Medical Detoxification

1
Medical Detoxification
2
Objectives

• Participants will be able to
• describe the clinical signs and symptoms of
  alcohol and sedative withdrawal
• describe the neurobiology of alcohol withdrawal
• describe the clinical methods used to manage
  alcohol and sedative drug detoxification

3
Medical Detoxification

• sedatives alcohol, alprazolam
• stimulants cocaine, amphetamines, nicotine
• opiates heroin, methadone, morphine

4
Assess for Risk of Alcohol Withdrawal

• History of DTs
• Daily use of alcohol (more than 12 drinks per
  day)
• History of morning drinking
• Prior treatment for alcohol problems

5
Outpatient versus Inpatient Treatment

• Medical criteria
• Absence of serious medical problems
• No history of drug withdrawal-induced delirium,
  seizures, or psychosis
• Abstinence criteria
• Patient agrees to abstinence and treatment
• Patient agrees to random testing
• Psychosocial criteria
• Patient has support of sober family and friends

6
Pathophysiology of Sedative Withdrawal

• GABA neurotransmitters
• Receptor complexes are primary central nervous
  system inhibitory sites
• Reduces nerve cell excitability
• Sedative brain receptors
• Specific receptors
• Alcohol - no specific receptor
• Drug receptor activation
• Activation stimulates GABA release
• Chronic sedative use depletes GABA

7
General Signs and Symptoms of Alcohol and
Sedative Withdrawal

• Tachycardia
• Increased systolic blood pressure
• Increased temperature (rule out infection)
• Diaphoresis
• Anxiety/fear
• Insomnia/nightmares
• Vomiting/diarrhea
• Tremor

8
Stages of Alcohol and Sedative Withdrawal
General Signs Hallucination Delirium
Stage 1 mild no no Stage
2 moderate yes no Stage
3 severe maybe yes (delirium tremens)
9
Alcohol/Sedative Withdrawal
10
Clinical Withdrawal Assessment Scale

• Temperature
• Pulse
• Respiration
• Blood Pressure
• Anxiety
• Agitation
• Tremor

• Diaphoresis
• Eating disturbance
• GI distress nausea, vomiting, diarrhea
• Sleep disturbances
• Clouding of sensorium
• Hallucinations
• Convulsions

Score Stage 1 10
11
Alcohol and Sedative Withdrawal

• Not all patients demonstrate all symptoms
• Progression from Stage 1 to 2 to 3 is usual
• Rapid development of Stage 3 in 12 hours is
  possible
• Treatment may not prevent development of delirium
  tremens
• 1/3 of patients with seizures will develop Stage 3

12
Withdrawal from Sedative Hypnotics Other than
Alcohol

• Clinical Characteristics
• Similar to alcohol
• Barbiturates - temperature, delirium, seizures
• Benzodiazepines - anorexia, insomnia, agitation
• Onset
• Alprazolam - 1-2 days
• Diazepam, phenobarbital - 5-10 days

13
Treatment Methods for Alcohol/Drug Withdrawal

• Supportive Care
• Nonpharmacological treatment
• Three Rs
• Reality
• Reassurance
• Respect

14
Medication for Sedative Withdrawal

• Intravenous fluids
• ß-blockers
• Thiamine
• Potassium
• Vistaril for nausea

15
Benzodiazepine Treatment for Alcohol and
Sedative Withdrawal

• Rationale
• Rapid induction
• Easy transition
• Adequate control of symptoms
• Prevention of Stage 2, 3 withdrawal
• Partially protective against seizures
• Side effects over-sedation, aspiration
  pneumonia, drug dependence

16
Benzodiazepine Treatment Loading Dose

• When should treatment be initiated?
• Depends on risk factors and symptoms
• How much medication should be used?
• 20-60 mg Diazepam in 3 divided doses orally
• Additional treatment
• Diazepam every 2 hours until symptoms are
  controlled
• Tapering unnecessary

17
Treatment Alternatives

• Chlordiazepoxide
• Lorazepam
• Oxazepam
• Valproic acid

• Clonidine
• Carbamazepine
• Chlormethiazole
• Phenobarbital

18
Medications no Longer in Widespread Use...

• Alcohol
• Bromides
• Paraldehyde

19
Alcohol Withdrawal Seizures

• Who should receive prophylactic treatment?
• Currently on an anticonvulsant
• History of epilepsy
• History of withdrawal seizures
• Magnesium level
• Prophylactic drug treatment
• Carbamazepine preferred over phenytoin
• Medication should be given early
• Loading dose Tegretol 100 mg every 2 hours x 4
  doses
• After, 200 mg every 6 hours x 7 days

20
Treatment of Delirium Tremens Not Responsive to
Valium

• Lorazepam 2-6 mg. every hour
• Haloperidol 1-5 mg. every 2-6 hours
• Haldol may decrease seizure threshold

21
Phenobarbital Protocol for Treatment of Sedative
Withdrawal

• Rapid Induction
• When compared to Librium (Smith, 1978)
• Decreased period of disability
• Decreased period of insomnia
• Decreased cardiovascular abnormalities
• Excellent anticonvulsant
• Only side effect is sedation
• Abuse potential is minimal
• Treatment for polydrug withdrawal

22
Phenobarbital Protocol for Treatment of Sedative
Withdrawal

• Loading and Supplemental (sodium luminal)
• 130-160 mg. IM as needed
• Phenobarbital (routine) orally
• 30 mg. 4 times a day x 3 days
• 15 mg. 4 times a day x 2 days
• 15 mg. twice a day x 1 day

23
Common Characteristics of Cocaine and Amphetamine
Withdrawal

• Depression, insomnia, fatigue, headache
• Irritability, poor concentration, and
  restlessness
• REM sleep may be increased for weeks after last
  use
• Intense drug craving
• Suicidal ideation is the norm

24
Cocaine Withdrawal Unique Features

• Paranoia and acute psychosis
• Intense craving and drug-seeking behavior
• Severe anhedonia, depression, and suicidal
  ideation

25
Amphetamine Withdrawal Unique Features

• Amphetamine psychosis may be difficult to
  separate from organic illness
• Symptoms
• feelings of persecution
• paranoia
• compulsive behavior
• visual or auditory hallucinations

26
Tobacco Withdrawal Specific Effects

• Symptoms
• increased appetite
• intense craving
• drug-seeking behavior

• irritability
• difficulty with concentration
• easily fatigued

• Recovering alcoholics report nicotine withdrawal
  and craving more severe than alcohol withdrawal

27
Summary of Clinical Characteristics of Stimulant
Withdrawal
Fatigue Sleep disorder Agitation Suicide
ideation Depression Agitation Craving Fatigue Tr
emors Agitation Craving

• Amphetamines
• Cocaine
• Nicotine

28
Drug Treatment for Cocaine and Amphetamine
Withdrawal

• Treatment of agitation/paranoia
• Mellaril 25-50 mg.
• Haldol 5 mg. IM/IV
• Treatment of cocaine craving
• ???
• Treatment of depression
• Amitriptyline 50-150 mg. h.s.

29
Grading Scheme for Opioid Withdrawal
Grade 0 drug craving, anxiety, drug-seeking
behavior Grade 1 yawning, sweating,
lacrimation, rhinorrhea Grade 2 mydriasis,
gooseflesh, muscle twitching Grade
3 insomnia, increased pulse, abdominal
cramps, vomiting, diarrhea Grade 0 no
medication necessary Grades 1-3 pharmacotherapy
30
Drug Treatment for Opiate Withdrawal

• Clonidine
• 0.1 mg. test dose
• then 0.2 mg. three times a day x 3-5 days, and
• 2 clonidine patch for 14 days
• Promethazine
• 25 mg. IM for nausea
• Lorazepam
• 2-4 mg. by mouth or IV for anxiety, restlessness
• Ibuprofen
• 800 mg. for muscle cramps and joint pain

31
Opioid Detoxification

• Buprenorphine
• Indication
• Dose
• Duration
• Side effects
• Efficacy

32
Opioid Detoxification

• Naltrexone
• Indication
• Dose
• Duration
• Protocol
• Side effects
• Efficacy

33
Methadone

• Patients on methadone maintenance
• Reduce 2-3 mg. per day down to 30 mg.
• Then 1-2 mg. per day
• Patients dependent on other opioids
• 10 mg. of methadone as an initial dose
• Average 24 hour dose is 20-30 mg.
• For detoxification, methadone should be tapered
  in 7-10 days