Transcript presentation-08-2-benzodiaz cannabis, nicotine and other

8.2: Managing
Benzodiazepine,
Cannabis, Nicotine
and other Withdrawal
Prepared by J. Mabbutt & C. Maynard
NaMO
September 2008
8.2: Managing other drug withdrawal:
Objectives
1.
During the session nurses & midwives will learn how to identify, assess
& manage a patient in benzodiazepine, cannabis, nicotine & other drug
withdrawal
2.
At the end the session, nurses will have a basic understanding
& knowledge to safely & effectively identify, monitor & manage
benzodiazepine, cannabis, nicotine & other drug withdrawal
8.2: Managing drug withdrawal

This presentation gives general guidelines for managing withdrawal.
Refer to Section 9 for specific details of withdrawal symptoms and
management for the most commonly used substances

For further information, refer to the New South Wales Drug and
Alcohol Withdrawal Clinical Practice Guidelines (2007)
http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html
8:2 Indications and guidelines
Benzodiazepine Withdrawal –
Option – Case Study

Present the post natal case study for benzodiazepine and other drug
withdrawal from Guidelines CD Rom Section 01

Discuss each section in small groups or as a large group and feedback
8:2 Indications and guidelines –
Benzodiazepine withdrawal – Onset &
duration of benzodiazepine withdrawal

Onset of withdrawal depends on the half-life of the particular benzodiazepine
used by the person

Withdrawal from short-acting benzodiazepines generally occurs earlier & is
more severe

Withdrawal symptoms do not necessarily decrease steadily from a peak,
but can follow a fluctuating course with good & bad periods

Eventually the good periods will last longer & become more frequent
Generic name
Trade name
Time to peak
concentration
Elimination half life †
Equivalent
dose ‡
Diazepam
Antenex
Ducene
Valium
Valpam
30-90 min
Biphasic: rapid phase
half-life, 3 hours;
elimination half-life,
20-48 hours
5 mg
Alprazolam
Alprax
Xanax
Kalma
1 hour
6-25 hours
0.5-1.0 mg
Bromazepam
Lexotan
0.5-4 hours
20 hours
3-6 mg
Clobazam
Frisium
1-4 hours
17-49 hours
10 mg
Clonazepam
Paxam
Rivotril
2-3 hours
22-54 hours
0.5 mg
Flunitrazepam
Hypnodorm
1-2 hours
20-30 hours
1-2 mg
Table 9.9: Absorption rates, half-life, & equivalent daily doses
of common benzodiazepines**
* Based on manufacturer’s product information.
†Elimination half-life: time for the plasma drug concentration to decrease by 50%.
‡ Equivalent dose: approximate dose equivalent to diazepam 5 mg.
Generic name
Trade name
Time to peak
concentration
Elimination half life †
Equivalent
dose ‡
Lorazepam
Ativan
2 hours
12–16 hours
1 mg
Nitrazepam
Alodorm
Mogadon
2 hours
16–48 hours
2.5–5 mg
Oxazepam
Alepam
Murelax
Serepax
2–3 hours
4–15 hours
15–30 mg
Temazepam
Euhypnos
Normison
Temaze
Temtabs
30–60 min after
tablets, 2 hours
after capsules
5–15 hours
10–20 mg
Triazolam
Halcion
1–3 hours
Biphasic: rapid phase
half-life, 2.5–3.5 hours;
elimination half-life, 6–
9 hours
0.25 mg
Zolpidem
Stilnox
0.5–3 hours
2.5 hours
Not known
Table 9.9: Absorption rates, half-life, & equivalent daily doses
of common benzodiazepines**
* Based on manufacturer’s product information. †Elimination half-life: time for the plasma drug concentration to decrease by 50%.
‡Equivalent dose: approximate dose equivalent to diazepam 5 mg.
8:2 Indications and guidelines –
Benzodiazepine withdrawal – Signs &
symptoms of benzodiazepines withdrawal

Subjective symptoms with few observable signs of withdrawal are a feature,
particularly of low dose withdrawal

Individuals may report feeling extremely mentally distressed (as though they
are “going mad”), although they may not have any obvious signs of physical
discomfort

This may result in the person not receiving the care that would be appropriate
during this time
Common symptoms
Less common symptoms
Uncommon symptoms
Anxiety
Nightmares, agoraphobia
Delusions
Insomnia
Feelings of unreality
Paranoia
Restlessness
Depersonalisation
Hallucinations
Agitation
Panic attacks
Seizures
Irritability
Nausea, dry retching,
decreased
Persistent tinnitus
Poor concentration
Increased sensory perception,
Confusion
Poor memory
Increased temperature, ataxia
Depression
Gastrointestinal unrest
Muscle tension, aches
and twitching
Menstrual changes
Table 9.10: Symptoms of benzodiazepine withdrawal
NSW Health (2007)
8:2 Indications and guidelines –
Benzodiazepine withdrawal –
Major complications of withdrawal
The major complications of withdrawal are:

Progression to severe withdrawal

Delirium with risk of injury (to self or others)

Risk of dehydration or electrolyte imbalance

Potential for seizures

Presence of concurrent illness, which masks or mimics withdrawal

Orthostatic hypotension
8:2 Indications and guidelines –
Benzodiazepine withdrawal –
Course of withdrawal

Withdrawal from short-acting benzodiazepines (e.g. oxazepam, temazepam,
alprazolam, & lorazepam) typically produces a faster and more severe onset
of symptoms

Withdrawal from long-acting benzodiazepines (e.g. diazepam, nitrazepam)
may be more difficult to undergo and complete
Figure 9.3: Withdrawal from short and long-acting benzodiazepines
Adapted from Frank L, Pead J. New concepts in drug withdrawal: a resource handbook
© 1995 State of Victoria. Reproduced with permission.
8:2 Indications and guidelines
Managing benzodiazepine withdrawal

Undertake nursing observations to identify & manage withdrawal symptoms
& prevent the progression to severe withdrawal
In particular, offer:

Reassurance regarding distorted sensory stimuli

Heat & massage for muscle aches

Symptomatic management to reduce the severity of symptoms
8:2 Indications and guidelines –
Managing benzodiazepine withdrawal –
Monitoring

There is no validated tool for recording benzodiazepine withdrawal symptoms
in an inpatient setting

The symptoms previously listed in Table 9.10 need to be monitored
8:2 Indications and guidelines –
Managing benzodiazepine withdrawal –
Pharmacological treatment (1)

Initial stabilisation of dose (preferably with a long-acting benzodiazepine) –
a gradual dose reduction preferably as an outpatient

In hospital: patients taking high doses, or polydrug users, should be stabilised
on a long-acting benzodiazepine (preferably, diazepam), at a dose about 40%
of their regular intake prior to admission (or 80 mg/day, whichever is lower)

Reduction & withdrawal should follow once their other medical condition has
been dealt with
From the New South Wales Drug and Alcohol
Withdrawal Clinical Practice Guidelines (2007)
8:2 Indications and guidelines –
Managing benzodiazepine withdrawal –
Pharmacological treatment (2)

Referral to Drug & Alcohol outpatient services or supportive GPs needs to be
arranged well in advance of discharge to organise a continued outpatient reduction
regime

Please contact a specialist Drug & Alcohol medical officer/nurse practitioner/
senior clinical nurse for advice & support

If patients stabilise on a dose in the range 40–80 mg of diazepam daily, withdrawal
should be at the rate of at least 5 mg per week until the dose reaches 40 mg, then
2.5 mg/week

A maximal rate of withdrawal would be to reduce the dose by 10 mg at weekly
intervals until 40 mg, then by 5mg at weekly intervals this will take 12 weeks as
an outpatient
New South Wales Drug and Alcohol Withdrawal
Clinical Practice Guidelines (2007)
8:2 Indications and guidelines –
Managing cannabis withdrawal – Onset
& duration of cannabis withdrawal (1)

Most symptoms commence on day 1, peaking at day 2-3, returning to baseline
after a week or two

Can be an onset of aggression (day 4) often peaking after 2 weeks of abstinence
and anger (day 6) also being particularly significant

There is a National Cannabis Prevention and Information Centre (NCPIC) with
has a range of resources and information regarding cannabis withdrawal, for
the workforce, users & families, http://ncpic.org.au/ – 1800 30 40 50
8:2 Indications and guidelines –
Managing cannabis withdrawal – Onset
& duration of cannabis withdrawal (2)
Special considerations include:

Patients with a comorbid mental health condition as there may be
unmasking of the mental illness during withdrawal

Appropriate assessment & management is required

Patients who use cannabis for chronic pain may require assessment
for adequate pain management & referral to specialist pain services

Patients with a history of aggression may require closer monitoring
and a higher dose of benzodiazepine
Common symptoms
Less common symptoms/equivocal
symptoms
Anger or aggression
Chills
Decreased appetite or weight loss
Depressed mood
Irritability
Stomach pain
Nervousness/anxiety
Shakiness
Restlessness
Sweating
Sleep difficulties, including
strange dreams
Table 9.13 Cannabis withdrawal symptoms (Budney et al., 2004:1975)
8:2 Indications and guidelines –
Managing cannabis withdrawal –
Monitoring

Cannabis withdrawal can be monitored by using a withdrawal assessment scale
such as the Cannabis Withdrawal Assessment Scale (see Appendix 5)

Not all patients will require medication for withdrawal

The following table lists medications for symptomatic relief of cannabis withdrawal
Symptom
Medication
Sleep problems
benzodiazepines, zolpidem zopiclone,
promethazine
Restlessness, anxiety,
diazepam
irritability
Stomach pains
buscopan, atrobel
Physical pain, headaches
paracetamol, non-steroidal antiinflammatory agents
Nausea
promethazine, metoclopramide
Table 9.14 Medications for relief of cannabis withdrawal
(NSW Health 2007)
8:2 Indications and guidelines –
Managing cannabis withdrawal –
Pharmacological Treatment

Given the wide interpersonal variability, dosages and prescribing schedules
will most effectively be decided upon only after a thorough exploration of the
individual patient’s symptom profile and circumstances.

Outpatient regimens might be:

7 days of diazepam 5 mg four times daily, zopiclone 7.5 mg at night, NSAIDs
/ buscopan as needed, or

7 days of zolpidem 7.5 mg at night
From the New South Wales Drug and Alcohol
Withdrawal Clinical Practice Guidelines (2007)
8:2 Indications and Guidelines
Nicotine withdrawal signs & symptoms (1)

Onset of withdrawal is usually within a few hours of the last cigarette
& withdrawal symptoms peak at 24-72 hours
Withdrawal symptoms vary, but can include the following:

Irritability

Cravings

Increased nervousness and tension

Sleep disturbance

Stomach upsets
8:2 Indications and Guidelines
Nicotine withdrawal signs & symptoms (2)

Bowel disturbance

Loss of concentration

Muscle spasm

Changes in taste

Headaches

Cough

Increased appetite
8:2 Pharmacological treatment
Treatment: Indication for in patient
nicotine withdrawal

There is generally no indication for admission into a Drug & Alcohol inpatient
facility but may be admitted into hospital & experience withdrawal from nicotine
consequently

Patients should be informed of the NSW Health Smoke Free Workplace
Policy (1999) & offered support to stop

NRT should be used when not contraindicated

Refer to NSW Health Guidelines GL2005_036: Nicotine Dependent Inpatients
http://www.health.nsw.gov.au/policies/GL/2005/pdf/GL2005_036.pdf
8:2 Nicotine withdrawal
Pharmacological treatment –
Pharmacotherapiesc

A holistic approach to smoking cessation is important and
a pharmacotherapy should be seen as one part of this approach
Pharmacotherapy options are:

Nicotine Replacement Therapy (NRT)

Bupropion

Other options such as clonidine, & nortriptyline
Type
Dose and Duration
Side Effects
Contraindications
Relative:
• Ischaemic
heart disease
Absolute:
• Recent MI
• Serious
arrhythmias
• Unstable
angina
• Pregnancy
Less than
10 cigs
per day
10-20 cigs
per day
More than
20 cigs
per day
Patches
None
Nicobate®
14 mg
Nicorette®
10 mg
Nicobate®
21 mg
Nicorette®
15 mg
Transient skin
irritation, itching,
dreams, sleep
disturbance,
indigestion,
diarrhoea
Gum
None
2 mg, 8-12
per day
4 mg, 8-12
per day
Jaw discomfort,
nausea, indigestion,
hiccups, excess
saliva, sore throat
Inhaler
None
Nicorette®
6-12
cartridges
per day
Not recommended
Mouth and throat
irritation, cough,
nausea and
indigestion
Table 9.16 Pharmacotherapy of nicotine replacement therapies
Type
Dose and Duration
Less
than
10
cigs
per
day
Bupropion
10–20
cigs per
day
Side Effects
Contraindications
Headaches, dry
mouth, impaired
sleep, seizures,
nausea, anxiety,
constipation and
dizziness
1. seizure disorders or
significant risk of seizure
2. bulimia
3. anorexia nervosa
4. bipolar disorders
More than
20 cigs per
day
150 mg for 3 days, then 150 mg
b.d. for 7 weeks
Table 9.17 Pharmacotherapy of bupropion (Zyban®)
From New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007)
8:2 Hallucinogen
Dependence and withdrawal

These drugs are not usually associated with dependence arising
from long term, high-level use

There is no evidence of a withdrawal syndrome from hallucinogens
even after abrupt cessation or substantial reduction in their use
8:2 Solvents
Withdrawal (1)

Withdrawal syndrome can occur in some cases, but it is generally mild
Symptoms include:

Anxiety

Depression

Headache

Nausea

Dizziness
8:2 Solvents
Withdrawal (2)

Drowsiness

Chills

Abdominal pains

Muscular cramps

Sometimes, confusion & hallucinations can occur after chronic solvent use
8:2 Indications and guidelines –
Ketamine withdrawal

Abrupt withdrawal can occur after cessation of long-term daily use
(White et al 2002)

There is no validated tool for recording ketamine withdrawal symptoms
Symptoms of withdrawal are:

Fear

Tremors; facial twitches

Craving

Animal studies show seizures, irritability & weight loss during ketamine withdrawal
8:2 Indications and guidelines
Gamma Hydroxybutyrate (GHB)
Withdrawal (1)

GHB use should be suspected in particular groups such as clubbers & body
builders who present with signs compatible with alcohol intoxication but record
a breath alcohol level of zero
– E.g. nystagmus, ataxia, nausea, vomiting, bradycardia & hypotension)

Withdrawal presents as rapid onset, prolonged alcohol withdrawal picture, with
less autonomic arousal and risk of seizures, but marked confusion, delirium &
hallucinations, waxing & waning over a two week period
8:2 Indications and guidelines
GHB withdrawal (2)

Management may require the use of both short & long acting benzodiazepines

Additional sedation with propofol may be required in some patients

There is no validated tool for recording GHB withdrawal symptoms
8:2 Steroids
Withdrawal

Generally, physical dependence does not appear to occur with steroid use