Anti-epileptics instead of benzodiazepines for outpatient etoh wd?

[lyla]

PGY3 here. Recently got a handout from my addiction/substance use rotation. There's actually several regimens it lists here as appropriate for outpatient etoh wd. It states benzos are 1st line, but if there are concerns for CNS depression due to concurrent opioid use, it also has regimens that use exclusively tegretol, depakote, or gabapentin.

Has anyone used those anti epileptics in lieu of benzos for outpatient mild-moderate etoh wd? And what has your experience been like?

Thanks!

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[TexasPhysician]

I would never do that. If use of etoh and opioids is high enough for CNS depression concerns, the patient needs to be at a higher level of care than outpatient.

 

[J ROD]

Not alone I have not and not acutely as mentioned above. After the "worst" part is over and if they are still anxious I have used gabapentin with good results. But in general, I detox inpatient and do not want to send them out on Benzos.

 

[Stagg737]

PGY3 here. Recently got a handout from my addiction/substance use rotation. There's actually several regimens it lists here as appropriate for outpatient etoh wd. It states benzos are 1st line, but if there are concerns for CNS depression due to concurrent opioid use, it also has regimens that use exclusively tegretol, depakote, or gabapentin.

Has anyone used those anti epileptics in lieu of benzos for outpatient mild-moderate etoh wd? And what has your experience been like?

Thanks!

The psychiatrists I have rotated with have all been of the opinion that detoxing is an inpatient process, if they're not willing to come inpatient to do it, they're not really ready to detox. If they came into the ER due to intoxication and detox is started, they don't really get the choice where I'm at. If they're impaired so much that CNS depression is a concern, they definitely should not be detoxing outpatient, and may need a higher level of care as TexasPhysician said.

 

[Armadillos]

Maybe it's a difference in severity of patients, but isn't a short outpatient benzo detox for someone with no complicating factors a pretty standard thing for even a IM/FM doc to do?? Prescribe a day or two at time and have them come in for vitals every morning?

 

[TexasPhysician]

Maybe it's a difference in severity of patients, but isn't a short outpatient benzo detox for someone with no complicating factors a pretty standard thing for even a IM/FM doc to do?? Prescribe a day or two at time and have them come in for vitals every morning?

I do outpatient detox routinely, and I have worked at an inpatient center as well. I believe that most detoxification can be handled on an outpatient basis, but high risk cases should be admitted.

Alcohol detox is higher risk than opioid detox. I see no reason to avoid benzos to give opioid agonist therapy. If anything, I'd go benzos + clonidine. Usually this is a recipe for relapse though as it is more comfortable to go benzo + opioid agonist. Such cases are why inpatient detox exists.

 

[Jules A]

Hugh Myrick included this in a presentation I saw him give. Here is an article that might be of interest OP:

A DOUBLE BLIND TRIAL OF GABAPENTIN VS. LORAZEPAM IN THE TREATMENT OF ALCOHOL WITHDRAWAL

 

[TexasPhysician]

Hugh Myrick included this in a presentation I saw him give. Here is an article that might be of interest OP:

A DOUBLE BLIND TRIAL OF GABAPENTIN VS. LORAZEPAM IN THE TREATMENT OF ALCOHOL WITHDRAWAL

My addiction facility had to ban php/iop/outpatient Gabapentin due to high rate of abuse. I couldn't believe the percentage used inappropriately. It had become the #1 requested drug.

 

[F0nzie]

My addiction facility had to ban php/iop/outpatient Gabapentin due to high rate of abuse. I couldn't believe the percentage used inappropriately. It had become the #1 requested drug.

They should go all out-- also ban Seroquel and double down on sleep hygiene. New slogan: "Detox like like a warrior".


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[TexasPhysician]

They should go all out-- also ban Seroquel and double down on sleep hygiene. New slogan: "Detox like like a warrior".


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Already have. Neurontin and Seroquel were top 2 problems.

 

[Jules A]

Already have. Neurontin and Seroquel were top 2 problems.

In the corrections arena also.

 

[SeniorWrangler]

I would never do that. If use of etoh and opioids is high enough for CNS depression concerns, the patient needs to be at a higher level of care than outpatient.

I think there's plenty of gray area. Outpatient etoh detox with benzos can be pretty problematic anyway, especially on the third or fourth go-round.

 

[Armadillos]

Already have. Neurontin and Seroquel were top 2 problems.

Anytime a med is being rx'd to people with problems with addiction as much as gabapentin is these days I would assume someone would be trying to abuse it.

That being said, is there much evidence of significant harm from gabapentin abuse?

My understanding was you can only absorb a limited amount which would not even result in a particularly "supratheraeutic" blood level. Additionally, I've seen lots of patients on lots of gabapentin and at worse they seem sedated, not intoxicated. Nor to people seem eurphoric when you start in inpatient.

I'm guessing the issues come from mixing it with the "good stuff"?

(This is not being confrontational, I don't know much about this)

 

[TexasPhysician]

Anytime a med is being rx'd to people with problems with addiction as much as gabapentin is these days I would assume someone would be trying to abuse it.

That being said, is there much evidence of significant harm from gabapentin abuse?

My understanding was you can only absorb a limited amount which would not even result in a particularly "supratheraeutic" blood level. Additionally, I've seen lots of patients on lots of gabapentin and at worse they seem sedated, not intoxicated. Nor to people seem eurphoric when you start in inpatient.

I'm guessing the issues come from mixing it with the "good stuff"?

(This is not being confrontational, I don't know much about this)

You may have yourself a wonderful opportunity to do clinical studies monitoring brain effects pre/post Gabapentin snorting. I can't imagine it would be beneficial but let us know.

 

[Armadillos]

You may have yourself a wonderful opportunity to do clinical studies monitoring brain effects pre/post Gabapentin snorting. I can't imagine it would be beneficial but let us know.

Lol fair enough, just was curious. We have all seen folks on the inpatient units drinking 20 cups of decaf or trying to get q5 minute PRN atarax all in an attempt to "feel something". Wondering if this is whats going on with gabapentin or if people are actually getting high on it.

 

[TexasPhysician]

Lol fair enough, just was curious. We have all seen folks on the inpatient units drinking 20 cups of decaf or trying to get q5 minute PRN atarax all in an attempt to "feel something". Wondering if this is whats going on with gabapentin or if people are actually getting high on it.

Most report a "high", but most still would prefer other highs.