Transcript Novel Detoxification from Opiates

Novel Opiate Detoxification
Techniques
Ken Roy, MD
Tulane Department of Psychiatry
Addiction Recovery Resources of New Orleans
504-780-2766
www.arrno.com
Topics
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The Physiology of Opiate Detoxification
The Natural History of Detoxification
Novel detoxification techniques
Management of Detoxification induced by
Naltrexone
Treatment and Long Term Recovery
Physiology of Opiate
Detoxification
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Limbic System
Locus Ceruleus
Gut and Smooth Muscle
Skeletal Muscle
Limbic System
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Opiate Agonist
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Euphoria
Sedation
Satiety
Detoxification
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Dysphoria
Agitation
Craving
Locus Ceruleus
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Opiate Agonist
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Unconcerned
Anergic
Hypotensive/Bradycardic
Detoxification
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Hypervigilant
Hyperalert
Hypertensive/Tachycardic
Gut and Smooth Muscle
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Opiate Agonist
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Relaxed tone
Reduced sensation
Constipation
Detoxification
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Spasm
Hypersensitive
Diarrhea
Skeletal Muscle
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Opiate Agonist
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Relaxed tone
Reduced sensation
Comfortable
Detoxification
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Spasm
Painful
Akathisia
Principles of Detoxification
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Use a drug with a long half-life and low
abuse potential
Use a drug that is smoothly eliminated
Replace the abused drug with the detox
drug
Initiate drug free treatment
Taper the detox drug
Natural History of Detoxification
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Scared, Anxious, Desperate, Agitated (days)
Sick, Whinny, Needy (days to weeks)
Pain, Cramps, Spasms, Nausea, Diarrhea
(days)
Angry, Drug seeking, Hungry, Craving
(weeks)
Chronic Euphoric Recall (weeks to months)
Severity of Detoxification
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Depends on the potential for addiction
Darvon may be low grade but long
Vicodin/Percodan usually moderate
Heroin is severe
Methadone is the worst
Length of Acute Detoxification
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Depends on the half life of the drug
Fentanyl may be very short
Vicodin/Percodan lasts a week or so
Heroin about the same
Methadone lasts a month
Subacute Detoxification
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Length depends on the half life of the drug
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Methadone may be months to a year
Chronic nagging craving
Chronic euphoric recall
Chronic dysphoria
Most frequent period of relapse
Drugs to use
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Limbic system
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Geodon, Zyprexa, anticonvulsants
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Dysphoria, agitation, craving
Responsible for anger
Locus Ceruleus
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Catapres (Clonidine)
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Most important drug in the first phase
Need to train staff to give enough
Can give up to 2.4mg in 24 hours
Zanaflex
More Drugs to use
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Gut and smooth muscle
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Skeletal muscle
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Bentyl, Sandostatin, Zofran
Vistaril
Zanaflex, Flexaril
NSAID’s
General agitation
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Xanax, Ativan, Zyprexa, Geodon
Types of Novel Detoxification
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Ultra Rapid Detoxification under anesthesia
Rapid induction of detoxification using
Naltrexone
Brief detoxification with Buprenorphine
Ibogaine
Detoxification With
Buprenorphine
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Now, if you apply for an exemption to
prescribe, rational detoxification is possible
Some will tolerate rapid detoxification (one
to two weeks)
Some will require stabilization prior to
detoxification
Buprenorphine is a great detoxification
medication
Maintenance With
Buprenorphine
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Partial agonist
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Binds to and activates receptor, but increasing
dose only results in partial activation
More competitively bound than almost all
mu receptor drugs
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Blocks Heroin and other opioids
Induces detox in Heroin/Methadone patient
unless they are already sick
Maintenance With
Buprenorphine
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Because of firm binding to receptor is
literally metabolized from the site
Detoxification symptoms are much more
tolerable
Patients may become involved in treatment,
NA and Recovery and simply “drop off”
into continued Recovery
Rationale for Rapid
Detoxification With Naltrexone
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Shorten acute detox
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Eliminate subacute detox
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Evidence for increased Beta Endorphins while taking
Naltrexone
Group participation while in very early treatment
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Over in hours to days
Patients aware that detox is over
Reduce drug seeking behavior
Natural History of Detoxification
Following Naltrexone Protocol
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Scared, Anxious, Desperate, Agitated
(obscure)
Sick, Whinny, Needy (4-24hrs)
Pain, Cramps, Spasms, Nausea, Diarrhea (424hrs)
Angry, Drug seeking, Hungry, Craving
(hours to a day)
Chronic Euphoric Recall (don’t see it)
How it Goes
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Stabilize on Buprenorphine
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Give loading doses
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One or more days
Treat detoxification symptoms in advance
in 1/2 hour give Naltrexone 150mg
Vigorously treat emerging symptoms with
PRN’s
ON ADMISSION – IN ADDITION TO
ROUTINE ADMIT ORDERS
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Buprenorphine 0.6 mg SL now and Q2h while awake.
Thorazine 50mg IM or PO Q6h prn nausea or vomiting or
agitation.
Bentyl 20mg IM or PO Q6h prn cramping abdominal pain.
Zanaflex 8mg Q4h prn skeletal muscle cramps, diaphoresis,
piloerection or signs or symptoms of opiate detoxification.
Imodium caps 2 Q6h prn diarrhea.
Seroquel 100mg PO qhs. Observe for orthostatic hypotension.
Catapres 0.1mg q1/2h prn pulse >80 up to 2.4mg/24 hrs.
Sandostatin 100mcg SC q4h prn nausea, vomiting or diarrhea.
Phenobarbital 90 mg q2h prn tremor or pulse > 110.
IF SEDATIVE AND/OR ALCOHOL
DEPENDENCE ALSO PRESENT
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1.
Change admit Phenobarbital order to 90mg PO on admit
and Q8h @ 6am, 2pm and 10pm
WHEN READY TO START DETOX
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Xanax 2mg PO now.
Zanaflex 8mg PO now.
Bentyl 20mg IM now.
Thorazine 50mg IM now.
Sandostatin 100mcg SC now.
Imodium caps 2 now.
Buprenorphine 0.6mg SL now.
Naltrexone 150mg PO in ½ hour and 50mg qam.
DC Buprenorphine after above.
Catapres 0.2mg with first dose of Naltrexone and continue previous prn Catapres order.
Notify for pulse over 90 or diastolic over 90.
Xanax 2mg PO q2h prn agitation in next 12 hours only, up to four prn doses total.
DC all prn’s 72 hours following first dose of Naltrexone
What to expect
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Initial sleepiness
Emerging profound acute detoxification
symptoms
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Period of lethargy and exhaustion
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Lasting 4 to 24 hours
2nd day
Period of anger
Group readiness
Following Detoxification
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Now treatment can start
Should be criteria based
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IOP (ARRNO, NFI, etc.)
RTC (ARRNO)
Support system involvement crucial
Recommend Naltrexone for 6-12 mos.
Experience
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More than 4000 cases
Four transfers to ER
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Two for dehydration
Two for over sedation
None in last four years
No deaths (within the month following detox) or
permanent morbidity
Perceived equal success in drug free recovery to
persons addicted to other drugs