medical detoxification

1: Medical Detoxification

2: Objectives Participants will be able to: describe the clinical signs and symptoms of alcohol and sedative withdrawal describe the neurobiology of alcohol withdrawal describe the clinical methods used to manage alcohol and sedative drug detoxification

3: sedatives alcohol, alprazolam stimulants cocaine, amphetamines, nicotine opiates heroin, methadone, morphine Medical Detoxification

4: Assess for Risk of Alcohol Withdrawal History of DTs Daily use of alcohol (more than 12 drinks per day) History of morning drinking Prior treatment for alcohol problems

5: Outpatient versus Inpatient Treatment Medical criteria Absence of serious medical problems No history of drug withdrawal-induced delirium, seizures, or psychosis Abstinence criteria Patient agrees to abstinence and treatment Patient agrees to random testing Psychosocial criteria Patient has support of sober family and friends

6: Pathophysiology of Sedative Withdrawal GABA neurotransmitters Receptor complexes are primary central nervous system inhibitory sites Reduces nerve cell excitability Sedative brain receptors Specific receptors Alcohol - no specific receptor Drug receptor activation Activation stimulates GABA release Chronic sedative use depletes GABA

7: General Signs and Symptoms of Alcohol and Sedative Withdrawal Tachycardia Increased systolic blood pressure Increased temperature (rule out infection) Diaphoresis Anxiety/fear Insomnia/nightmares Vomiting/diarrhea Tremor

8: Stages of Alcohol and Sedative Withdrawal

9: Alcohol/Sedative Withdrawal

10: Clinical Withdrawal Assessment Scale Temperature Pulse Respiration Blood Pressure Anxiety Agitation Tremor Diaphoresis Eating disturbance GI distress: nausea, vomiting, diarrhea Sleep disturbances Clouding of sensorium Hallucinations Convulsions

11: Alcohol and Sedative Withdrawal Not all patients demonstrate all symptoms Progression from Stage 1 to 2 to 3 is usual Rapid development of Stage 3 in 12 hours is possible Treatment may not prevent development of delirium tremens 1/3 of patients with seizures will develop Stage 3

12: Withdrawal from Sedative Hypnotics Other than Alcohol Clinical Characteristics: Similar to alcohol Barbiturates - temperature, delirium, seizures Benzodiazepines - anorexia, insomnia, agitation Onset: Alprazolam - 1-2 days Diazepam, phenobarbital - 5-10 days

13: Treatment Methods for Alcohol/Drug Withdrawal Supportive Care Nonpharmacological treatment Three R’s: Reality Reassurance Respect

14: Medication for Sedative Withdrawal Intravenous fluids ß-blockers Thiamine Potassium Vistaril for nausea

15: Benzodiazepine Treatment for Alcohol and Sedative Withdrawal Rationale Rapid induction Easy transition Adequate control of symptoms Prevention of Stage 2, 3 withdrawal Partially protective against seizures Side effects: over-sedation, aspiration pneumonia, drug dependence

16: Benzodiazepine Treatment: Loading Dose When should treatment be initiated? Depends on risk factors and symptoms How much medication should be used? 20-60 mg Diazepam in 3 divided doses orally Additional treatment: Diazepam every 2 hours until symptoms are controlled Tapering unnecessary

17: Treatment Alternatives Chlordiazepoxide Lorazepam Oxazepam Valproic acid Clonidine Carbamazepine Chlormethiazole Phenobarbital

18: Medications no Longer in Widespread Use... Alcohol Bromides Paraldehyde

19: Alcohol Withdrawal Seizures Who should receive prophylactic treatment? Currently on an anticonvulsant History of epilepsy History of withdrawal seizures Magnesium level <1.2 mg % Prophylactic drug treatment: Carbamazepine preferred over phenytoin Medication should be given early Loading dose: Tegretol 100 mg every 2 hours x 4 doses After, 200 mg every 6 hours x 7 days

20: Treatment of Delirium Tremens Not Responsive to Valium Lorazepam 2-6 mg. every hour Haloperidol 1-5 mg. every 2-6 hours Haldol may decrease seizure threshold

21: Phenobarbital Protocol for Treatment of Sedative Withdrawal Rapid Induction When compared to Librium (Smith, 1978) Decreased period of disability Decreased period of insomnia Decreased cardiovascular abnormalities Excellent anticonvulsant Only side effect is sedation Abuse potential is minimal Treatment for polydrug withdrawal

22: Phenobarbital Protocol for Treatment of Sedative Withdrawal Loading and Supplemental (sodium luminal) 130-160 mg. IM as needed Phenobarbital (routine) orally 30 mg. 4 times a day x 3 days 15 mg. 4 times a day x 2 days 15 mg. twice a day x 1 day

23: Common Characteristics of Cocaine and Amphetamine Withdrawal Depression, insomnia, fatigue, headache Irritability, poor concentration, and restlessness REM sleep may be increased for weeks after last use Intense drug craving Suicidal ideation is the norm

24: Cocaine Withdrawal: Unique Features Paranoia and acute psychosis Intense craving and drug-seeking behavior Severe anhedonia, depression, and suicidal ideation

25: Amphetamine Withdrawal: Unique Features “Amphetamine psychosis” may be difficult to separate from organic illness Symptoms: feelings of persecution paranoia compulsive behavior visual or auditory hallucinations

26: Tobacco Withdrawal: Specific Effects Symptoms: increased appetite intense craving drug-seeking behavior irritability difficulty with concentration easily fatigued

27: Summary of Clinical Characteristics of Stimulant Withdrawal Amphetamines Cocaine Nicotine

28: Drug Treatment for Cocaine and Amphetamine Withdrawal Treatment of agitation/paranoia: Mellaril 25-50 mg. Haldol 5 mg. IM/IV Treatment of cocaine craving: ??? Treatment of depression: Amitriptyline 50-150 mg. h.s.

29: Grading Scheme for Opioid Withdrawal

30: Drug Treatment for Opiate Withdrawal Clonidine 0.1 mg. test dose then 0.2 mg. three times a day x 3-5 days, and #2 clonidine patch for 14 days Promethazine 25 mg. IM for nausea Lorazepam 2-4 mg. by mouth or IV for anxiety, restlessness Ibuprofen 800 mg. for muscle cramps and joint pain

31: Opioid Detoxification Buprenorphine Indication Dose Duration Side effects Efficacy

32: Opioid Detoxification Naltrexone Indication Dose Duration Protocol Side effects Efficacy

33: Methadone Patients on methadone maintenance: Reduce 2-3 mg. per day down to 30 mg. Then 1-2 mg. per day Patients dependent on other opioids 10 mg. of methadone as an initial dose Average 24 hour dose is 20-30 mg. For detoxification, methadone should be tapered in 7-10 days