E.  Assess Level Of Intoxication And/Or Physiological Dependence

 

OBJECTIVE

 

Obtain the necessary data to guide the patient's detoxification process.

 

ANNOTATION

 

Indications for stabilization include intoxication or risk of withdrawal:

1.        Intoxication:

·         The most common signs and symptoms involve disturbances of perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior.

·         Patients should be medically observed at least until the blood alcohol level (BAL) is decreasing and clinical presentation is improving.

·         Highly tolerant individuals may not show signs of intoxication.  For example, patients may appear "sober" even at BALs well above the legal limit (e.g., 80 or 100 mg percent).

2.        Consider withdrawal risk from each substance for patients using multiple substances.

Table 1.  Signs and Symptoms of Intoxication (APA, 1994)

Types of Intoxication	Signs and Symptoms
Alcohol and Sedative-Hypnotics	·     Slurred speech ·     Incoordination ·     Unsteady gait ·     Nystagmus ·     Impairment in attention or memory ·     Stupor or coma
Cocaine or Amphetamine	·     Tachycardia or bradycardia ·     Pupillary dilation ·     Elevated or lowered blood pressure ·     Perspiration or chills ·     Nausea or vomiting ·     Psychomotor agitation or retardation ·     Muscular weakness, respiratory depression, or chest pain ·     Confusion, seizures, dyskinesias, dystonias, or coma
Opiate	·     Pupillary constriction (or dilation due to anoxia from overdose) ·     Drowsiness or coma ·     Slurred speech ·     Impairment in attention or memory ·     Shallow and slow respiration or apnea Note: Acute opiate intoxication can present as a medical emergency with unconsciousness, apnea, and pinpoint pupils.

 

 

Symptoms of withdrawal from sedative-hypnotics or alcohol

1.        Signs and symptoms of withdrawal from sedative-hypnotics or alcohol include two or more of the following, developing within several hours to a few days after cessation or reduction in heavy and prolonged use:

·            Autonomic hyperactivity (e.g., diaphoresis, tachycardia, and elevated blood pressure)

·            Increased hand tremor

·            Insomnia

·            Nausea and vomiting

·            Transient visual, tactile, or auditory hallucinations or illusions

·            Delirium tremens (DTs)

·            Psychomotor agitation

·            Anxiety

·            Irritability

·            Grand mal seizures

2.        The potential for a withdrawal syndrome can be gauged only imprecisely by asking the patient the pattern, type, and quantity of recent and past substance use.

3.        Consider standardized measures to assess the severity of withdrawal symptoms.  The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) has good reliability and validity for assessing severity of withdrawal symptoms from alcohol (see Appendix A-1).

4.        CIWA-Ar has 10 provider ratings.  Interpret total scores as follows:

·            Minimal or absent withdrawal: £ 9

·            Mild to moderate withdrawal: 10-19

·            Severe withdrawal: > 20

 

Symptoms of opioid withdrawal

1.        The opioid withdrawal syndrome can be protracted with intense symptoms, though the syndrome itself poses virtually no risk of mortality.  However, there is significant mortality risk from overdose for those who relapse following unsuccessful detoxification attempts, as a result of loss of opioid tolerance.

 

2.        Signs and symptoms of opioid withdrawal include any or all of the following, which may develop at a time appropriate for the ingested opioid (e.g., within 6-12 hours after the last dose of a short acting opioid, such as heroin, or 36-48 hours after the last dose of a long acting opioid, such as methadone):

·            Craving for opioids

·            Restlessness or irritability

·            Nausea or abdominal cramps

·            Increased sensitivity to pain

·            Muscle aches

·            Dysphoric mood

·            Insomnia or anxiety

·            Pupillary dilation

·            Sweating

·            Piloerection (i.e., gooseflesh)

·            Tachycardia

·            Vomiting or diarrhea

·            Increased blood pressure

·            Yawning

·            Lacrimation

 

Physiological dependence

Determine the presence of tolerance or withdrawal, as documented in DSM-IV diagnostic criteria.

Tolerance is identified by either of the following:

·            A need for markedly increased amounts of the substance to achieve intoxication or desired effect.

·            Markedly diminished effect with continued use of the same amount of the substance.

Withdrawal is identified by either of the following:

·            The characteristic withdrawal syndrome for the substance (refer to DSM-IV for further details).

·            The same (or a closely-related) substance is taken to relieve or avoid withdrawal symptoms.

Evaluate patients using multiple substances (e.g., opioids and sedative-hypnotics) for risk of withdrawal from each substance.

 

DISCUSSION

 

Recent intake of a substance can be assessed from the history, physical examination (e.g., alcohol on the breath), or toxicological analysis of urine or blood.  The specific clinical picture in substance intoxication depends on the substance(s) used, the duration of use at that dose, tolerance, time since last dose, expectations of effects, and the environment or setting of use.

 

DSM-IV (APA, 1994) substance intoxication is:

·            The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance.  Note: Different substances may produce similar or identical syndromes.

·            Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, and impaired social or occupational functioning) and develop during or shortly after use of the substance.

Note:  The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Consider using standardized assessment of withdrawal symptoms.	Sullivan et al., 1989 Gossop, 1990 Zilm & Sellers, 1978	II-2		A

QE = Quality of Evidence; R = Recommendation (See Introduction)