Substance-use disorders: A whirlwind tour Anthony Worsham, MD Best Practices Division of Hospital...

Substance-use disorders: A whirlwind tour

Anthony Worsham, MDBest Practices

Division of Hospital MedicineDepartment of Internal Medicine

University of New Mexico Health Sciences CenterWednesday, June 19, 2013

The dose makes the poisonWhat is it that is not a poison? All things are poison and nothing is without poison. Solely, the dose determines that a thing is not a poison.--Paracelsus (1493–1541), the Renaissance Father of Toxicology, in his Third Defense

Erickson TB, The approach to the patient with an unknown overdose, Emerg Med Clin N Am 25 (2007) 249–281http://en.wikipedia.org/wiki/Paracelsus

The publication of The Core Competencies… represents the first attempt to define the specialty of Hospital Medicine.

PurposeThe Core Competencies provide a framework for

professional and curricular development based on a shared understanding of the essential knowledge, skills and attitudes expected of physicians working as hospitalists.

Core CompetenciesClinical Conditions

•Acute Coronary Syndrome•Acute Renal Failure•Alcohol and Drug Withdrawal•Asthma•Cardiac Arrhythmia•Cellulitis•Chronic Obstructive Pulmonary Disease•Community Acquired Pneumonia•Congestive Heart Failure

•Delirium and Dementia•Diabetes Mellitus•Gastrointestinal Bleed •Hospital-Acquired Pneumonia•Pain Management•Perioperative Medicine •Sepsis Syndrome•Stroke•Urinary Tract Infection •Venous Thromboembolism

Alcohol and Drug WithdrawalCore Competency: Knowledge

Hospitalists should be able to:

• Describe the effects of drug and alcohol withdrawal on medical illness and the effects of medical illness on substance withdrawal.

• Recognize the complications from substance use and dependency.

• Distinguish alcohol or drug withdrawal from other causes of delirium.

• Describe the indicated tests required to evaluate alcohol or drug withdrawal.

• Identify patients at increased risk for drug and alcohol withdrawal using current diagnostic criteria for withdrawal.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat acute alcohol and drug withdrawal.

• Identify local trends in illicit drug use.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with drug or alcohol withdrawal.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. Journal of Hospital Medicine. Volume 1, Issue S1, pages 6–7, 2006.

Alcohol and Drug WithdrawalCore Competency: Skills

Hospitalists should be able to: • Elicit a thorough and relevant history, with emphasis on substance use.• Recognize the symptoms and signs of alcohol and drug withdrawal, including prescription and OTC

drugs.• Differentiate delirium tremens from other alcohol withdrawal syndromes.• Assess for common co-morbidities in patients with a history of alcohol and drug use.• Perform a rapid, efficient and targeted physical examination to assess alcohol or drug withdrawal and

determine life-threatening co-morbidities.• Apply DSM-IV Diagnostic Criteria for Alcohol Withdrawal.• Formulate a treatment plan, tailored to the individual patient, which may include appropriate

pharmacologic agents and dosing, route of administration, and nutritional supplementation.• Integrate existing literature and federal regulations into the management of patients with opioid

withdrawal syndromes. for patients who are undergoing existing treatment for opioid dependency, communicate with outpatient treatment centers and integrate dosing regimens into care management.

• Manage withdrawal syndromes in patients with concomitant medical or surgical issues.• Determine need for the use of restraints to ensure patient safety.• Reassure, reorient, and frequently monitor the patient in a calm environment.• Assess patients with suspected alcohol or drug withdrawal in a timely manner, identify the level of

care required, and manage or co-manage the patient with the primary requesting service.


Alcohol and drug withdrawalCore competency: Attitudes

Hospitalists should be able to:• Use the acute hospitalization as an opportunity to counsel patients about abstinence, recovery and the

medical risks of drug and alcohol use.• Communicate with patients and families to explain goals of care plan, discharge instructions and

management after release from hospital.• Appreciate the indications for specialty consultations.• Initiate prevention measures prior to discharge, including alcohol and drug cessation measures.• Manage the hospitalized patient with substance use in a non-judgmental manner.• Employ a multidisciplinary approach, which may include psychiatry, pharmacy, nursing and social

services, in the treatment of patients with substance use or dependency.• Establish and maintain an open dialogue with patients and families regarding care goals and limitations.• Appreciate and document the value of appropriate treatment in reducing mortality, duration of

delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient with contact information for follow-up care, support and rehabilitation.

• Utilize evidence based national recommendations to guide diagnosis, monitoring and treatment of withdrawal symptoms.


Alcohol and drug withdrawalCore competency: System Organization

and ImprovementTo improve efficiency and quality within their organizations, Hospitalists

should:

• Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with alcohol and drug withdrawal.

• Promote the development and use of evidence based guidelines and protocols for the treatment of withdrawal syndromes.

• Advocate for hospital resources to improve the care of patients with substance withdrawal, and the environment in which the care is delivered.

• Lead, coordinate or participate in multidisciplinary teams, which may include psychiatry, to improve patient safety and management strategies for patients with substance abuse.


Camí J, Farré M, Drug Addiction, N Engl J Med, 2003;349:975-86.

Renner JA, Ward EN, Drug Addition, Massachusetts General Hospital Comprehensive Clinical Psychiatry

Identify local trends in illicit drug use

New Mexico Department of Health . New Mexico Substance Abuse Epidemiology Profile: July 2011.http://nmhealth.org/erd/SubstanceAbuse/2011%20New%20Mexico%20Substance%20Abuse%20Epidemiology%20Profile.pdf

49% Prescription opioids(i.e.,methadone,oxycodone,morphine)

36% heroin

31% cocaine

29% tranquilizers/musclerelaxants

16% antidepressants

median age of unintentional drug overdose: 43.7years

Elicit a thorough and relevant history, with emphasis on substance use

Obtain all prescription bottles and other containers when possible. Perform a pill count. Be sure that the bottles contain the medications listed. Identify any unknown tablets.

Contact the prescribing physician(s) or the pharmacy as listed on the bottles to determine previous overdoses or other medications that the patient may have available.

Identify underlying medical and psychiatric disorders and medication allergies. Review past medical records.

Talk to the patient’s family and friends in the emergency department. If necessary, call the patient’s home to ask questions of others. The persons providing the important elements of the history should be identified in the chart.

Search the patient’s belongings for drugs or drug paraphernalia. A single pill hidden in a pocket, for example, may provide the most important clue to the diagnosis.

Have family members (or the police) search the patient’s home, including the medicine cabinet, clothes drawers, closets, and garage: such searches may also provide clues that make the diagnosis. This has the added benefit of involving the family in the patient’s care.

Always look for track marks on the patient. Consider body packing or body stuffing.

Kulig K, Ling LJ, General Approach to the Poisoned Patient. Rosen's Emergency Medicine, 7th ed., 2009.

Approach to the poisoned patient

Erickson TB, The approach to the patient with an unknown overdose, Emerg Med Clin N Am 25 (2007) 249–281

Ford MD, Acute Poisoning, Goldman's Cecil Medicine, 24th ed., 2011.

Recognize the symptoms and signs of alcohol and drug withdrawal

Toxidrome: a constellation of signs and symptoms characteristic of a class of drugs

Shannon MW, A General Approach to Poisoning, Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed., 2007.

Cholinergic syndromeMnemonics

DUMBBELS • Defecation• Urination• Miosis• Bronchorrhea• Bronchoconstriction• Emesis• Lacrimation• Salivation

SLUDGE• Salivation• Lacrimation• Urination• Defecation• Gastrointestinal

dysfunction• Emesis

Describe the indicated tests required to evaluate alcohol or drug withdrawal

Bast RP et al, Limited Utility of Routine Drug Screening in Trauma Patients, Southern Medical Journal, 2000, 397-399.

Limited utility of tox screens?Diagnostic and management decisions are made before toxicologic test

results are returned.

Benign diagnostic intervention may preclude the need for these tests (e.g., response to naloxone in opiate intoxication

Few specific interventions or antidotal therapies depend on toxicologic test outcomes.

The incidence of overall morbidity is low (less than 1%) in the setting of optimal patient management, including decontamination and supportive therapy.

Toxicity is often apparent on presentation.

There is a lack of rapid commercial assays for somedrugs commonly involved in emergency room evaluations (e.g. oxycodone, ketamine, GHB).


ED Triage Protocol Tox-SI-OD

ED Triage Protocol Tox-SI-OD

ED AMS-Withdrawal

ED AMS-Withdrawal

Describe the indicated tests required to evaluate alcohol or drug withdrawal

Osterloh JD, Haller CA, Laboratory Diagnoses and Drug Screening, Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed., 2007.

Moeller KE, Urine Drug Screening:Practical Guide for Clinicians, Mayo Clin Proc. 2008;83(1)66-76

Quantification of Toxins


Osmolar Gap

Levine M et al, Toxicology in the ICU: Part 1: General Overview and Approach to Treatment Chest 2011; 140( 3 ): 795 – 806

Poisoning pearls

• Protracted coughing with hydrocarbon ingestions

• Inability to swallow or drooling with caustic ingestions

• Hematemesis with iron ingestions• Intractable seizures with isoniazid overdose• Loss of consciousness with carbon monoxide

Guidelines for In-Hospital Disposition ICU

• Need for intubation• Seizures• Unresponsiveness to verbal stimuli• Arterial carbon dioxide pressure greater than 45 mm Hg• Cardiac conduction or rhythm disturbances (any rhythm except sinus arrhythmia)• Close monitoring of vital signs during antidotal therapy or elimination procedures• The need for continuous monitoring• QRS interval greater than 0.10 second, in cases of tricyclic antidepressant

poisoning• Systolic blood pressure less than 80 mm Hg• Hypoxia, hypercarbia, acid-base imbalance, or metabolic abnormalities• Extremes of temperature• Progressive deterioration or significant underlying medical disorders• Suicidality

Mofenson HC et al, Medical Toxicology, Physical and Chemical Injuries, Bope & Kellerman: Conn's Current Therapy 2013

Diagnostic algorithm usingthe size of the pupils

Ford MD, Acute Poisoning, Goldman's Cecil Medicine, 24th ed., 2011.

Apply DSM-IV Diagnostic Criteria for Alcohol Withdrawal

Highlights of Changes from DSM-IV-TR to DSM-5

• DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant.

• The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list, with two exceptions.

– The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been added.

– In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence.

• Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”).

American Psychiatric Association. Highlight of Changes from DSM-IV-TR to DSM-5. http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

Highlight of Changes from DSM-IV-TR to DSM-5

• Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5.

• Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more, a severe disorder.

• The DSM-IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence.

• Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without criteria (except craving).

• Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.

American Psychiatric Association. Highlight of Changes from DSM-IV-TR to DSM-5. http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

Substance-related disordersDSM-5 classification

• Substance use disorders• Substance-induced disorders

– Substance intoxication– Substance withdrawal

• Substance/medication-induced mental disorders

• Other substance-induced disorders• Unspecified substance-related disorderAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Substance-related disorders10 classes of drugs

• alcohol• caffeine• cannabis• hallucinogens

– PCP– other hallucinogens

• Inhalants• opioids

• sedatives, hypnotics, and anxiolytics

• stimulants (amphetamine-type substances, cocaine, and other stimulants)

• tobacco• other (or unknown)

substances

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Abuse versus dependenceDSM IV-TR

Alcohol abuse

A. A maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within a 12-month period:

• Recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household)

• Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use)

• Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct)

• Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication).

B. Never met criteria for alcohol dependence.

Alcohol dependence

A. A maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period:

• Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol

• The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms

• Drinking in larger amounts or over a longer period than intended.• Persistent desire or one or more unsuccessful efforts to cut down or

control drinking• Important social, occupational, or recreational activities given up or

reduced because of drinking• A great deal of time spent in activities necessary to obtain, to use, or

to recover from the effects of drinking• Continued drinking despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking.

B. No duration criterion separately specified, but several dependence criteria must occur repeatedly as specified by duration qualifiers associated with criteria (e.g., “persistent,” “continued”).

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed., text rev.).

Substance-use disordersDiagnostic criteria

• Criteria A– Impaired control (Criteria 1-4)– Social impairment (Criteria 5-7)– Risky use (Criteria 8-9)– Pharmacological criteria (Criteria 10-11)


Substance use disorderDiagnostic criteria

A. A problematic pattern of __ use leading to clinically significant impairment or distress, as manifested by at least two or the following, occuring within a 12-month period:



1. __ is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control __ use.

3. A great deal of time in spent in activities necessary to obtain __, use __, or recover from its effects.

4. Craving, or a strong desire or urge to use __.



5. Recurrent __ use resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued __ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of __.

7. Important social, occupational, or recreational activities are given up or reduced because of __ use.



8. Recurrent __ use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by __.



10. Tolerance, as defined by either of the following:– a. A need for markedly increased amounts of __ to achieve

intoxication or desired effect.– b. A markedly diminished effect with continued use of the

same amount of __.

11. Withdrawal, as manifested by either of the following:– a. The characteristic withdrawal syndrome for __– b. __ (or a closely related substance) is taken to relieve or

avoid withdrawal symptoms.

Substance use disordersDiagnostic criteria

• Specifiers– In early remission: no criteria met at least 3 months but

less than 12 months– In sustained remission: no criteria met for 12 months or

longer– In a controlled environment– Severity

• Mild: presence of 2-3 symptoms• Moderate: presence of 4-5 symptoms• Severe: presence of 6 or more symptoms


Substance IntoxicationDiagnostic Criteria

A. Recent ingestion of __.B. Clinically significant problematic behavioral or

psychological changes (e.g., __) that developed during, or shortly after, __ use.

C. # (or more) of the following signs of symptoms developing during, or shortly after, __ use:

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.


Substance withdrawalDiagnostic Criteria

A. Cessation of (or reduction in) __ use that has been heavy and prolonged.

B. # (or more) of the following signs and symptoms developing within __ after Criteria A.

C. The signs or symptoms in Criteria B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition, and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specifier: with perceptual disturbance.


Permutations

• 10 substances x 5 conditions = 50• Exceptions:• No caffeine intoxication disorder• No hallucinogen or inhalant withdrawal

disorders• Hallucinogen persisting perception disorder• No tobacco intoxication disorder• Gambling disorderAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

AlcoholIntoxication

B. Inappropriate sexual or aggressive behavior, mood lability, impaired judgment

C. 1 or more of:

•Slurred speech

•Incoordination

•Unsteady gait

•Nystagmus

•Impairment in attention or memory

•Stupor or coma

Withdrawal (2+ within hrs-days)

•Autonomic hyperactivity•E.g., sweating or pulse rate >100 bpm

•Increased hand tremor

•Insomnia

•Nausea or vomiting

•Transient visual, tactile, or auditory hallucinations or illusions

•Psychomotor agitation

•Anxiety

•Generalized tonic-clonic seizures


Alcohol BAC and effects

Kelly JF, Renner JA, Alcohol-Related Disorders, Massachusetts General Hospital Comprehensive Clinical Psychiatry

Alcohol withdrawal time course

4 classic categories: withdrawal tremulousness,hallucinations, seizures, and DT

ALCOHOL ABUSE AND DEPENDENCEPATRICK G. O’CONNOR

O’Connor PG, Alcohol Abuse And Dependence, Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 31.

CAGE questionnaire

1.Have you ever felt you needed to Cut down on your drinking?

2.Have people Annoyed you by criticizing your drinking?

3.Have you ever felt Guilty about drinking?

4.Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

CAGE test scores >=2 is positive

Excessive drinking: specificity 76%, sensitivity of 93%

alcoholism: specificity of 77%, sensitivity of 91%

Kitchens JM (1994). "Does this patient have an alcohol problem?". JAMA 272 (22):1782–7.

Alcohol withdrawal syndrome admission management goals

1. Monitor course of syndrome, ensuring patient safety2. Use methods to abort progression and treat

symptoms3. Manage comorbid medical, surgical, toxicologic, and

psychiatric problems4. Anticipate need for intensive care monitoring and

therapy5. Ensure multidisciplinary approach to management,

including preparation for rehabilitation

Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585

Objectives for alcohol withdrawal services

1. To interrupt a pattern of heavy and regular alcohol use

2. To alleviate withdrawal symptoms

3. To prevent severe withdrawal complications

4. Facilitate linkages to ongoing treatment for alcohol dependence.

5. To get help with any other problems

N.B. Successful completion of alcohol withdrawal does not prevent recurrent alcohol consumption and additional interventions are needed to achieve long-term

Australian Alcohol Guidelines.

Admission studies for patients with moderate to severe alcohol withdrawal syndrome

1. Complete blood cell count

2. Baseline metabolic panel with serum electrolytes (including magnesium), glucose, renal

function tests

3. Blood alcohol, and urine and blood toxicology studies

4. Serum calcium, phosphate, lipase, CPK activity

5. Liver function tests, including INR and serum AST, ALT, bilirubin, ammonia

6. Chest radiograph

7. Electrocardiogram, cardiac biomarkers, echocardiogram

8. Urinalysis

9. Arterial blood gas analysis

10. Blood, urine, and sputum cultures

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CPK, creatine

phosphokinase; INR, international normalized ratio.

a Laboratory, imaging, and clinical evaluations must be individualized.


Alcohol labs

Blood alcohol level

Alcohol-use disordersMarc A Schuckit, Lancet 2009; 373: 492–501

Alcohol treatment medications

O’Connor PG, Alcohol Abuse And Dependence, Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 31.

UNM CIWA protocol

Risk factors for severe course of AWS, including seizures and delirium

1. Prior episodes of AWS requiring detoxification, including seizures or delirium (kindling)

2. Grade 2 severity or higher on presentation (CIWA-Ar Score >10)

3. Advanced age

4. Acute or chronic comorbid conditions, including alcoholic liver disease, co-intoxications,

trauma, infections, sepsis

5. Detectable blood alcohol level on admission

6. Use of “eye opener,” high daily intake of alcohol, or number of drinking days/month

7. Abnormal liver function (serum aspartate aminotransferase activity >80 U/L)

8. Prior benzodiazepine use

9. Male sex

Abbreviation: CIWA-Ar, Clinical Institute of Withdrawal Assessment for Alcohol, revised.


Potential indications for ICU management

1. Advanced Stage 2 or greater alcohol withdrawal syndrome

2. Critical comorbid conditions including: trauma; severe sepsis; respiratory failure; acute respiratory distress syndrome; hemodynamic instability; gastrointestinal bleeding; hepatic failure; pancreatitis; rhabdomyolysis; co-intoxication; coagulopathies; acute CNS process; cardiac arrhythmias, ischemia, or congestive failure; severe fluid or electrolyte defects; renal failure; persistent fever; or complex acid-base defects

3. Escalating intravenous bolus or continuous-infusion sedation therapy

4. Persistent fever >39 C


DeliriumDiagnostic Criteria

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

D. The disturbances in Criteria A or C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.


DeliriumDiagnostic criteria

Specifiers:

Substance intoxication delirium Substance withdrawal delirium

Medication-induced delirium Delirium due to multiple etiologies

Delirium due to another medical condition

Acute: lasting a few hours or days

Persistent: lasting weeks or months


Differentiate delirium tremens from other alcohol withdrawal syndromes

• 5% of patients with alcohol withdrawal• Constellation of symptoms: confusion, hallucinations, fever

(with or without evidence of infection), and autonomic hyperresponsiveness with hypertension and profound tachycardia

• Suspect in any agitated patient withdrawing from alcohol with BP >140/90 mm Hg, HR > 100/min, T > 101 Fahrenheit

• Mortality 5-15%

Erwin WE et al, Delirium tremens, Southern Medical Journal (May 1998, 91:5), 425-432.

Acetaminophen metabolism

Salhanick SD, Shannon MW, Acetaminophen, Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed., 2007.

Algorithm showing current recommendations for N-acetylcysteine (NAC) treatment of acetaminophen overdose.

Chun LJ et al, Acetaminophen Hepatotoxicity and Acute Liver Failure, J Clin Gastroenterol 2009;43:342–349.

CaffeineIntoxication (5 or more of):

•Restlessness

•Nervousness

•Excitement

•Insomnia

•Flushed face

•Diuresis

•Gastrointestinal disturbance

•Muscle twitching

•Rambling flow of thought and speech

•Tachycardia or cardiac arrhythmia

•Periods of inexhaustibility


Withdrawal (3 or more within 24 hr of:)

•Headache

•Marked fatigue or drowsiness

•Dysphoric mood, depressed mood, or irritability

•Difficulty concentrating

•Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness)


CannabisIntoxication

B. Impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal

C. 2 or more within 2 hrs of:

•Conjunctival injection

•Increased appetite

•Dry mouth

•tachycardia

Withdrawal (3 or more within 1 wk:)

•Irritability, anger, or aggression

•Nervousness or anxiety

•Sleep difficulty (e.g., insomnia, disturbing dreams)

•Decreased appetite or weight loss

•Restlessness

•Depressed mood

•At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache


Synthetic marijuanaSpice and K2

• Synthetic marijuana (often known as “K2” or “Spice”)consists of plant material that has been laced with substances (synthetic cannabinoids) that users claim mimics Δ9-tetrahydrocannabinol(THC), the primary psychoactive active ingredient in marijuana, and are marketed toward young people as a “legal” high.

• According to data from the 2011 Monitoring the Future survey of youth drug-use trends, 11.4 percent of 12th graders used Spice or K2 in the past year, making it the second most commonly used illicit drug among seniors.

• The effects of synthetic marijuana include agitation, extreme nervousness, nausea, vomiting, tachycardia (fast, racing heartbeat), elevated blood pressure, tremors and seizures, hallucinations, and dilated pupils.

White House, Office of National Drug Control Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath Salts, etc.), http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts

Proposed Clinical Criteria forCannabinoid Hyperemesis

Essential for diagnosis• Long-term cannabis use

Major features• Severe cyclic nausea and vomiting• Resolution with cannabis cessation• Relief of symptoms with hot showers or baths• Abdominal pain, epigastric or periumbilical• Weekly use of marijuana

Supportive features• Age less than 50 y• Weight loss of >5 kg• Morning predominance of symptoms• Normal bowel habits• Negative laboratory, radiographic, and endoscopic test results

Simonetto DA et al, Cannabinoid Hyperemesis: A Case Series of 98 Patients, Mayo Clin Proc. 2012;87(2):114-119

HallucinogensPCP Intoxication

B. belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgment

C. 2 or more within 1 hr:•Vertical or horizontal nystagmus•Hypertension or tachycardia•Numbness or diminished responsiveness to pain•Ataxia•Dysarthria•Muscle rigidity•Seizures or coma•hyperacusis

Other hallucinogen intoxication

B. Marked anxiety or depression, ideas of reference, fear of “losing one’s mind,” paranoid ideation, impaired judgment

C. 2 or more of:

•Pupillary dilation

•Tachycardia

•Sweating

•Palpitations

•Blurring of vision

•Tremors

•incoordination


Jimson weedDatura stramonium

• Contains anticholinergics atropine and scopolamine and is hallucinogenic

• Symptoms of toxicity usually occur within 30-60 minutes after ingestion and may continue for 24-48 hours because the alkaloids delay gastrointestinal motility.

• Ingestion of Jimson weed manifests as classic atropine poisoning. Initial manifestations include dry mucous membranes, thirst, difficulty swallowing and speaking, blurred vision, and photophobia, and may be followed by hyperthermia, confusion, agitation, combative behavior, hallucinations typically involving insects, urinary retention, seizures, and coma.

• Treatment consists of supportive care, gastrointestinal decontamination (i.e., emesis and/or activated charcoal), and physostigmine in severe cases.

Epidemiologic Notes and Reports Jimson Weed Poisoning -- Texas, New York, and California, 1994. MMWR (1995) 44(03);41-44. https://en.wikipedia.org/wiki/Datura_stramonium

Inhalant Intoxication

B. belligerence, assaultiveness, apathy, impaired judgment

C. 2 or more of:•Dizziness•Nystagmus•Incoordination•Slurred speech•Unsteady gait•Lethargy

•Depressed reflexes•Psychomotor retardation•Tremor•Generalized muscle weakness•Blurred vision or diplopia•Stupor or coma•Euphoria


OpioidsIntoxication

B. Initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment

C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) + 1 or more of:

•Drowsiness or coma

•Slurred speech

•Impairment in attention or memory

Withdrawal (3+ within min-days:)

•Dysphoric mood


•Muscle aches

•Lacrimation or rhinorrhea

•Pupillary dilation, piloerection, or sweating

•Diarrhea

•Yawning

•Fever

•insomnia

Management of injecting drug users admitted to hospitalPaul S Haber, Abdullah Demirkol, Kezia Lange, Bridin Murnion, Lancet 2009; 374: 1284–93

Sedative-, Hypnotic-, or Anxiolytic-related disorders

Intoxication

B. Inappropriate sexual or aggressive behavior, mood lability, impaired judgment

C. 1 or more of:

•Slurred speech

•Incoordination

•Unsteady gait

•Nystagmus

•Impairment in cognition (e.g., attention, memory)

•Stupor or coma

Withdrawal (2+ within hrs-few days)

•Autonomic hyperactivity (e.g., sweating or pulse greater than 100 bpm)

•Hand tremor

•Insomnia


•Transient visual, tactile, or auditory hallucinations or illusions


•Anxiety

•Grand mal seizuresAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

StimulantsIntoxication

B. Euphoria or affective blunting; changes in sociability; hyperviligance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment

C. 2 or more of:•Tachycardia or bradycardia•Pupillary dilation•Elevated or lowered blood pressure•Perspiration or chills•Nausea or vomiting•Evidence of weight loss•Psychomotor agitation or retardation•Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias•Confusion, seizures, dyskinesias, dystonias, or coma

Withdrawal

Dysphoric mood + 2+ within few hours-days:

•Fatigue

•Vivid, unpleasant dreams

•Insomnia or hypersomnia

•Increased appetite

•Psychomotor retardation or agitation


Bath salts

• •Bath salts contain manmade chemicals related to amphetamines that often consist of methylenedioxypyrovalerone (MDPV), mephedrone, and methylone, also known as substituted cathinones.

• Similar to the adverse effects of cocaine, LSD and methamphetamine, bath salt use is associated with increased heart rate and blood pressure, extreme paranoia, hallucinations, and violent behavior, which causes users to harm themselves or others.

White House, Office of National Drug Control Policy, Synthetic Drugs (a.k.a. K2, Spice, Bath Salts, etc.), http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts

Amphetamine effects

Albertson TE et al, Amphetamines and derivatives, Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed.200

“Faces of Meth”

Faces of Meth, Multnomah County Sheriff’s Office, http://www.facesofmeth.us/


Amphetamine treatment algorithm


Tobacco Withdrawal

Cessation followed within 24 hours by four (or more) of the following signs or symptoms:

• Irritability, frustration, or anger• Anxiety• Difficulty concentrating• Increased appetite• Depressed mood• insomniaAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Other (or Unknown) Substances

• Anabolic steroids• Nonsteroidal anti-inflammatory drugs• Cortisol• Antiparkinsonian medications• Antihistamines• Nitrous oxide• Amyl-, butyl-, or isobutyl-nitrites• Betel nut• Kava• Cathinones (e.g., khât)


Substance/medication-induced mental disorders

A. The disorder represents a clinically significant presentation of a relevant mental disorder.

B. There is evidence from the history, physical examination, or laboratory findings of both of the following:

1. The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and

2. The involved substance/medication is capable of producing the mental disorder.

C. The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental disorder could include the following:

1. The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or

2. The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal.

D. The disorder does not occur exclusively during the course of a delirium.

E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Substance/medication-induced mental disorders

• Psychotic disorders• Bipolar disorders• Depressive disorders• Anxiety disorders• Obsessive-compulsive and related disorders• Sleep disorders• Sexual dysfunctions


Discussion &Action Items

• Which labs are needed for patients with overdose? Do all such patients need to be admitted? If not, when is it safe to discharge them?

• Do all alcohol withdrawal patients need to be admitted? If not, when, to where, and with what medications (if any)?

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