Transcript Detox Medications

DETOX
MEDICATIONS
Why Medicate withdrawal ?
• To prevent seizures (Etoh, barbiturates,
benzodiazepines)
• To prevent DTs
• To make the client comfortable enough to
consider engagement in treatment.
• To prevent psychiatric Decompensation
THE BENZODIAZEPINES ARE THE
PRIMARY SEDATIVES/ANXIOLYTICS
IN DETOX
The goal in detox is to achieve a state of
Minimal sedation/anxiolysis to Moderate
sedation.
The patient should be easily arousable, with
ability to maintain his/her airway, with no
drop in blood pressure.
BZD = Benzodiazepine
• They are commonly used for :
– Insomnia = hypnotic
– Acute anxiety, = anxiolytic
– Anticonvulsants
– Muscle relaxants
– Agitation /anxiety in AXIS I disorders= sedative
• They enhance the effect of GABA in the brain.
Which contains/controls brain talk
BZDs: Long half-life vs Short half-life
• SHORT T ½ : Lorazepam/oxazepam T ½
between 8 -30 hrs
• LONG T ½ : Librium/Valium T1/2 between 30100 hrs.
• Long acting: Like librium
• less frequent dosing,
• less variation in plasma concentration
• Less severe withdrawal phenomena …but
– they accumulate,
• increase risk of daytime psychomotor impairment,
• increased daytime sedation
LIBRIUM
• First BZD released in 1960
• Librium half Life: 3-100 hours
• + Active metabolites: Desmethyldiapepam :
half life: 30-200 hrs
• Dependent on Liver metabolism
• Librium 10 mg = Ativan 1 mg
Benzodiazepines
Short-acting
• Oxazepam & Lorazepam
• Advantages
– They can be administered IM or IV (in monitored settings)
– They have no significant active metabolites
– They are metabolized & excreted principally through
kidneys (& do not jeopardize already-damaged liver)
• Disadvantages
– They need to be administered more frequently.
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Benzodiazepines--contraindication
Alcohol Intoxication,
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Narrow Angle Glaucoma
• Pregnancy **
• Respiratory Depression
• Sleep Apnea**
Managing clients with:
• Hepatic Encephalopathy –DELIRIUM.
• Severe Chronic Obstructive Pulmonary Disease,
• Severe Hepatic Disease
BILI-jaundice
PT
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AST/ALT,, platelets—bruising, petechiae
ALBUMIN, ascites, edema
AVOID MEDICATIONS THAT ALTER
CNS STATUS/RESIRATORY DRIVE
• Benzodiazepines
• Anti-histamines which have an anti-cholinergic affect
BZD side affects
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Drowsiness/confused/slurred speech
Dizziness/ Ataxia
Dyspnea
Decreased reflexes
• Dis-inhibition / Paradoxical increase in
aggression (in persons with preexisting brain
damage)
DURING THE WEEK OF DETOX
• CLIENTS ARE SEDATED WITH BZDs
• If a patient requests a SMOKE BREAK
– CONSIDER
– Risk of falling due to unsteadiness with BZDs
– Risk of seizures highest during the first 48 hrs. of detox.
– CIWA score-
– Delay smoke break if they have just been medicated
with BZD, have mod/severe CIWA, or are unsteady
on feet.
– Offer Nicotine Patch / Nicotine Inhalers may be used
(not gum or lozenges: risk of aspiration in the sedated)
Drug interactions
• BZD: can increase the plasma concentrations of
dilantin and digoxin
• Kava OTC can potentiate the action of BZDs
through synergistic overactivation of GABA
receptors.
• Antacids and food can decrease the plasma
concentration of BZDs
• Smoking can increase the metabolism of BZDs.
• Use the DRUG INTERACTION CHECKER on
MEDSCAPE!!!
Antihistamines
BENADRYL/HYDROXYZINE
• Anxiolytic Not proved effective for long term
therapy
• Neuroleptic induced parkinsonism-HELPFUL
• Neuroleptic acute dystonia--HELPFUL
• Neuroleptic induced akathisia- HELPFUL
• Hypnotics: Safe, but not superior to BZD
The antihistamines
• Additive with other depressants like alcohol, or sedative
hypnotic drugs, and psychotropic drugs
BUT THERE ARE SIDE AFFECTS:
Sedation, dizziness, hypotension, all of which
can be severe in elderly persons
Anticholinergic: dry mouth, urinary retention, burred vision,
constipation: Not the 1st choice in someone dehydrated, or
men with prostatic hypertrophy, or someone severely agitated
Paradoxical excitement and agitation
GI : Epigastric distress, nausea, vomiting, diarrhea, constipation.
Benadryl: CNS excitation: delirium
Opiate abusers add antihistamines to enhance the euphoria.
SLEEP AIDES
• TRAZADONE: Antidepressant
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Inhibits neuronal uptake of serotonin (but not NE)
T1/2 : 4-9 hrs.
Metabolized by liver
+ SSRI
increased risk of GI bleeds
Don’t combine with antipsychotics / cardiac drugs that
prolong QT c
– SEROTONIN SYNDROME
–DON’T USE IN SOMEONE RECENTLY
ABUSING COCOAINE which also
blocks the re-uptake of serotonin.
MORE on Trazodone
• >10%
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Blurred vision (11-15%)
Dizziness (20-28%)
Drowsiness (24-40%)
Dry mouth (15-34%)
Fatigue (11-15%)
Headache (16-20%)
Nausea/vomiting (11-15%)
Frequency Not Defined
Sedation
Priapism—in men protracted erections.
And in 1-10%
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1-10%
Constipation
Edema
Confusion
Disorientation
Incoordination
Nasal congestion
Orthostatic hypotension
Syncope
Tremor
Weight change
This is a drug with
interactions with multiple
drugs.
MEDSCAPE DRUG
INTERACTION CHECK IS
IMPORTANT.
WE WILL BE
DISCONTINUING ITS USE
IN DETOX
OTHER ALTERNATIVES TO ASSIST SLEEP
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Melatonin—hormone produced by pineal gland
– 3-5 mg @ HS. Increasing sedation when combined with hydroxyzine/BZDs.
– It’s been used with Alzheimer's disease, benzodiazepine or nicotine
withdrawal, cancer (adjunctive treatment), headache (prevention), insomnia,
jet lag, shift-work disorder, sleep disorders , thrombocytopenia (chemoinduced), winter depression, tardive dyskinesia
Abdominal cramps
Alertness decreased
Circadian rhythm disruption
Daytime fatigue
Depression (transient)
Dizziness
Drowsiness
Dysphoria in depressed patients
Headache
Irritability
SAFE FOR SLEEP
• Hydroxyzine
– Safe Hypnotic: 25-50 mg @ HS
• BENZODIAZEPINES
– Ativan—short acting : 1 mg @ HS
ANTI-EMETICS
• PHENERGAN: 12.5-25 mg PO/IV/IM/PR q4-6hr PRN:
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Time of onset 20 minutes (po/im)
• Blocks dopamine receptors
• Blocks alpha-adrenergic receptors in the brain
• Antihistaminic effect: blocking H1-receptors
CONTRAINDICATIONS:
• Subq/IV=tissue necrosis
• BPH
• Narrow angle glaucoma
• Pyloroduodenal obstruction, stenosing peptic ulcer, bladder
neck obstruction
PHENERGAN: Because it blocks
DOPAMINE receptors in the
Mesolimbic area
has been reported to cause Hallucinations,
nervousness, irritability), involuntary
movements (e.g., fixed upward stare, neck
twisting, tongue movements), restlessness,
shaking (tremor)
PHENERGAN: Because it blocks
dopamine receptors
PHENERGAN has been reported to cause
NEUROLEPTIC MALIGNANT SYNDROME
Sudden confusion, extreme drowsiness), very
high fever, seizures, irregular/fast heartbeat,
increased sweating, muscle rigidity
PHENERGAN IS SEDATING
due to Anti-histamine effect!
• Severe CNS depression
• Coma
• Severe respiratory depression
IF A CLIENT IS SEDATED BUT NAUSEATED DON’T ADD
PHENERGAN TO THE MIX!!
IF A CLIENT IS HAVING DIFFICULTY BREATHING , AND ASKS FOR
SOMETHING FOR NAUSEA, DON’T GIVE PHENERGAN
zofran
• Selective 5-HT3 receptor antagonist
• Ondansetron has no effect on dopamine
receptors, therefore doesn't cause EPS
• Can prolong the QTc interval
• Do not give in Severe Hepatic Impairment
(Child-Pugh score 10 or greater): No more
than 8 mg/day
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>10%
Headache (6-27%)
Malaise/fatigue (9-13%)
Diarrhea (8-16%)
Dizziness (7-12%)
Constipation (3-11%)
1-10%
Hypoxia (9%)
Drowsiness (8%)
Fever (7-8%)
Gynecological disorder (7%)
Anxiety (6%)
Urinary retention (5%)
Pruritus (1-5%)
Injection site pain (4%)
Paresthesia (2%)
Cold sensation (2%)
LFT's increased
ondansetron
DIARRHEA
• LOMOTIL : diphenoxylate/atropine
• Diphenoxylate: act on smooth muscle of
intestinal tract, inhibiting GI motility &
excessive GI propulsion similar to morphine
• Atropine: subtherapeutic quantity of atropine
is added to discourage deliberate overdose of
diphenoxylate
– 13-16 years old: 5 mg PO TID
LOMOTIL
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1-10%
Anticholinergic effects
Blurred vision
Sedation
Nausea
Vomiting
Abdominal discomfort
Dryness of skin/mouth
IMODIUM/Kaopectate 1-D/
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1-10%
Anticholinergic effects
Blurred vision
Sedation
Nausea
Vomiting
Abdominal discomfort
Dryness of skin/mouth
HYPER ADRENERGIC FLOW
• CATAPRESS—Alpha Agonist-
PVR, BP, PULSE
– Off-label Uses
• EtOH withdrawal: 0.3-0.6 mg PO q6hr
• Smoking Cessation: 150-400 mcg/day PO OR 100-200
mcg/day patch q7Days
• Restless Legs Syndrome: 100-300 mcg/day, up to 900
mcg/day
• Menopausal Flushing: Apply 100 mcg/day patch
change q7Days, OR 50 mcg PO BID initially, may
increase up to 400 mcg BID
• Heroin withdrawal
CATAPRESS
• Hypotension
• Avoid in clients with; Severe CAD, recent MI,
conduction disturbances, cerebrovascular
disease, chronic renal failure
• Rebound hyptertension, with sudden
cessation
Don’t give to a client withdrawing from heroin
who is dehydrated!! Remember it drops BP!!
Thiamine & Multivitamins
• 30-80% of patients are deficient
• Thiamine does not reduce risk of seizures or
delirium tremens
• Thiamine does reduce risk of Wernicke’s
encephalopathy
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IM Thiamine
• Patients with WKS should be with thiamine 100
mg IV, followed by 10 0 mg IM daily for 7-10 days
and then 100 mg by mouth daily
• Give with magnesium, which is necessary for
thiamine metabolism
MUSCLE RELAXANTS
• FLEXERIL
– related to cyclic antidepressants
– norepinephrine potentiation,
– potent anticholinergic
– sedation
– Reduces motor activity
– Use caution in urinary retention, narrow-angle
glaucoma or other anticholinergic drugs
GABAPENTINE
• Restless Legs Syndrome
• Indicated for moderate-to-severe primary restless legs
syndrome 600 mg PO qDay with food at about 5 PM
• Muscle Cramps (Off-label)
• 100-300 mg PO qHS; titrate to 300-400 mg TID PRN
• Anxiety (Off-label)
• Initial 300 mg PO qHS, THEN 300 mg PO TID, further
increase as tolerated
• Diabetic Neuropathy (Off-label)
• Initial 900 mg/day PO; increase to 1800-3600 mg/day
THE ANALGESICS
• TYLENOL & LIVER
• Motrin & Gut/Kidney
• NEVER exceed 4
grams/day
• Smaller amounts can
cause hepatic damage
• Can cause gastritis
• Can result in GI bleeding
• Can decrease renal
function
• Don’t combine with other
NSAIDs/ASA
ANTIELEPTICS
• TEGRETOL
• As effective as
oxazepam
• Dose: 200mg TID x 10
days
• Low abuse potential
• Minimal Cognitive
Effects
• Used in BZD withdrawal
MILD AND MODERATE
WITHDRAWAL