Detoxification/Withdrawal

download report

Transcript Detoxification/Withdrawal



Differences between adolescent and adult
patterns of use, effects on brain, concerns
with detoxification/withdrawal.
Understand top concerns with particular
substances
 Alcohol
 Opiates/opioids
 Cannabinoids
 Methamphetamine/cocaine/stimulants


Continues to develop until 20s
Back to front

Different patterns of use
 Alcohol: binge vs. daily
 Polypharmacy as a general rule


Substances effect adolescent differently
The younger age at initiation the more risk
for abuse/dependence

Pattern of Use
 Binge type
 Less likely to be daily drinkers

Less sensitive to the sedating effects of
alcohol
 Higher BAC
 More blackouts
 More damage


More likely to overdose than go through
medically significant withdrawal
What happens with alcohol overdose?
 Increasing BAC leads to increasing sedating
effects
 Loss of muscle control, stupor, coma, death
 Death from aspiration, choking, respiratory
depression

Requires significant duration of daily drinking
with tolerance
 60% who meet criteria for dependence will
experience some symptoms of withdrawal (>90%
mild to moderate)


6-24 hours from last drink
Changes to major neurotransmitters in brain
 Enchances GABA-major inhibitory neurotransmitter


Homeostatic changes
Increase in blood pressure, heart rate, anxiety,
n/v, seizure, death




Clinical Institute Withdrawal Assessment
Questionnaire /Assessment done by
clinician/nurse
Score 10 or more needs medical
treatment/evaluation
What to do if limited nursing?






Nausea and Vomiting
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache, fullness in
head
 Disorientation



J Clin Psychopharmacol 1991; 11:291-295


Heroin
Prescription Drugs
 Hydrocodone (vicodin, norco)
 Oxycodone
 Morphine
 Methadone










Sedation
Pupil Constriction
Slurred speech
Impaired attention/memory
Constipation/ urinary retention
Nausea
Confusion/delirium
Seizures
Slowed heart rate
Respiratory depression
 Depends on which opiate:
▪ Onset of action.
▪ Hydrocodone (peak .5hr, duration 3-4 hours)
▪ Methadone (peak: 2-4 hours, duration 24 hours)
▪ Tolerance of individual
▪ Tolerance to respiratory depression may be slower than tolerance to
euphoric effects
 Symptoms of overdose:
▪ Triad:
▪ Altered LOC
▪ Respiratory Depression (RR<12)
▪ Miotic Pupils

Withdrawal
 Cows

Basic life support
 Assess Ventilation
▪ Support ventilation
 Naloxone hydrochloride – opioid antagonist
▪ .4mg to .8mg, may have to be repeated
▪ May need higher doses and multiple repeated doses
over time


Not life-threatening but so uncomfortable
prompts relapse.
Onset of symptoms depends on the duration
of use and ½ life of drug used
 Heroin: onset 4-6 hours
 Methadone: onset: 36 hours


Neurophysiologic rebound in target organs
The generalized CNS suppression during use
is replaced by CNS hyperactivity.


Supportive measures
Medication assisted
 clonidine

CVS
 Ventricular irritability
 Hypertension
 Tachycardia
 Myocardial Infarction

Neurologic
 Seizure
 Stroke
 Hyperthermia



Rhabdomyolysis
Acute Renal Failure
Insomnia


CVS

Neurologic
 Cardiomyopathy
 Memory Impairment
 Myocardial Infarction
 Deficits in judgment
 Strokes
 Poor impulse control
Pulmonary

Infectious
 Pulmonary
 HIV/Hepatitis C
Hypertension
 COPD
 Skin infections
 Complications IVDA

Psychosis
 Acute:
▪
▪
▪
▪
Classically paranoid
Persecutory delusions
Ideas of Reference
Heightened awareness
 Chronic:
▪ Psychosis can persist after
acute episode or recur with
little or no further MA use.
▪ Sensitization

Mood Disorder
 Mania during
intoxication
 Depression during
withdrawal
 Anxiety





Confirm diagnosis by urine toxicology screen
Gastric lavage or activated charcoal for
ingestion
Seizures: Diazepam
Psychosis /Agitation: Diazepam +/antipsychotic
Hyperthermia: external cooling

Hyperarousal
 Agitation, severe craving, nightmares

Vegetative Symptoms
 Decreased energy, craving sleep, increased
appetite

Anxiety-related symptoms
 Anxiety, loss of interest, anhedonia, psychomotor
retardation

Severe dysphoria, mood volatility, irritability
and sleep pattern disruption


Drug of choice- most daily marijuana use
Intake:
 Adverse events: paranoia, increased blood
pressure/HR

Withdrawal
 Symptoms similar to nicotine withdrawal
 No real treatment for withdrawal




Mixture of herbs or dried, shredded plant
material that is typically sprayed with
chemicals that are similar to THC
Street names: Spice, K2, Black Mamba,
Blaze, JWH-018, 073, Kronic(added BZ),
krypton (added opioid)
Typically smoked
Sold in Europe since 2002-2004. Widely
available for purchase on Internet in 2006





2010: states began banning product
2011: schedule 1 drug
First cannibinoid identified was JWH-018 and
CP47,497. Now there are well over 20 new
synthetic cannabinoids.
10 -100 more potent than THC
Strong affinity to CB1 receptors
 Responsible for psychoactive effects
 Central and peripheral nervous sx,
 Cardiovascular system



Some of herbal ingredients added may have
psycho-active potential (opioid-like, Bz,etc)
Onset 3-5 minutes
Duration of action: 1-8 hours


Depends on dose
Mood effects
 Euphoria and dysphoria
 Hyperactivity, anxiolysis and anxiety

Perceptual effects




Change in time perception
Hallucinations/psychotic states
Paranoia
Depersonalization/dissociation

Cognition effects:
 Fragmented thinking
 Short term memory impairment

Motor effects
 Ataxia, loss of coordination, slurred speech


Immunosuppressive
Cardiovascular effects
 Increased heart rate, orthostatic hypotension



Unpredictable toxicology
Adverse effects are dose dependent
Emerging evidence that adverse effects are
more severe
 Especially in teens (as is Marijuana)


Seizures
Psychosis
 Growing acceptance that cannabis use may
increase the risk of psychosis and/or psychosis like
conditions. Cannabis risk is mild.
▪ 41% increased risk in developing psychosis for cannabis
users v. non-cannabis users
▪ 109% increase for heavy cannabis users
 Commonly reported in SC users
▪ Clearly associated with both the onset and exacerbation
of recurrent psychotic episodes

Mood and Anxiety
 Anxiety
 Catatonia

Cardiovascular effects
 Increased heart rate
 Pediatrics: Adolescents presenting with chest
pain, confirmed myocardial infarction.