Severe Alcohol Withdrawal: Complexity and Controversy (1.5 CME)
(1.5 CME) In this conference recording from the 2019 Annual Conference, you will learn:
|As addiction medicine is growing as a specialty and with the public due to the opioid epidemic. Thus, addiction medicine specialists are increasingly likely to be called upon as experts to guide other providers in best practices for treatment of medical problems related to substance use disorders. As 15.1 million adults had an alcohol use disorder based on 2016 NSDUH survey results and increasing rates of emergency department visits related to alcohol, it is important for addiction medicine providers to understand the management alcohol withdrawal. The risk of alcohol withdrawal in hospitalized patients has been reported as 8%, with a 20% incidence of severe withdrawal in patients who develop alcohol withdrawal . Morbidity associated with alcohol withdrawal includes mechanical ventilation, increased length of stay in hospital and the ICU, and infection and though mortality from severe alcohol withdrawal syndrome has improved over the last 50 years up to 4% of hospitalized patients with severe alcohol withdrawal delirium die. With this ongoing morbidity and mortality, there are still many questions left unanswered. Who will develop severe symptoms from alcohol withdrawal? Are benzodiazepines the best option for treatment of withdrawal? What other therapies could be instituted to decrease the morbidity of severe withdrawal? In this workshop we describe how the pathophysiology and resultant clinical presentation of alcohol withdrawal informs the rationale behind the use of GABA and non-GABA medications and treatment protocols for severe withdrawal. The pharmacology of both GABA agents (benzodiazepines, barbiturates, and gabapentinoids) and non-GABA agents (general anesthetics, alpha 2 agonists, anticonvulsants, and NMDA antagonists) will be reviewed. The evidence base for the efficacy and safety of the various management strategies will be discussed, such as how to assess severity of alcohol withdrawal in the critically ill patient and the use benzodiazepine sparing regimens. Instruction will be through an interactive case-based format (4-5 cases) with expert faculty describing different approaches and highlighting key points throughout the case discussion. Examples of cases include a patient with alcohol withdrawal related delirium who has received 200 mg diazepam in the past 24 hours with discussion of the role for adjunct agents versus use of barbiturates; a patient with alcohol withdrawal who is mechanically ventilated and unable to extubate due to agitation when sedation is lowered, how can the severity of alcohol withdrawal be assessed and is there a role for use alpha 2 agonists?|
|1.) Describe the pathophysiology of severe alcohol withdrawal|
|2.) Describe how alcohol withdrawal may present in the acute care (emergency department and hospital) setting|
|3.) Explain the use and controversies of GABAergic and non-GABAergic agents for the treatment of severe alcohol withdrawal in the emergency department and hospital setting and the adjunctive agents available|
JoAn Laes, MD, Attending Physician, Division of Addiction Medicine, Hennepin County Medical Center, Minneapolis, MN; Core Medical Toxicology Faculty, Minnesota Poison Control System, Minneapolis, MN; Medical Director, Mission Detox Center, Plymouth, MN and 1800 Detox, Minneapolis, MN, ASAM Medical Toxicology workgroup Chair.Dr. Laes' practice is focused on inpatient addiction medicine and toxicology consultation and outpatient treatment of opioid and other substance use disorders. She is board certified in Internal Medicine, Addiction Medicine, and Medical Toxicology. She completed internal medicine residency at Hennepin County Medical Center and medical toxicology fellowship at Regions Hospital in St. Paul, Minnesota.
, MD, FACMT, FAACT, DFASAM
|Timothy Wiegand, MD, FACMT, FAACT, DFASAM is the Director of Toxicology for the University of Rochester Medical Center and an Associate Professor of Emergency Medicine with secondary appointment in Public Health Sciences. He holds Board Certification in Medical Toxicology and Addiction Medicine and has an active clinical practice through the Department of Emergency Medicine running the Toxicology Consult Service, which serves as the foundation for the toxicology/addiction rotation at URMC. Dr Wiegand is also the Associate Fellowship Director for the URMC Combined Addiction Medicine Fellowship and he serves as Medical Director for Huther Doyle a Rochester, NY area outpatient addiction treatment program. Dr. Wiegand is active professionally with a variety of professional organizations and he serves on the Board of Directors for the American College of Medical Toxicology, was recently elected to the American Society of Addiction Medicine Board of Directors as an At-Large Director (starts April, 2019) and is President Elect of the New York Society of Addiction Medicine. Dr. Wiegand also serves on the Board of the Medical Toxicology Foundation which has as a priority to support research, innovation and education related to the interface of toxicology and addiction in particular related to the opioid and overdose epidemic. Dr. Wiegand lectures on a variety of toxicology and addiction subjects at the national and international level and common subjects include the treatment of drug and alcohol withdrawal in paticular the use of buprenorphine to stabilize opioid withdrawal in the Emergency Department and hospital settings. A significant component of his clinical, research and educational time and effort involves buprenorphine use including perioperative use and in acute pain management for patients maintained on buprenorphine for opioid dependence.|
Lewis S. Nelson
|Dr. Nelson is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School in Newark, NJ. He is board certified in emergency medicine, medical toxicology, and addiction medicine. He is a member of the Board of Directors of the American Board of Emergency Medicine and the Accreditation Council for Continuing Medical Education, and a Past-President of the American College of Medical Toxicology. He is an editor of the textbook Goldfrank’s Toxicologic Emergencies and on the editorial boards of several journals. He provides direct clinical care to patients in the ED and through the New Jersey Poison Information & Education System. His areas of specific expertise include the consequences of opioids, alternative (to opioid) pain management strategies, emerging substances of abuse, and medication safety.|
|Kurt C. Kleinschmidt, MD, FACMT, FASAM is a Professor of Emergency Medicine at the University of Texas Southwestern Medical Center in Dallas, Texas. He is Chief of the Division of Medical Toxicology. His areas of interest include Substance Use Disorders and snake envenomations. He graduated from the University of South Florida College of Medicine in 1986, completed his emergency medicine residency at Madigan Army Medical Center in 1990, and finished a clinical fellowship in Medical Toxicology at the University of Texas Southwestern Medical Center in 1999. He is board certified in Emergency Medicine (1991), Medical Toxicology (2002), and Addiction Medicine (2015). He became the Medical Director of the Perinatal Intervention Program in Parkland Health and Hospital system in 2016. He served as the Toxicology Program Director from 2004-2018.|
ACCME Accreditation Statement
The American Society of Addiction Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
AMA Credit Designation Statement
The American Society of Addiction Medicine designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ABPM Maintenance of Certification (MOC)
The American Board of Preventive Medicine (ABPM) has approved this activity for a maximum of 1.5 LLSA credits towards ABPM MOC Part II requirements.
ABAM Transitional Maintenance of Certification (tMOC)
This course has been approved by the American Board of Addiction Medicine (ABAM). Physicians enrolled in the ABAM Transitional Maintenance of Certification Program (tMOC) can apply a maximum of 1.5 AMA PRA Category 1 Credit(s)™ for completing this course.
ABIM Maintenance of Certification (MOC)
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn 1.5 Medical Knowledge MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.