Alcohol Use Disorder and Marijuana Use Disorder

What are the agents for withdrawal?

1st line: Benzodiazepines

2nd line: Carbamazepine, Divalproex Sodium

What are the agents for maintenance?

1st line: Naltrexone, Acamprosate

2nd line: Disulfriam

Without formal treatment, only 20-30% of patients with alcohol use disorder are likely to remain abstinent or in long-term remission

True

Which of the following agents is considered first-line therapy for alcohol withdrawal?

Carbamazepine

Lorazepam

Gabapentin

Divalproex sodium

Lorazepam

Mr. Smith presents to the ER with whole body tremors, visual hallucinations, profound confusion, tachycardia, hypertension, and fever >104F. He has a history of heavy drinking but his last drink was 4 days ago. He is likely experiencing:

Korsakoff psychosis

Delirium tremens (DT)

Mild alcohol withdrawal that can be treated as an outpatient

Delirium tremens (DT)

Which side effect or warning/precaution is associated with acamprosate?

Hepatic injury

Respiratory depression

Suicidal ideation

Seizures

Suicidual ideation

Acamprosate is contraindicated when CrCl is less than 30 mL/min

True

False

True

Disulfiram may be appropriate to treat individuals with alcohol dependence who?

Prefer three times weekly dosing

Want to use a long-acting injectable formulation

Are extremely motivated to remain sober

Use topical acne medication

Are extremely motivated to remain sober

Acute intoxication with synthetic cannabinoids (K2 or spice) can cause anxiety and psychosis

True

False

True

___ is a sign of cannabis withdrawal?

Decreased appetite/anorexia

Mrs. Green has OUD and AUD. She is currently being treated with methadone for OUD, and has CrCl<30 mL/min. Which medication is most appropriate for long-term treatment of her AUD?

Disulfiram

Oral naltrexone

Lorazepam

Acamprosate

Disulfiram

What are the chronic effects of AUD?

- Pancreatitis

- Steatosis (fatty liver), hepatitis, cirrhosis

- Thiamine and folate deficiencies (inadequate dietary intake or malabsorption)

What is Wernicke-Korsakoff Syndrome?

- Caused by thiamine (vitamin B1) deficiency with chronic AUD

- Vision changes (nystagmus)

- Korsakoff Psychosis: hallucinations

What is a sign or symptom of alcohol intoxication?

Nstagmus

What are signs and symptom of alcohol withdrawal?

- Hand tremor

- Hallucinations or illusions (rare)

- Seizure activity (rare)

- Delirium Tremens (DT)

What are Delirium Tremens (DT)?

Whole body tremors, visual hallucinations, profound confusion, tachycardia, hyperthermia, fever > 104 F, agitation, diaphoresis

Clinical Institute Withdrawal Assessment Alcohol Revised Rating Scale (CIWA-Ar)

Gold standard for alcohol withdrawal assessment

CIWA-Ar scoring

<8: mild withdrawal; medication not likely necessary

8-18: moderate withdrawal; medication indicated

>18: severe withdrawal; medication indicated

Alcohol Use Disorder Identification (ADUIT) Rating Scale

>8: identify heavy drinkers and those with alcohol use disorder

What is non-pharm treatment for AUD?

Self help groups and 12-step approaches (AA)

What is the treatment for acute alcohol intoxication?

- Thiamine daily to prevent Wenicke's encephalopathy

- Glucose containing IV fluids AFTER thiamine because thiamine is a cofactor in normal glucose metabolism

What benzodiazepines are FDA approved for AUD?

Chlordiazepoxide, clorazepate, diazepam, and oxazepam are FDA approved for acute alcohol withdrawal

How are benzodiazepines dosed?

Symptom-triggered dosing of benzodiazepines is the current standard of care

When are long acting benzodiazepines preferred?

Long-acting agents are preferred to prevent breaththrough withdrawal symptoms

Diazepam

Chlordiazepoxide

When are short acting benzodiazepines preferred?

Short-acting agents are preferred to prevent severe hepatic impairment or in the elderly

Lorazepam

Oxazepam

What agents are NOT 1st line for withdrawal?

- Valproic acid (VPA), divalproex sodium, phenobarbital, gabapentin, and carbamazepine should NOT be considered 1st line treatment

- May be beneficial for mild-moderate at an outpatient setting

What is the MOA of naltrexone?

mu opioid receptor antagonist

Does naltrexone reduce alcohol cravings?

Yes!

What are the contraindications of naltrexone?

Opioid use within last 7 days, acute hepatitis, severe hepatic impairment, hepatic injury

What should you avoid with naltrexone?

Avoid use of opioid medications

What is the MOA of acamprosate?

NMDA receptor antagonist

What is the warning for acamprosate?

Suicidal ideation

What is the contraindication for acamprosate?

CrCl <30 mL/min

What does acamprosate do?

May decrease cravings for alcohol and alleviate negative reinforcement

What is the MOA of disulfiram?

Inhibits ALDH, an enzyme involved in metabolism of ethanol

What do disulfriam do?

- Deters alcohol consumption due to flushing reaction

- Goal of treatment is to increase motivation

What patients are typically successful with disulfriam?

Successful patients are typically highly motivated to remain abstinent

What are warnings for disulfriam?

Severe hepatic impairment, psychosis

What are the contraindications for disulfriam?

Use of ethanol or metronidazole

What to avoid with disulfriam?

Avoid alcohol containing products (cough or cold agents, mouthwashes)

Patient education for disulfriam?

You can experience a disulfiram-alcohol reaction for up to 14 days after disulfiram is discontinued.

What is disulfriam flushing reaction caused by?

Disulfiram flushing reaction is caused by accumulation of acetaldehyde, a major but toxic metabolite of alcohol formed by the alcohol dehydrogenase.

When can disulfriam be initiated?

Do not initiate disulfiram for at least 12 hours after ingestion of alcohol.

Pregnancy treatment in AUD?

Abstinence during pregnancy is the standard of care

Adolescents treatment in AUD?

Psychotherapy

No medications are currently FDA approved for the treatment of AUD in adolescents

Elderly treatment in AUD?

Lorazepam or oxazepam

Which medication is contraindicated in CrCl <30 ml/min?

Acamprosate

Which medication is symptom-guided dosing based on the CIWA-Ar alcohol withdrawal rating scale

Benzodiazepines

What medication is contraindicated in hepatitis or severe liver impairment?

Naltrexone

Which medication is second-line treatment for alcohol dependence (maintenance/prevention)?

Disulfiram

Which medication is 1st line treatment for alcohol withdrawal?

Benzodiazepine

Which medication is contraindicated in combination with metronidazole?

Disulfiram

Which medication is contraindicated in combination with opioid therapy

Naltrexone

What are signs and symptoms of a cannabis intoxication?

Increased appetite

What are signs and symptoms of a cannabis withdrawal?

Anorexia or weight loss

What is the treatment for cannabis use disorder?

There are no established medication treatment options for cannabis use disorder