Psych

#Alcohol withdrawal: 

History of alcohol withdrawal? 

History of alcohol use, last drink

AUDIT-C score: initiate CIWA >3-4 

ICU level of care because requiring medications q1-2 hours, delirium tremens, CIWA >20 despite medication, inability to protect airway 

Phenobarbital weight based dosing IV 

-Librium 25mg Q8 for first 72 hours 

-CIWA protocol; Ativan 1-2mg PRN based on CIWA 

-Continue IVF resuscitation PRN 

-Thiamine 100mg daily 

-Folate 1mg daily 

-Thiamine 500mg TID for 2 days and then 250mg IV / IM for 5 days if concern for Wernicke's encephalopathy  

-start naltrexone after 4 days of abstinence 

-stat POC glucose, RFP, mag, CBC, INR, PTT, LFTs, CXR

-consider CT head to exclude subdural hematoma

-If patient has had a withdrawal seizure:  Rapidly escalate to a cumulative dose of at least 15 mg/kg phenobarbital if mental status allows, consider adding pyridoxine 100 mg IV/PO.

-If altered mental status & Wernicke encephalopathy is possible:  500 mg IV q8hr.

-If normal mental status:  100 mg IV daily to prevent Wernicke encephalopathy.

-Delirium tremens symptoms: Agitated delirium with hypertension, tachycardia, and diaphoresis. Diffuse tremor. Hyperreflexia. Hallucinations. Low-grade fever. Nausea, vomiting

https://emcrit.org/ibcc/etoh/#top

#tobacco use disorder 

age of first use, duration, number of cigarettes a day, prior treatments, and time to first cigarette in the morning 

Selecting a starting dose of nicotine gum, is based on time to first cigarette (TTFC) upon waking. If the TTFC is > 30 minutes, select the 2 mg nicotine gum, if TTFC is < 30 minutes, select the 4mg gum 

how do you feel about your tobacco use?”. 

-Patient referred to smokefree.gov for assistance with quitting

#chronic pain syndrome 

Home regimen:  

Naloxone access? 

Major risk factors for opioid overdose include receiving more than 50 morphine milligram equivalents per day and receiving opioids and benzodiazepines concurrently

Naltrexone, acamprosate, disulfiram, topiramate, and gabapentin are suggested by the American Psychiatric Association guideline on alcohol use disorder as medications to be offered to patients with moderate to severe alcohol use disorder.

A monthly injection of naltrexone for the treatment of alcohol use disorder may enhance patient adherence

For patients with chronic insomnia refractory to cognitive behavioral therapy for insomnia (CBT-I) or who decline to participate in CBT-I, either low-dose doxepin or a nonbenzodiazepine benzodiazepine receptor agonist (e.g., zolpidem, zaleplon, eszopiclone) is recommended after a discussion of risks and benefits

Brief behavioral therapy for insomnia is an alternative to cognitive behavioral therapy for first-line treatment of chronic insomnia.

Sleep hygiene may be used as a component of behavioral therapies for insomnia but has not been shown to be effective as a standalone therapy for chronic insomnia