© Hoyle Leigh & Jon Streltzer 2015
Hoyle Leigh and Jon Streltzer (eds.)Handbook of Consultation-Liaison Psychiatry10.1007/978-3-319-11005-9_2020. Substance Related and Addictive Disorders
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Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Ho1356 Lusitana St., 4th Floor, Honolulu, HI 96813, USA
20.1 Introduction
Substance abuse is a major problem in consultation liaison psychiatry, disproportionate to the degree of substance abuse in the community. Twenty to thirty percent of consultations in a general hospital have been reported to involve a substance abuse diagnosis, and this has been consistent over time (Bourgeois et al. 2005; Alaja et al. 1998).
A number of medical complications, direct and indirect, occur due to the use of substances of abuse, and result in medical admissions. Motor vehicle accidents, falls, and other kinds of trauma are so frequently associated with substance use that trauma services routinely do urine toxicology to screen new admissions for drugs and alcohol (Silver & Sporty 1990).
The consultation-liaison psychiatrist is typically called upon to diagnose and treat patients for the substance abuse problems that are present. Motivating the patient for treatment and/or making some kind of long-term treatment plan is often the main reason for the consult. In addition, there may be an acute problem associated with intoxication or withdrawal that needs to be assessed and managed. These issues are discussed with a focus on the practical issues facing the consultation-liaison psychiatrist (Haber et al. 2009).
20.2 Alcohol
The consultation liaison psychiatrist will frequently be called to assist in the care of patients with alcohol use disorder.
20.2.1 Diagnosis
DSM-5 lists 11 criteria, 2 of which are required to diagnose alcohol use disorder. These criteria include tolerance, withdrawal, loss of control of use, craving, and various adverse effects on activities and functioning. The patient can be considered in early remission if no criteria are met for at least 3 months, and in sustained remission if no criteria are met for at least 12 months. A separate diagnosis, alcohol intoxication, is diagnosable if alcohol causes clinically significant behavioral or psychological problems and one of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma. Most of these signs aren’t readily elicited when the patient is examined in the emergency room or in a hospital bed. For the consultation-liaison psychiatrist, the importance of diagnosing alcohol intoxication is to avoid too early treatment of alcohol withdrawal, possibly exacerbating the intoxicated state.
Alcohol withdrawal is a separate disorder caused by the reduction in or cessation of heavy, prolonged alcohol use. Two or more of certain signs or symptoms are required to make the diagnosis. These include autonomic hyperactivity such as diaphoresis or rapid pulse, hand tremor, insomnia, nausea or vomiting, transient sensory illusions or hallucinations, agitation, anxiety, and generalized seizures.
The diagnosis of alcohol withdrawal delirium is specified in a separate section of DSM 5. It requires a disturbance in attention and cognition, such as disorientation and fluctuating states of awareness, all of which are due to alcohol withdrawal.
The most common reason for psychiatric consultation with the alcoholic patient has to do with the prevention or treatment of alcohol withdrawal. Alcohol withdrawal delirium, or delirium tremens, can be life threatening, and it is important to treat this condition vigorously if this diagnosis is suspected. Referring physicians may be confident that alcohol withdrawal delirium is present, or they may be unsure or unaware of it and think that a functional psychosis is present instead. In addition to a history of alcohol dependence and a mental status consistent with delirium, physical signs are usually present and help clarify the diagnosis. These include tremor, increased deep tendon reflexes, and often ankle clonus, all signs easily checked at the bedside during the consultation. Vital signs will usually indicate autonomic instability, but these are nonspecific and cannot be relied upon alone. The likelihood of alcohol withdrawal producing symptoms is related to a number of factors, including the duration of drinking, the amount of alcohol consumed on average per day, and the age and weight of the patient. It is common for the patient to underestimate the amount of alcohol imbibed. On rare occasions the patient may overestimate the amount, particularly if the patient knows this may lead to more vigorous drug treatment. Collateral information can be extremely helpful in determining the extent of alcohol dependence.
20.2.2 Treatment of Alcohol Withdrawal
Case vignette: A 220–lb, 55–year–old man with a history of alcohol abuse developed delirium 2 days after being hospitalized for a medical problem. The psychiatric consultant, suspecting alcohol withdrawal, recommended diazepam, 20 mg orally every 2 h unless asleep. Within 3 days he had fully recovered and the dose was rapidly tapered. When the patient was confronted with the fact that his delirium had been due to alcohol withdrawal, he insisted that he never drank more than three or four beers per day. His wife, however, pointed out that he drank a case of beer or more every night.
There are a number of methods for managing alcohol withdrawal. The benzodiazepines are the treatment of choice due to effectiveness and the lack of toxicity. The general principle is to give benzodiazepines in sufficient doses to ameliorate the delirium. This usually means that the patient will go to sleep, after which the delirium often breaks (Kotorii et al. 1982).
Structured protocols have been recommended for determining the dose of the benzodiazepines. A common one is called CIWA (Clinical Institute Withdrawal Assessment). In this protocol the dose of benzodiazepines is determined by rating various signs and symptoms consistent with alcohol withdrawal. Studies have shown that in a population of alcohol abusers in which no one goes into alcohol withdrawal delirium, less benzodiazepines are likely to be used than another method involving giving a fixed dose. No studies have been reported of CIWA’s effectiveness for patients already in actual alcohol withdrawal delirium. Thus, it is possible that this protocol may not be reliably effective enough for the population of alcoholics that are actually going to go into withdrawal. Practically, this protocol may be of little value on a medical floor where the nurses are not familiar or experienced in its use (Bostwick and Lapid 2004). They are unlikely to keep track of the relatively complicated ratings necessary to determine the benzodiazepine dose. If this protocol is ordered on a medical floor, the patient will commonly get very little in the way of benzodiazepines, irrespective of the clinical condition (Stanley et al. 2005).
A similar, but even more complicated protocol has been tested in surgical patients. This protocol was triggered using lorazepam with the development of any alcohol withdrawal symptom, but almost half of these patients went on to develop delirium anyway. It is not known if the protocol reduced the number of patients who would have developed delirium or not, but the author’s observation that short-acting benzodiazepines can trigger alcohol withdrawal symptoms is consistent with this study. In any event, such a protocol would require extensive training of nurses, however, and practicalities would make it difficult to use (Neyman et al. 2005).
A much simpler technique that can be easily managed on the medical ward is to give a long-acting benzodiazepine on a fixed schedule, and monitor frequently to see if the dose needs to be adjusted. If the patient is found to be in withdrawal delirium, 20 mg of diazepam every 2 h can be given and the dose held if the patient is asleep. If there is no improvement after two or three doses, the dose needs to be raised accordingly. By holding the dose if the patient sleeps, excessive and prolonged sedation will be avoided. This is an easy protocol for the nurses to follow, and they will not experience difficulties with it.
There is some controversy about which benzodiazepines are superior, with the argument based on whether the short acting lorazepam is superior because it is not solely metabolized by the liver (as it is also secreted in urine), or whether long-acting benzodiazepines are superior because they do not wear off rapidly and will not enhance the precipitation of withdrawal symptoms every few hours. The literature consists mostly of opinion. I could find no reports of problems associated with long-acting benzodiazepines in patients with liver disease. If one does not continue to dose when the patient is sleeping, the patient is not likely to be overdosed due to inability to metabolize the drug. On the other hand, there are reports where the delirium is exacerbated by the use of intermittent short-term benzodiazepines, not uncommon in this author’s experience. When the benzodiazepine wears off it seems to stimulate the withdrawal, just as giving alcohol, and then letting it rapidly wear off, might be expected to do. If the short acting benzodiazepines are given frequently, however, such as by continuous intravenous drip, then this should not be a problem.
Once the delirium breaks, and the patient is able to sleep soundly, the benzodiazepine can be tapered very rapidly. If the patient is mentally clear, tapering the benzodiazepine over 2–3 days should cause no problems.
To prevent or treat Wernicke’s encephalopathy, thiamine 500 mg IV should be given three times a day for 3–5 days (Parker et al. 2008; Patient.co.uk 2014). Such patients should continue thiamine 100 mg per day.
Some alcohol dependent patients who have had numerous episodes of delirium tremens and have been alcoholics for a long time may not completely clear from their episode of withdrawal delirium. They may have a residual dementia (Korsakoff’s psychosis). If alcohol is not reintroduced they may slowly improve over a period of months. When the mental status changes seem to have stabilized, benzodiazepines are probably no longer useful and they can increase the probability of cognitive disturbance.
20.3 Opioids
Consultations involving issues associated with prescription pain medications are discussed in Chap. 22. In this section, the focus is on patients using illicit opioids.
Not infrequently, heroin addicts are hospitalized for medical conditions, and psychiatric consultation is requested. Referring physicians are often quite uncomfortable with these patients, not understanding their lifestyle, and communication is difficult. The psychiatric consultant should attempt to begin treatment for their narcotic dependence to the extent possible while they are in the hospital. Indeed, such patients are a captive audience while receiving medical treatment; sobriety is maintained with its benefits on cognition. A relationship can be developed and they will not run away. A psychotherapeutic intervention, be it support, confrontation, or motivational enhancement (Baer et al. 1999) has a better chance to take hold.
The opioid addict should not be forced to endure withdrawal as a punishment for drug abuse. There is no evidence that this leads to a better outcome. Detoxification should occur as comfortably as possible in the hospital while the patient is being treated for a medical condition. Ideally, the consultant knows how long the patient will be in the hospital, and this determines the speed of detoxification, especially when outpatient follow-up compliance cannot be assured, as is usually the case.
Case example: A 33–year–old man was admitted for cellulitis of the leg. He was heroin dependent, and when seen the day after admission, he complained that he was “jonesing” (a slang term for being in withdrawal). He was postured in a curled up position, and had piloerection and dilated pupils. He had not slept the previous night. Administration of 20 mg methadone made him comfortable after an hour. He stabilized on 15 mg twice per day, was eating well, sleeping satisfactorily, and pupils were about 3 mm in diameter. He complained that he still felt as if he were in withdrawal and thought 45–50 mg of methadone per day would do the trick. Instead, he was told that discharge was anticipated in a week, and he would be detoxified and encouraged to go to a drug treatment program. He insisted that he be maintained on methadone, and that the dose should be raised, because he would follow up with a methadone program where they were expecting him and would maintain him on 95 mg per day. He was told that if the program were indeed going to maintain him, this could be done in the hospital, but it would have to be coordinated with the methadone program. He reluctantly gave permission to contact them since this was the only possibility he could get his desired dosing schedule, and this was done, but the story turned out differently. The patient was indeed known to the methadone treatment program, but he had never followed through to enter treatment or even be detoxified. The program would need to carefully evaluate him before considering accepting him as a client—they would not automatically accept him for maintenance on 95 mg, or any dose.
The patient was counseled on what to do to get in the program. He was told that for the remaining time in the hospital he would be given a liquid solution of methadone to regulate the dose better, and it was advisable that he not be told the dose. He balked at this. He was then told that if he insisted on knowing the dose, it would automatically be lowered each time because his complaints might reflect anxiety, but if he did not know the dose, his complaints would be evaluated carefully with every attempt being made to keep him comfortable. He agreed to not be told his dose. He was given a 30 cc liquid solution of juice and varying doses of methadone. He was started at 9 mg three times per day, with a reduction of 2 mg per dose the next day, and 1 mg per dose each day after that. At discharge, he was given a solution of 1 mg per 30 ml, and told to take 1 tablespoon (15 ml) every 12 h until none was left. He was given 90 ml. Even if he took it all at once, it would not hurt him, being too small a dose to resume a physical dependence. In any event, he would have had a week of psychotherapy to motivate him to enter a treatment program, and he would have a greater opportunity for such, being free of an opioid habit.
Heroin addicts may or may not try to hide their addiction when they are seen in the general medical hospital often for trauma. It is not uncommon that they will try to smuggle in a supply of heroin with them to use while they’re being treated.
Case example: A 32–year–old man was admitted to the hospital with a broken mandible. Three days after admission he demanded to see a psychiatrist. He stated that he had brought a supply of heroin with that, but had not anticipated that his hospitalization would be longer than 2 days, so he had run out. He believed he was experiencing opioid withdrawal and desperately wanted help. Although 20 mg of methadone can often be expected to alleviate heroin withdrawal, this patient claimed that his supply was very good stuff, and indeed, after 30 mg of methadone he was still very uncomfortable and had dilated pupils. The next day he was given 40 mg and his pupils went down to 3 mm, at which time he felt comfortable. The dose was then reduced steadily each day while he was in the hospital. He revealed his multiple social problems to the psychiatric consultant during follow–up visits. After a few days, he acknowledged that heroin was at the center of his problems, and he agreed to placement in a residential treatment program.
In some hospitals, the use of methadone for detoxification is discouraged. This is unfortunate since there is no restriction on the use of methadone for detoxification from opioid dependence in the hospital when the patient is admitted for treatment a medical condition. Clonidine is sometimes recommended as an alternative. The use of this drug can be appealing, since it is not a narcotic, and it does suppress some withdrawal symptoms. It is only partially effective in this regard, however, and large doses are often needed, which can interfere with the concurrent medical treatment. Furthermore, the patient is likely to remain much more uncomfortable in contrast to methadone, and clonidine itself will have to be tapered (Ling et al. 2005).
Reports of the utility of buprenorphine in the hospital setting are increasing. Evidence is accumulating that buprenorphine has advantages over methadone in the treatment of some opioid addicts (Gowing et al. 2009). For heroin addiction, sublingual dosing of 4–24 mg over 24 h will likely eliminate withdrawal symptoms. The dose can then be rapidly tapered over a few days, or even stopped after 1 day, and the patient is likely to remain physically comfortable, with minimal to no withdrawal symptoms. Follow-up drug treatment after discharge from the hospital is critical, however, or else the relapse rate is extremely high.
Buprenorphine is a major therapeutic advance in the treatment of opioid use disorders. It is a partial agonist at the mu opioid receptor. Clinically, this means there is a ceiling effect and raising the dose beyond a certain point has essentially no effect. Thus, respiratory depression rarely occurs even in overdose situations, unless the individual has no tolerance to opioids or mixes buprenorphine with other drugs or alcohol. In the treatment of opioid withdrawal, one or two doses is usually all that is needed to eliminate withdrawal symptoms and restore the patient to reasonable comfort. Caution is warranted, however, to make sure the patient is actually in opioid withdrawal. Dilated pupils, clammy skin, piloerection, insomnia, poor appetite, and body aches are clinical signs of withdrawal that predict a good immediate response to buprenorphine.
If the patient has high doses of opioids in his/her system, then buprenorphine can precipitate withdrawal symptoms. This is because buprenorphine affiliates to the mu opioid receptor more strongly than most other opioids, and will replace them on the receptor. Being only a partial agonist, however, it may not stimulate the receptor enough to prevent the withdrawal symptoms caused by loss of the other opioid. This is particularly a problem if the patient had been taking methadone at doses of more than 20–30 mg daily for extended periods of time. In that case, methadone must be tapered to a dose less than 30 mg, the amount depending on how long they had been taking methadone daily. To continue treatment with buprenorphine in outpatient follow-up, the prescriber must have an additional waiver on his/her narcotics license to prescribe buprenorphine for opioid use disorders.
20.4 Stimulants: Amphetamines and Cocaine
The stimulant drugs amphetamine, methamphetamine, and cocaine have much in common, with the primary clinical difference being duration of action with cocaine wearing off much more rapidly. Amphetamine pills were a common source of substance abuse problems in the 1960s and 1970s. A smokable form of methamphetamine became widely abused in the 1980s in Hawaii (Jackson 1989), and it has since spread throughout the country. Stimulant abuse with methamphetamine is now common although cocaine remains most popular in the Eastern part of the USA and is also widely prevalent in the rest of the country. Stimulants are the cause of many hospital admissions, and consultation-liaison psychiatrists frequently are consulted (Baberg et al. 1996). Cardiac complications are often present in otherwise young, healthy-appearing individuals (Hawley et al. 2013)
Some of these patients are in amphetamine or cocaine withdrawal, sleeping most of the time and quite hungry. They may appear severely depressed when awake. If the depression does not clear in 2 or 3 days, it may need specific treatment. These patients are usually not management problems, but will have varying degrees of denial about their problem. When they are confined to the hospital because of their medical problem, there is an opportunity to confront their denial and strongly recommend treatment and a change in their lifestyle. Ideally, there is a significant other that is supportive in the hospital and encourages the person.
Related posts:
The Why and How of Psychiatric Consultation
Interviewing in Consultation-Liaison Psychiatry
Systems and Ethical Issues in CL Psychiatry: Hospital as a Social System, Sick Role and Doctor Role, Ethical and Legal Issues
Somatic Symptom and Related Disorders
The Renal Dialysis and Kidney Transplant Patient
Obstetrics and Gynecology Patients: Menstrual Cycle, Pregnancy, and Postpartum-Related Psychiatric Disorders
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