It sounds weird, he knows, but Hugh Myrick, MD, likes alcohol withdrawal. “Alcohol withdrawal is what got me to be a psychiatrist,” he told attendees at the Internal Medicine Meeting 2017 session “Approach to Alcohol Withdrawal in the Hospital: Riding the Pink Elephant.”
Dr. Myrick, who is director of the addiction sciences division at the Medical University of South Carolina and associate chief of staff of mental health at the Ralph H. Johnson VA Medical Center in Charleston, shared both his passion for treating alcohol withdrawal and some specific tips for hospitalists.
The first step, of course, is identifying patients likely to experience withdrawal symptoms. “We haven't done a great job of characterizing it at this point in time and determining who is at risk for withdrawal,” he said.
There are some known factors that predict risk of the most severe symptoms of withdrawal, seizures and delirium tremens. “What's the best predictor of either? Having had either,” said Dr. Myrick. “The more times a person comes through detox, the more severe the symptoms are. Once a person comes in for around that fifth detox episode, their chance of having a seizure goes up dramatically.”
Other predictors of withdrawal include medical illness (which might be evidenced by lab abnormalities, such as electrolytes or liver function), older age, and presentation with a blood alcohol count over 0.300.
Patients without these factors may still be at risk for mild to moderate withdrawal, which includes anxiety, insomnia, irritability, tremor, headache, gastrointestinal disturbance, diaphoresis, and increased blood pressure and heart rate. They should be treated, Dr. Myrick said.
“If we don't treat those other symptoms of alcohol withdrawal, people know how to make them better again, right? They just start drinking,” he said.
Assessing a patient's interest in stopping or reducing alcohol use is important to treatment, because of the problem of “kindling,” a term used to describe how past withdrawals increase the risk of severe withdrawal symptoms.
“If they don't want to quit drinking, we might actually be causing harm by detoxing them, because you're going to worry about that kindling thing,” said Dr. Myrick.
If a patient is to be detoxed, the traditional gold-standard treatment has been benzodiazepines. That's the solution many hospitals and physicians choose, with wide variation in which exact drug is used, according to Dr. Myrick. “If your residency used Ativan, you still use it. If you used phenobarb, you might still use phenobarb,” he said.
However, benzos are not his preferred first-line treatment. Research has shown that they increase alcohol cravings. “Benzodiazepines can drive alcoholics back to drinking again, so not a great medication to use in the alcoholic population,” he said.
Instead, many experts, including him, prefer gabapentin. Advantages include that it suppresses withdrawal, doesn't interact with alcohol, has a simple metabolism and low potential for abuse, and causes little to no ataxia, according to Dr. Myrick. “The dose we use now is 400 mg [three times per day], and sometimes we'll push that a little higher,” he said.
Whether you detox patients on a benzodiazepine or gabapentin, use order sets and the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale to decide how much they get. “There are plenty of studies out there to show that we give too much benzodiazepine when we write a taper,” said Dr. Myrick.
The CIWA-Ar is a 10-item scale that assesses the severity of a patient's alcohol withdrawal symptoms. “Using a symptom-triggered instrument like this...the patient only gets the medication when they need it,” he said.
It can also be helpful in situations where a prescribed taper is providing insufficient symptom control for a patient with severe withdrawal. “If you have the CIWA-Ar for backup, the nursing staff then has something they can give the patient at three in the morning and don't have to call you when the patient looks like they could break through and have a seizure,” said Dr. Myrick.
Patients in detox should also receive thiamine, folic acid, and a multivitamin, he noted.
After a few days of this, some might think that treatment is complete. “Historically, we've all been trained that detox is four to seven days after somebody stops drinking,” said Dr. Myrick. “I'm a protracted withdrawal believer. I will leave folks on [medication] for two weeks, three weeks, because I'm probably going to prevent some of those protracted withdrawal symptoms.” Such symptoms include insomnia, irritability, and anxiety and can drive patients to drink again.
To help keep patients from resuming drinking, Dr. Myrick is also a believer in medication, which only about 10% of the 1.2 million patients treated for alcohol use disorder receive. “If there were 1.2 million people seeking treatment for depression, what percent would be on a medication? 110%, right?” he said.
Medication options include disulfiram (Antabuse). “As an addiction psychiatrist, I love Antabuse. The trouble is you've got use it in the right patient population. The person absolutely has to know they can't go to dinner tonight and have wine sauce or they can't have an aftershave that has alcohol in it,” said Dr. Myrick.
Another issue is that the drug works best when the patient is witnessed taking it, he added. Even greater adherence issues are associated with acamprosate, which is dosed on a thrice-daily schedule. “I can't take an antibiotic three times a day for five days, so I'm going to expect someone to take it every single day for months on end?” he said.
The third option is naltrexone. “It's not a great medication to absolutely stop drinking. There's good data that it will help people cut down on their drinking. You can talk to folks and they say it [alcohol] just doesn't taste the same,” said Dr. Myrick.
In addition to pills, naltrexone is available in an extended-release formulation that is injected once a month. “We save this medication for our folks that either have problems with compliance on oral or they just failed oral. We'll go this route and we've had some blockbuster success with it,” said Dr. Myrick.
To achieve such successes, medication may be necessary, but it is usually not sufficient, he noted. “Somebody will come up to me and say, ‘I tried that on my alcoholic population and it didn't work.’ My question is ‘What else do you do?” Some kind of support, even just connecting a patient with Alcoholics Anonymous, is critical to effectively treating alcohol use disorder.