunct therapy with benzodiazepines to im- prove control of withdrawal. Carbamazepine or gabapentin can also be used as monotherapy if benzodiazepines are contraindi- cated. Valproic acid does not have sufficient evidence to support its use as monotherapy. There is not enough evidence to support the use of anticonvulsants over benzodiazepines, particularly in patients at high risk of severe withdrawal, delirium, or seizures. Gabapentin may be an effective adjunct bridge therapy between the treatment of alcohol withdrawal and long-term management of AUD. Gabapentin has been associated with increased absti- nence rates and fewer heavy drinking days compared with place- bo in the management of AUD. Valproic acid should be avoided in patients with liver disease as well as in women of childbearing potential (American Society of Addiction Medicine, 2020). Alpha-2 Adrenergic Agonists and Beta Blockers Alpha-2 adrenergic agonists such as clonidine can be useful as adjunct therapy in patients with anxiety or autonomic hyperactiv- ity that is not controlled by benzodiazepines. Beta-adrenergic an- tagonists, also known as beta blockers, can also be used to treat persistent hypertension or tachycardia. Patients with alcohol with- drawal who experience cardiac symptoms such as tachycardia or hypertension that are not alleviated by correcting electrolyte im- balances or dehydration, or through the use of benzodiazepines, can benefit from the use of alpha2 agonists or beta blockers. These agents should not be used as monotherapy in withdrawal treatment, as they can reduce the symptoms of withdrawal with-
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Book Code: RPUS3024
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