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Tuesday 5th February 2008, 9pm, BBC Two Recent research has analyzed the link between the harmful effects of drugs relative to their current classification by law with some startling conclusions.

Perhaps most startling of all is that alcohol, solvents and tobacco (all unclassified drugs) are rated more dangerous than ecstasy, 4-MTA and LSD (all class A drugs). If the current ABC system is retained, alcohol would be rated a class A drug and tobacco class B.

• The 9.6% of adult alcoholics drink 25% of the alcohol that is consumed by all adult drinkers. • American youth who drinking before the of age 15 are four times more likely to become alcoholics than young people who do not drink before the age of 21. • Every year, 1,400 American college students between the ages of 18 and 24 die from alcohol-related inadvertent injuries, including motor vehicle accidents. • In the United States during 2004, 16,694 deaths occurred as a result of alcohol-related motor-vehicle crashes. This amount was approximately 39% of all traffic fatalities. This amounts to one alcohol-related death every 31 minutes.

American Journal of Psychiatry

Unmanaged Alcohol withdrawal will kill your patients.

Alcohol Models

Alcohol binds to GABA, enables ion channel to stay open longer. More clˉ to enter the cells

GABA’s effect is to reduce neural activity by allowing chloride ions to enter the post-synaptic neuron. These ions have a negative electrical charge, which helps to make the neuron less excitable.

Ethanol has a complex mode of action and affects multiple systems in the brain. Parietal Lobes Reading, writing, and language disorders Difficulty recognizing visual and tactile information Difficulty with dressing, drawing, and hand-eye coordination Distortions in body image and spatial abilities (i.e., inattention to information received on one side of the visual field Frontal Lobes Disruptions in complex motor skills, including speech Difficulties planning, organizing, and sequencing events Loss of control over emotions and behavior (i.e., personality changes), decreased selfawareness, poor judgment and reduced social skills Decreased attention and loss of memory

The Cerebellum coordinates muscle movement. When alcohol affects the cerebellum, muscle movements become uncoordinated.

Temporal Lobes Specific memory impairments (i.e., prosopagnosia— inability to recognize faces) Difficulty understanding spoken language (i.e., aphasia) Impaired sense of smell

The Cerebral Cortex initiates the muscular movement by sending a signal through the medulla and spinal cord to the muscles. As the nerve signals pass through the medulla, they are influenced by nerve impulses from the cerebellum, which controls the fine movements, including those necessary for balance.

Absorption from the Gut •Time of day •Drinking pattern •Dose form •Concentration of ethanol in the beverage •Recent and current food (it tends to be much higher in fasting) •Gastric emptying time

Images displayed in the coronal orientation from MRI and DTI studies of a 61-year-old healthy man (upper images) and a 60year-old alcoholic man (lower images). The highresolution MRI slices are at the same locations as the fractional anisotropy images of the DTI panels. Note on the MRI the thinner corpus callosum displaced upward by enlarged ventricles and, on the DTI, less well delineated white matter tracts in the alcoholic man compared with the healthy man.

Late alcohol withdrawal is also known as delirium tremens—the DTs—and consists of the worsening autonomic dysregulation that is responsible for the morbidity and mortality attributed to alcohol withdrawal. It begins after early withdrawal—usually 72 hours or more after the last drink. Some patients do not progress from early to late withdrawal, and their symptoms simply subside after a few days, with or without treatment. But it is impossible to predict which patients will progress and which will not. The signs of late withdrawal consist of worsening diaphoresis, nausea, and vomiting (which may result in aspiration pneumonia), delirium with frank hallucinations, and rapid, severe fluctuation in vital signs. Sudden changes in blood pressure and heart rate may result in complications such as myocardial infarction or a cerebrovascular event. Untreated late withdrawal results in significant morbidity and even death. Adequate treatment of early withdrawal prevents progression to late withdrawal.

• An acute confusional state caused by withdrawal from alcohol. Usually begins 3-4 days after withdrawal, though may occur while individual is still drinking (possibly due to a reduced alcohol level). • It is either of sudden onset or there is a prodromal phase of restlessness, anxiety and insomnia, with above symptoms of alcohol withdrawal. Additionally there is reduced level of consciousness, disorientation in time and place, impairment of sensory stimuli with hallucinations. Visual hallucinations may be Lilliputian, complex, frightening or vivid. The symptoms are worse at night and last for 2-3 days.

Clinical Institute Withdrawal Assessment (For Alcohol, Revised)

It is a scale used to measure CNS hyperactivity observed in alcohol withdrawal. It is a standardized assessment used in Emergency Rooms, Outpatient Treatment Clinics and for Inpatient Hospitalizations.

Ciwa-AR is a symptom triggered assessment, based on your observations.

• For an initial interview consider: • The severity of withdrawal coincides with the: • Amount of alcohol ingested, • assess Breath Analysis (BA) or Serum ETOH • Duration of alcohol use • Assessment hints, ask: • “How long have you been drinking?” • “What do you usually drink?” • “When was your last drink?”

Rate the patient according to the 10 categories on the bedside assessment sheet. 

Determine the score. (Less then 10 usually do not need more medication for withdrawal. Max score is 67)

Medicate with PRN’s to keep the patient slightly sedate or calm.

Alterations in ECG, in particular an increase in QT interval, and EEG abnormalities including may occur during early withdrawal

You do not want this

Polymorphic ventricular tachycardia (Torsade de Pointes) 2/2 hypomagnesimia and prolonged QT interval

 The next few slides give the overview of how the CIWA-AR appears in CPRS and the correct assessment techniques.  CIWA-AR uses two assessment techniques for data collection:  Subjective data (patient answers direct questions)  Objective data (observation by nurse)

CIWA-AR CPRS Screen Shots

Screen Shot: Tremor

Screen Shot: Paroxysmal Sweats

Screen Shots: Anxiety

Screen Shot: Agitation

Screen Shot: Tactile Disturbances

Screen Shots: Auditory Disturbances

Screen Shots:Visual Disturbances

Screen Shots: Headache

Screen Shots: Orientation

Screen Shots: Total Score

CLINICAL INSTITUTE WITHDRAWAL ASSSESSMENT OF ALCOHOL SCALE - REVISED (CIWA-AR) NAUSEA AND VOMITING 4 - Intermittent nausea with dry heaves TREMOR 1 - Not visible, but can be felt fingertip to fingertip PAROXYSMAL SWEATS 4 - Beads of sweat obvious on forehead ANXIETY

7 - Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions AGITATION 7 - Paces back and forth during most of the interview, or constantly thrashes about TACTILE DISTURBANCES 4 - Moderately severe hallucinations AUDITORY DISTURBANCES 3 - Moderate harshness or ability to frighten VISUAL DISTURBANCES 6 - Extremely severe hallucinations HEADACHE, FULLNESS IN HEAD 3 - Moderate ORIENTATION AND CLOUDING OF SENSORIUM 3 - Disoriented for date by more than 2 calendar days


Alcohol Addiction is a biopsycho-social-spiritual disease . CIWA-aR is a symptom triggered assessment designed to assess severity of withdrawal. Alcohol withdrawal can kill your patient if you “fail to rescue� with the CIWA-aR.

• Rehydration Correct any electrolyte imbalance (banana bag) Mg for cardiac disturbances, • Risk of precipitating Wernicke’s encephalopathy 3 days parenteral thiamine, folic acid, MVI • Correct hypoglycemia with caution (2/2 glucose loading precipitates encephalopathy.) • Reducing regimen of benzodiazepines or Chlordiazepoxide • Treat seizures with rectal or IV diazepam • Consider anticonvulsant for elective withdrawal if there is a history of withdrawal seizures

CIWA-AR for Acute Alcohol Withdrawal