Detox – Then What? | slideum.com

Detox – Then What?

Transcript Detox – Then What?

Overview of Medical and Non-Medical Detox

CAPTASA January 30, 2015

Practice Gaps- Why are we even talking about this again?

 Medical Detox is severely limited in availability  Varies greatly in quality and effectiveness  Some may be appropriate for Non-Medical Detox  Who ought to get what and why

Objectives of this activity:  Review the options available for Detox  I will provide my experience with Medical detox  Hopefully we can increase the awareness that Detox is essential to prepare a person to receive Treatment  But Detox is

not

Treatment

“I know I’ve got a tarnished reputation… But Man I can sure think on my toes”

Assembly of Dust Bootlegger's Blues

Who Needs Detox?

 Anyone using recently or regularly- who is ready for change  Using what?- Alcohol, Sedatives and Opiates  To Start Treatment or Start Over

Some are Ready, Some Not So much

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 3 rd Ed. Page 612

We do it for them- their the ones with the problem

“Of course an alcoholic ought to be freed from his physical craving for liquor, and this often requires a definite hospital procedure, before psychological measures can be of maximum benefit.” William D. Silkworth, MD The Doctor’s Opinion

Dopamine Pathways – Pleasure pathways

frontal cortex striatum hippocampus alcohol cocaine heroin nicotine amphetamines opiates THC PCP ketamine nucleus accumbens substantia nigra/VTA heroin alcohol benzodiazepines barbiturates

Which drugs need medical detox ?



Alcohol



Sedative/hypnotics



Opiates



Any that are impacting ability to begin Tx

Most Common forms of Detox  Nothing  In a jail cell  Alone  Die using  A few lucky ones get Medical help or a caring Hand

Usual Medical Detox approach



Benzo’s for Alcohol



Benzo’s for Benzo’s



Opiates for opiates

“We live in the age of wonder drugs: first we give the patient the drugs, then we wonder…” Adolph L. Sachs, MD Head of Neurology University of Iowa

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 .

GABA- the down button

NMDA- the up button

Here’s what I did

 History of Use  What are they using? How they use it?

 How much, especially in last 7-10 days  How long using  Other medical conditions- High Blood Pressure, Heart Disease, Lung Disease, Seizures, Infections, Past Detox experiences…

My Experience with Benzodiazepines

ASAM Textbook, 3 rd 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”

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

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.

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

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

Buprenorphine for High Dose Opiate W/D  Buprenorphine 4-8 mg SL, on day 2 or 3  Can repeat dose in 12 hours  Cramps, Sweats and Diarrhea are good guides to effect  Rarely use more than 12 mg in 24 hours  Rarely use more than 4 days  Always use plain Buprenorphine and use SL observed doses

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

“The Art of Medicine consists in amusing the Patient while Nature cures the Disease.” Voltaire

Non-Medical Detox  Works for a motivated individual  Need informed, caring staff  Need quick Medical help if things go sideways  But it’s a viable option and many do get well this way

Non-Medical Detox  Individuals undergoing detoxification are in the midst of a personal and a medical crisis  That can facilitate a real opportunity for them to acknowledge their problem and become willing to consider a change  Research indicates that detoxification is often followed by reduced drug-use and treatment-seeking behavior

Social Detox Pluses  Costs! Much less than Medical Model Detox  But that does

not mean

lower rates of effectiveness or lower standards of care  The level of personal care by staff at a

social model detox

program is frequently found to be higher because most people working in these facilities are also in recovery  So they can empathize with the people in treatment.

Here’s what they do…

 History of Use  What are they using? How they use it?

 How much, especially in last 7-10 days  How long using  Other medical conditions- High Blood Pressure, Heart Disease, Lung Disease, Seizures, Infections, Past Detox experiences…

What about Seizures?

 Don’t panic  Most likely with Benzo’s and/or Alcohol  Can occur up to a week after last use, but usually in first 72 hours  Rarely life threatening  Get them safely to floor or in bed  On side, either is fine  Time it and watch their breathing

What are the DT’s  They aren’t what most folks think.

 Most of the time when someone says they have or have had DT’s they didn’t  DT’s are fatal 10% of the time, even with treatment at a hospital  They are most common with Alcohol, but occur with mixtures as well  Change in Mental Status, plus unstable vital signs

What Delirium Is

 This is important!

 Confused  Combative  Unstable Vital signs  Need Medical Care quickly

When would transfer to Medical Detox be needed?

 Change in mental status  Hallucinations  Fever or rise in temperature  Significant dehydration  Significant increases or decreases in blood pressure and heart rate  Upper and lower gastrointestinal bleeding