Transcript Presentation

Detoxification
Pharmacology
Rochelle Head-Dunham, M.D., FAPA
Medical Director,
Louisiana Office for Addictive Disorders
Goals & Objectives
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Discuss general guidelines and
considerations for withdrawal and
detoxification
Discuss detoxification protocols
for three major classes of substances of
dependence
Withdrawal Syndrome
The characteristic group of signs and
symptoms that typically develop after a
rapid, marked decrease or discontinuation
of a substance of dependence,
which may or may not be clinically
significantly of life threatening.
Withdrawal Syndrome
Withdrawal severity and duration depend on several
factors:
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7.
Nature of substance
Half-life and duration of action
Length of time substance used
Amount used
Use of other substances
Presence of other medical and psychiatric conditions
Individual biopsychosocial variables
The Clinical Assessment
The diagnosis of dependence is made through a careful patient
history and physical examination, focusing on the following
information:
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Drug type, route and duration of use, symptoms with cessation and
last use
Risk factors, symptoms and previous testing for blood-bourn
pathogens
Past Medical History and review of symptoms of chronic use such as
malnutrition, tuberculosis infection, trauma, endocarditis, and sexually
transmitted diseases
Physical Examination to include vital signs, and cardiac status for
evidence of fever, heart murmur, or hemodynamic instability; exam
should focus on skin areas for scarring, atrophy, infection
Laboratory Evaluation should include a complete blood count,
comprehensive chemistry panel, HIV testing, EKG, Chest x-ray,
screening for STD’s
Urine Drug Screens and Breath Analysis (Alcohol)
Detoxification
The physiological process of withdrawal
from a substance of dependence
which requires medication management,
careful monitoring, and
the availability of lifesaving emergency
interventions.
Detoxification Levels of Care
Severity of Withdrawal dictates appropriate
level of care:
Medical Detoxification (24-hour care, hospital
setting)*
 Medically Supported Detoxification (24 hour
care, non-hospital/residential setting with
profession medical staff)
 Social Detoxification (24 hour care, nonhospital/residential setting without professional
medical staff)
*May occur in outpatient setting with skilled clinician.
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Detoxification
General Consideration
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2.
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5.
High index of suspicion, non-judgmental
questions, careful screening and assessment
Anticipate inaccurate/minimized reports of use
Psychological withdrawal for all, physiological
for some
All withdrawal syndromes not clinically
significant
Dangerous syndromes: Alcohol,
Sedative/hypnotic and Anxiolytic Withdrawal;
Opiate withdrawal is extremely uncomfortable
Detoxification
General Consideration (con’d)
6.
7.
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10.
Rule of thumb: Substitute long acting,
cross-tolerant substance with gradual
tapering by 10-20% per day
Use adequate dosages for comfort
Limit access to controlled substances
Detox alone is rarely adequate treatment
Management of co-morbid medical and
psychiatric conditions
Role of Medication in Detoxification
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Stabilization of psychological or physiological
withdrawal symptoms
Medical emergencies: Alcohol, Sedativehypnotics, Benzodiazepines,
Remediation of non-life threatening, relapsetriggering symptoms
Stabilization of co-morbid conditions
ALCOHOL
Detoxification
Alcohol Withdrawal
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1.
2.
3.
Autonomic dysfunction-Insomnia-Anxiety
Onset 8+ hrs, Peak 48hrs, Diminished 5dys, Duration
3-6 months
Withdrawal Syndromes:
Mild, moderate or life-threatening severity (increased
severity with BAL>100mg/dl)
3% Withdrawal Seizures (w/in 48hrs of abstinence)
Delirium Tremens (DTs) – Medical Emergency!
(w/in 48-72hrs of abstinence)
(4-5% Prev., M&M<5% w/o tx, <1% w/tx)
Withdrawal Assessment
Clinical Institute Withdrawal Assessment-Alcohol,
revised (CIWA-Ar)
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Nausea
Tremor
Diaphoresis
Anxiety
Auditory disturbances
Orientation
Agitation
Tactile disturbances
Visual disturbances
Headaches
Withdrawal Severity: 0 (not present) to 67
(extreme); Higher = >risk
 8-10 Mild
–Supportive, no Meds
(i.e. Social Detox)
 10-15 Moderate - Some meds (BZP)
(i.e. Medically Supported Detox)
 15/> Severe - DT Risk
(i.e.. Hospitalization)
N.B. May also be used to monitor
recovery and medication management
Sample Medication Protocol
Days 1-2 : Lorezepan 1-2 mg three times a day
Days 3-4: Lorezepam 1-2 mg twice daily
Day 5:
Lorezepam 1-2mg, daily
*Adjust dosage and duration for intoxication or
prolonged withdrawal
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Adjunctive treatments:
1.
Seizure history: Tegretol 200mg/Neurontin 400mg (5dy taper)
Sympathetic activity: Clonidine 0.1-0.2q8hrs (3-5dys)
Fluids, MVI, Thiamine
Manage co-morbid conditions
2.
3.
4.
BENZODIAZEPINES
General Consideration
Sedative-hypnotic (Benzodiazepine)
Detoxification
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Symptoms similar to alcohol but no objective
measure/scoring system
High risk of delirium, seizures and death
requires treatment
Sub-clinical symptoms may persist for months
Tolerance develops within 3-4 weeks of regular
use
Onset of withdrawal symptoms determined by
half-life of compound
Benzodiazepine
Detoxification guidelines:
 Slow-tapering of the compound or use of a
longer acting benzodiazepine recommended
(i.e., Clonazepam TID with 10% tapering
daily)
 Sedatives for insomnia (i.e. antidepressants)
 Avoid beta blockers (mask symptoms)
 Anti-seizure medications adjusted and
monitored
OPIATES
Opiate Indications for Use
1. Addiction Maintenance Therapy
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Methadone (Pure Mu Opioid Agonist)
Naltrexone (Opioid Antagonist)
Buprenorphine (Opioid Agonist- Antagonist)
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(N.B. LAMM now Minimally Available)
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2.
Pain Management
Opiate Detoxification
Key Considerations:
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Medical Detoxification = Standard of Care
Methadone short-term substitution therapy =
the preferred method of detoxification, but…
Goal of treatment = reducing withdrawal
discomforts, with or without Methadone or
Narcotic Substitution
Opiate Detoxification
Key Considerations (con’d):
 Comprehensive, long-term treatment is
equally important as alleviating acute
symptoms
 Fear and Anticipatory Anxiety = predominate
emotional responses to detoxification
 Counseling prior to detoxification is
necessary (i.e. expectations of withdrawal,
treatment planning, patient
responsibilities…)
 Treatment should be: individualized,
reviewed and approved by a physician
Opiate Detoxification and
Pregnant Women
CONTRAINDICATED!
Methadone maintenance is the recognized
standard of care for decreased risk of
miscarriage and premature labor.
Opiate Withdrawal Syndrome
1. Not life threatening,
Extremely uncomfortable
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2. Symptom onset and
duration, half-life
dependent
3. Common Sns & Sxs:
 Yawning
 Sweating
 Tearing
 Abdominal Cramps
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Nausea and/vomiting
Diarrhea
Weakness
Dilated Pupils
Goose bumps
Muscle twitching aches and
pain
Anxiety
Insomnia
Increased pulse
Increased Resp rate
Elevated Blood pressure
Opiate Detoxification
Pharmacological Guidelines (cont.)
Naltrexone
 Only opioid antagonist approved in the United
States
 Used for rapid detoxification due to accelerated
binding and blocking of mu receptors, precipitating a
profound withdrawal
 Limitation: must be administered in hospital or
supervised environment when prescribed for rapid
detoxification
Opiate Detoxification
Advantages of Methadone
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Daily dosing due to 24 hour half-life, requiring slower
tapering schedule
Long half-life safe for all opiates
Safe in pregnancy
May be used in combination with other medications
for co-occurring disorders or mild withdrawal
symptoms
Decreases morbidity and mortality, hepatic damage,
and HIV
Exception: licensing requirements, very addictive
Opiate Detoxification
Methadone Guidelines:
 Stabilize Withdrawal: 5-10 mg prn every 4-6
hours to control objective signs of withdrawal
 Monitor respiratory depression and excessive
sedation until stabilized
 Detoxification: Reduce by 10%/day after
stabilized for 2-3 days
 Clonidine 0.1-0.2mg/day for duration
Opiate Detoxification
Levels of Care
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Inpatient Setting
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Outpatient Setting
1.
Duration: 4-7 days
Usual dose to suppress
symptoms: 30-40mg/day
Methadone
Immediate Referral to drugfree treatment setting
Clonidine (Catapres) can
be considered an effective
alternative treatment for
inpatient opioid
detoxification but not
outpatient
1.
21 day protocol sufficient
for most stable, motivated
patients
180 day protocol, done
within an opioid agonist
therapy program, should
be considered to work on
patients’ early recovery
problems, while stabilized
on relatively low dose (5060mg) Methadone
2.
3.
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2.
Opiate Detoxification
Buprenorphine
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History: October 2000amended Control Substance
Act: 30 patient/MD max for opioid dependence
treatment, with DEA waiver; Goal: accessibility,
expanded treatment capacity
Partial mu agonist antagonist: ceiling effect (safer),
sublingual absorption, Suboxone preferred
Dosing instructions dependent on half-life of
substituted opiate
Average tolerable maintenance dose is 4-32 mg
SL/day to every 3rd day
Detox at 10%/day as tolerated
Opiate Detoxification
Pharmacological Guidelines (cont.)
Adjunctive Treatments
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Nonsteroidal Anti-inflammatory Agents for pain and fever
(i.e. Tylenol, Aleve)
Alpha-adrenergic blocker for sympathetic hyperactivity
such blood pressure, nausea, vomiting, diarrhea, cramps
and sweating
(i.e. Clonidine/Catapres)
Antidiarreals and anti-emetics to control gastrointestinal
symptoms (i.e. Bentyl, Phenergan)
Antidepressants/Antipsychotic for dysphoria, anxiety and
insomnia (i.e. Trazedone/Elavil/Seroquel with/without
Lexapro)
Psychotropics for co-morbid psychiatric conditions along
with medications for medical conditions
Concluding Comments
1.
2.
3.
4.
6.
All withdrawal syndromes are not clinically
significant
Dangerous syndromes: Alcohol, Sedative/hypnotic
and Anxiolytic withdrawal; Opiates withdrawal,
extremely uncomfortable
Substitute long acting, cross-tolerant substance
with gradual tapering by 10-20% per day
Detox alone is rarely adequate treatment
Management of co-morbid medical and psychiatric
conditions