Transcript Detox – Then What?

CAPTASA 2009
th
9 Annual
Conference
Embassy Suites
Lexington, KY
January 23, 2009
Detox – Then What?
“Dare to be naïve.”
R. Buckminster Fuller
Medical Detox
A Way That Works
Why bother?
A Safe Withdrawal from Alcohol and
other Drugs
A Withdrawal that is Humane and
Protects Dignity
Prepare the Patient for Ongoing
Treatment
Principles of Addiction Medicine
3rd Ed. Page 612
The patient is the
one
With the
problem
Which drugs need
medical detox ?
Alcohol
Sedative/hypnotics
Opiates
Dopamine Pathways – Pleasure pathways
striatum
frontal
cortex
hippocampus
alcohol
substantia
nigra/VTA
cocaine
nucleus
heroin
nicotine
accumbens
amphetamines
opiates
THC
PCP
ketamine
heroin
alcohol
benzodiazepines
barbiturates
We should write that spot down.
Usual detox approach
Benzo’s for Alcohol
Benzo’s for Benzo’s
Opiates for opiates
My Experience with
Benzodiazepines
Opiates don’t have to be
detoxed, right?
Only if you want them to stay in Tx
Only if you care about their dignity
How many are pure Opiate users?
Alcoholics Anonymous, page 22
from ‘There is A Solution”
Perhaps he goes to a doctor who gives him
morphine or some sedative with which to
taper off. Then he begins to appear at
hospitals and sanitariums.
This is by no means a comprehensive
picture of the true alcoholic, as our behavior
patterns vary. But this description should
identify him roughly.
ASAM Textbook, 3rd Ed. Page 643
Clinical experience shows that
phenobarbital is most useful and
effective with polysubstance
dependence, high-dose
dependence, and in patients with
unknown dose or erratic
“polyphramacy”
“Well, I woke up this morning
And I got myself a beer.
The future’s uncertain
And the end (enemy) is always
near.”
Roadhouse Blues-Jim Morrison
GABA- the down button
NMDA- the up button
Here’s what I do
Hx of Use (What, How much, How
long, other medical conditions…)
Load with Phenobarb- (stop the train
from leaving the station)
Add on’s depending on drugs used
Mg++ for Alcohol
Clonidine for Opiates
Phenobarb dosage
Load
Regular dose taper
PRN’s based on CIWA score
DAYS 1&2
Phenobarbital 180 mg PO now, then
Phenobarbital 60 mg PO every 6 hours X
8 doses
Obtain CIWA score every 4 hours
If CIWA score greater than 15, give
Phenobarbital 260 mg IM
If CIWA score 8-15, give Phenobarbital
120 mg PO
DAYS 3&4
Phenobarbital 60 mg PO every 12 hours X
4 doses
Obtain CIWA score every 6 hours
If CIWA score greater than 15, give
Phenobarbital 120 mg PO
If CIWA score 8-15, give Phenobarbital 60
mg PO
Magnesium Sulfate
Based on Alcohol use and age of Patient
1 Gm IM every 8 hours
At least 2 doses
Up to 4 for high volume drinkers and those
with seizure Hx*
PO Magnesium oxide is poor alternative,
limit is 400mg BID
*Magnesium is not for seizures
Magnesium in Alcohol withdrawal
Mg-NMDA connection
Clonidine dosage
Clonidine 0.1 mg PO now, then
Clonidine 0.1 mg PO every 6 hours X 8
doses, then
Clonidine 0.1 mg PO every 8 hours X 3
doses, then
Clonidine 0.1 mg PO every 12 hours X 2
doses
Hold Clonidine if BP less than 90/55
Thiamine is critical for Tx
of Alcoholism
Thiamine 100 mg IM now,
then 100 mg a day x 5
days.
Folic acid 1 mg a day for 5
days.
Detox protocol at Schwartz Center
Phenobarb 180 mg
now
Then Phenobarb 60
mg every 6 hr x 8
doses
Then Phenobarb 60
mg every 12 hr x 4
doses
Magnesium oxide 400
mg BID x 3 days
Thiamine 100 mg
daily x 5 days
Folic acid 1 mg daily x
5 days
Clonidine 0.1 mg TID
x 2 days and BID x 2
days
Phenobarb equivalents
30 cc 100 proof alcohol = 30 mg
Xanax 1 mg = 30 mg
Ativan 2 mg = 30 mg
Klonopin 2 mg = 30 mg
Valium 10 mg = 30 mg
Librium 25 mg = 30 mg
What about Delirium?
This is where dehydration is important
First load with Phenobarb and push
dose
Avoid anticholenergic drugs
Risperdal 2mg + Ativan 2mg PO
Haldol 5mg +Ativan 2mg+ Benadryl
50mg all IM
Then What?
“The important thing is not
to stop questioning.”
Albert Einstein
Abstinence and Spiritual
based Recovery isn’t sexy
nor profitable
It can be a lonely and unpopular
message, but it is the Truth…
Don’t listen to friends
when the Friend inside
you says “Do this!”
Mahatma Gandhi
Addiction is a brain
disease
a primary illness, not a symptom
secondary to a psychiatric disorder
Brain Reward Center:
Median Forebrain
Nucleus Accumbens
Ventral Tegmental Area
Dopamine
Can Amphetamines Help
Cure Cocaine Addition?
“It’s an idea that really does need to
be rigorously evaluated”
Frank Vocci, director of pharmTx
NIDA
Time magazine 12/8/2008
“One of the first duties of
the physician is to
educate the masses not to
take medicine.”
Sir William Osler, Aphorisms from
his Bedside Teachings
Everybody is on drugs
except when they
really need them…
Rita Rudner
“…has not been
systematically studied in
humans for its potential for
abuse …”
From PDR under Effexor,
Cymbalta, Paxil, Seroquel,
Neurontin, Zyprexa, Celexa…
Clinical Antipsychotic Trials of
Intervention Effectiveness
Although they were first developed for
schizophrenia, antipsychotic drugs are
now broadly used for other disorders,
including behavioral signs and
symptoms… Despite their widespread use
in these conditions, the overall
effectiveness and safety of these drugs
remain unclear.
Clinical Antipsychotic Trials of
Intervention Effectiveness
While industry-sponsored research is
critical to new product development, its
emphasis is on meeting regulatory and
marketing requirements and on obtaining
expanded marketing claims for the drug,
not on evaluating the effectiveness of the
product at the general population level.
Clinical Antipsychotic Trials of
Intervention Effectiveness
…although a variety of claims of efficacy
and safety have been made, they are
often based on insufficient evidence.
Among the reasons for this is the fact that
traditional clinical trials have excluded
many patients with schizophrenia,
including those who are substance
abusers, violent or uncooperative, thus
making it difficult to generalize the
results…
Clinical Antipsychotic Trials of
Intervention Effectiveness
…the exact nature and extent of the
clinical advantages of the atypical drugs
are not known. Moreover, they cost
more than ten times as much as
most older drugs.
Morbidity and Mortality in
People with Serious Mental
Illness
National Association of
State Mental Health
Program Directors
Medical Directors Council
M & M in People with SMI report
…with time and experience the second
generation antipsychotic medications
have become more highly associated
with
weight
gain,
diabetes,
dyslipidemia, insulin resistance and the
metabolic syndrome and the superiority
of clinical response (except for clozapine)
has been questioned.
Additional Evidence of
the Abuse Potential of
Quetiapine
Reeves and Brister VA Med Center
Jackson, MS April 2007 SMA Journal
Alcoholics Anonymous, page 64
from “How It Works”
…for we have been not only
mentally and physically ill, we
have been spiritually sick.
When the spiritual malady is
overcome, we straighten out
mentally and physically.
“The 12-step model of
recovery is the core
technology in the short and
long term treatment of
alcoholism and addiction…
the standard of care”
Garrett O’Connor, MD
CAPTASA 2005
Willingway Four Truths
The total Cause of Alcoholism and
Drug Addiction is Unknown.
Alcoholism is at least in part a
Chemical illness.
There is a relationship between
Alcoholism and Addiction to other
drugs.
Alcoholism is an illness of the total
person (body, emotions, mind and
spirit).
www.willingway.com
$634.5M settlement for
OxyContin maker
The firm and the current and
former executives, including the
CEO, pleaded guilty in U.S.
District Court in Abingdon, Va., to
a felony charge of misleading
doctors and consumers about the
drug's risks of abuse and
addiction, CNN said Wednesday.
CDC: Antidepressants
most prescribed drugs in
U.S.
" Doctors are now medicating
unhappiness” said Dworkin.
"Too many people take drugs
when they really need to be
making changes in their lives."
CNN 7-9-07
Alcoholics Anonymous, page 58
from “How It Works”
There are those, too, who suffer
from grave emotional and
mental disorders, but many of
them do recover if they have
the capacity to be honest.
Drugs that are problems for Addicts
Antidepressants
Stimulants
Antihistamines
Cough suppressants
Antipsychotics
Mood Stabilizers
Muscle relaxants
Neurophysiology of Recovery
Extended withdrawal for years
Structural and functional brain
abnormalities
Gradual normalization over first
recovery decade
Addiction may sensitize for
mental dysfunction
•If you understand,
everything is just as it is
•If you don’t understand,
everything is just as it is
Zen proverb
Detox Protocol
CIWA
e-mail to physicians interested
[email protected]