11) guia de la asociacion americana de psiquiatria.pdf

8/11/2019 11) guia de la asociacion americana de psiquiatria.pdf

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Based on Practice Guideline for the Treatment of Patients With Substance Use Disorders:Alcohol, Cocaine, Opioids, originally published in November 1995. A revision of thispractice guideline was begun in 2002 and is expected to be completed in fall 2003.

TREATING

SUBSTANCE USE DISORDERSA Quick Reference Guide

1


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For Continuing Medical Education creditfor APA Practice Guidelines,visitwww.psych.org/cme.

To order individual Practice Guidelines or the2002 Compendium of APA Practice Guidelines,

visitwww.appi.org or call 800-368-5777.


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TREATING SUBSTANCE USE DISORDERS 3

Introduction

Treating Substance Use Disorders: A Quick Reference Guide is a sum-mary and synopsis of the American Psychiatric Associations PracticeGuideline for the Treatment of Patients With Substance Use Disorders,which was originally published in The American Journal of PsychiatryinNovember 1995 and is available through American PsychiatricPublishing, Inc. (A revision of this Practice Guideline was begun in 2002

and is expected to be completed in fall 2003.) The Quick ReferenceGuide is not designed to stand on its own and should be used in con-junction with the full text of the Practice Guideline. Graphical algorithmsillustrating the treatment of substance use disorders are included.

Statement of Intent

The Practice Guidelines and the Quick Reference Guides are not intend-ed to be construed or to serve as a standard of medical care. Standardsof medical care are determined on the basis of all clinical data availablefor an individual case and are subject to change as scientific knowledgeand technology advance and practice patterns evolve. These parametersof practice should be considered guidelines only. Adherence to them willnot ensure a successful outcome in every case, nor should they be con-strued as including all proper methods of care or excluding other accept-able methods of care aimed at the same results. The ultimate judgmentregarding a particular clinical procedure or treatment plan must be madeby the psychiatrist in light of the clinical data presented by the patientand the diagnostic and treatment options available.

The development of the APA Practice Guidelines and Quick ReferenceGuides has not been financially supported by any commercial organiza-tion.


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TREATING SUBSTANCE USE DISORDERS4

C. Assessment...................5

E. Substance-SpecificRecommendations1. Alcohol Use

Disorders................162. Cocaine Use

Disorders................213. Opioid Use

Disorders ................23

D. Overall TreatmentIssues1. Formulation and

Implementation of aTreatment Plan............10

2. Treatment Settings.......113. Pharmacological

Treatments..................134. Psychosocial

Treatments..................14

B. PsychiatricManagement1. Establish and maintain

a therapeuticalliance ....................7

2. Monitor clinicalstatus .......................7

3. Manage intoxicationand withdrawal .........8

4. Develop and facilitateadherence to atreatment plan ...........8

5. Use relapse preventionstrategies ..................9

6. Provide education......97. Diagnose and treat

comorbid psychiatricdisorders ..................9

OUTLINE

A. Goals of SubstanceUse Treatment..............5


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Detailed history of the patients past and present substance use,including effects on cognitive, psychological, behavioral, and physiological

functioning and pattern of substance use: where, with whom, how much, and by

what route of administration.

General medical and psychiatric history and examination (includinga complete physical and mental status examination) to determine comorbid medical and psychiatric disorders and assess for signs and symptoms of current intoxication or

withdrawal.

C. Assessment

The psychiatrist should obtain information from the patient, available

family members and peers, current and past treaters, employers, andothers as appropriate. Assessment should include the following:

A. Goals of Substance Use Treatment

Reduce use of substance or achieve complete abstinence. Abstinence is the ideal outcome. Many patients are unable or unwilling to achieve abstinence. Controlled use is unattainable for many patients.

Reduce frequency and severity of relapse.

Improve psychological and social functioning. Repair disrupted relationships. Reduce impulsivity. Develop social and vocational skills. Obtain and maintain employment.


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History of prior substance use treatments (e.g., settings, context,modalities, duration, and adherence) and outcomes (e.g., subsequentsubstance use and social and occupational functioning achieved)

Family history of substance use or psychiatric disorder

Social history (including school or vocational adjustment, peerrelationships, financial and legal problems)

Qualitative or quantitative screening of blood, breath, or urine forsubstances and laboratory tests for abnormalities that mayaccompany acute or chronic substance use

Screening and assessment for infectious and other diseases (e.g.,HIV, tuberculosis, hepatitis, bacterial endocarditis) that are often

found in substance-dependent persons and are particularly prevalentwith the use of substances by injection

C. Assessment (continued)


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1. Establish and maintain a therapeutic alliance.

Look for the following: Potential emergence of self-destructive, suicidal, or homicidal

thoughts or behaviors Treatment-emergent side effects Evidence of relapse

- Breath, blood, saliva, and urine testing for abused drugs is ofteninitially conducted frequently and on a random basis.

- An elevation of state markers, such as mean corpuscular volume(MCV) or gamma-glutamyl transpeptidase (GGT), may indicate areturn to drinking.

Evidence of complications of chronic substance use (e.g., dementiawith chronic heavy use of alcohol)

2. Monitor clinical status.

The primary goal is to have the patient learn, practice, andinternalize changes in attitudes and behavior conducive to relapseprevention.

A stronger alliance predicts less substance use and betterpsychological functioning during follow-up.

B. Psychiatric Management

During the ongoing process of choosing among and implementingvarious treatments, psychiatric management is crucial to monitoring thepatients clinical status and coordinating treatment components.


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Monitor attitudes about participating in treatment and complyingwith specific recommendations.

Address barriers to treatment participation.

4. Develop and facilitate adherence to a treatment plan.

Provide acutely intoxicated patients with reassurance andcontainment in a safe and monitored environment.

Ascertain which substances have been used, route ofadministration, dose, time since last dose, and whether level ofintoxication is waxing or waning.

Hasten removal of substances from the bodye.g., by gastriclavage (if the substance has been recently ingested), or by

increasing rate of excretion (e.g., by hydration). Reverse drug effects by administering antagonists (e.g., naloxone

for heroin overdose) that can displace agonists from neuronal andother receptors.

Watch for withdrawal syndromes in physically dependentindividuals who discontinue or reduce their substance use afterheavy or prolonged use.

Treat with medications to ameliorate withdrawal symptoms (e.g.,clonidine for opioid withdrawal).

Replace the abused drug with a drug in the same or a similar classwith a longer duration of action and taper the longer-acting drug.

Consider psychosocial treatments, along with other strategies, for

intoxication and withdrawal.

3. Manage intoxication and withdrawal.


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Help the patient anticipate and avoid drug-related cues (e.g.,instruct the patient to avoid drug-using peers).

Train the patient to self-monitor states associated with increasedcraving.

Use contingency contracting (e.g., set up positive and negativereinforcements in advance).

Teach desensitization and relaxation techniques to reduce the

power of drug-related stimuli. Help patients develop alternative, nonchemical coping responses. Provide social skills training.

5. Use relapse prevention strategies.

Educate the patient, family, and significant others about substanceuse disorders and treatment.

6. Provide education.

Diagnose and treat comorbid psychiatric disorders that affect the course and outcome of the substance use disorder, may complicate the substance use treatment, may reemerge with cessation of substance use, and may require the addition of specific treatments (e.g., an

antidepressant medication).

7. Diagnose and treat comorbid psychiatric disorders.


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Intensify monitoring for substance use during periodsof high risk of relapse.High-risk periods include early stages of treatment, times of transition to less intensive levels of care, the first year following cessation of active treatment, and periods of intensified life stress and lifestyle changes.

Treat in the least restrictive setting that is likely to be safe andeffective.

Choose site of care based on the patients ability to cooperate with and benefit from the treatment offered, capacity for self-care, ability to refrain from illicit use of substances, ability to avoid high-risk behaviors,

need for particular treatments that may be available only in certainsettings,

history of response in particular settings, and preference for a particular treatment setting.

Move from one level of care to another on the basis of the abovefactors and an assessment of the patients ability to benefit from adifferent level of care.Table 1 (p. 12) suggests appropriate treatment settings for differentpatient-related factors.

2. Treatment Settings


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TABLE 1. Treatment Settings

HospitalizationConsider for patients who

have a drug overdose that cannot be safely treated in an outpatient or emergencyroom setting (e.g., cardiac instability or toxicity, decreasing levels of consciousness),

are at risk for severe or medically complicated withdrawal syndromes (e.g., pasthistory of delirium tremens),

have comorbid general medical conditions (e.g., severe cardiac disease) that makeambulatory detoxification unsafe,

have a documented history of not engaging in or benefiting from treatment in a lessintensive setting (e.g., residential or outpatient),

have a level of psychiatric comorbidity that would markedly impair their ability toparticipate in treatment or whose comorbid disorder would by itself require hospital-level care (e.g., depression with suicidal thoughts, acute psychosis),

manifest substance use or other behaviors that constitute an acute danger tothemselves or others,

have not responded to less intensive treatments and whose substance use disorderposes an ongoing threat to their physical and mental health or endangers others.

Residential treatment(e.g., 24-hour open-milieu care)Consider for patients who

do not meet the clinical criteria for hospitalization and whose lives and socialinteractions have come to focus predominantly on substance use,

lack sufficient social and vocational skills and drug-free social supports to maintainabstinence in an outpatient setting,

demonstrate denial that could respond to interpersonal and group confrontation.

Partial hospitalizationConsider for patients who

require intensive care but have a reasonable probability of refraining from illicit useof substances outside a restricted setting,

are leaving hospitals or residential settings but who remain at high risk for relapse, are thought to lack sufficient motivation to continue in outpatient treatment, have severe psychiatric comorbidity, have a history of relapse to substance use in the immediate posthospital or

postresidential period, are returning to high-risk environments and who have limited psychosocial supports

for remaining drug free, are doing poorly in intensive outpatient treatment.

OutpatientConsider for patients who

demonstrate a clinical condition or have environmental circumstances that do notrequire a more intensive level of care.


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3. Pharmacological Treatments

To decrease the reinforcing effects of abused substancesFor example, the narcotic antagonist naltrexone blocks the subjectiveand physiological effects of subsequently administered opioid drugs.

To discourage the use of substancesTwo strategies are as follows: Induce unpleasant consequences through a drug-drug interaction

(e.g., disulfiram to discourage alcohol use). Couple substance use with an unpleasant, drug-induced condition

(e.g., prescribe succinylcholine, which interferes with respiratoryfunction, or emetine, to induce vomiting) under carefully controlledconditions.

To treat intoxication and withdrawal states (see section B.3,p. 8)

To reduce or eliminate symptoms of withdrawal and decrease cravingThis may be accomplished by substituting an agonist for thatparticular class of substances (e.g., methadone for opioids).

To treat comorbid psychiatric conditionsPotential problems include the following: Overdose may result from potentiation of drug effects (e.g., when

antidepressants and alcohol are combined). Lack of adherence to prescribed treatment is a serious issue. Treatments may themselves be abused (e.g., benzodiazepines). It is

important to choose medications with low abuse potential (e.g.,selective serotonin reuptake inhibitors [SSRIs] for depression).

Drug-drug interactions may occur between several prescribedmedications or between prescribed medications and abusedsubstances.

For selected patients, medications may be used for the followingpurposes:


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4. Psychosocial Treatments

Cognitive behavior therapies (CBTs)

Goals of CBTs Alter cognitive processes that lead to maladaptive behaviors. Intervene in chain of events leading to substance use.

Help reduce acute or chronic drug craving. Promote and reinforce the development of effective social skills and

behaviors.

Types of CBTs Standard cognitive therapymodifies maladaptive thinking

patterns to reduce negative feelings and behavior (e.g., substanceuse).

Relapse preventionemploys cognitive behavior techniques to helppatients develop self-control to avoid relapse.

Motivational enhancement therapyadopts an empathic approachto motivate the patient.

Behavior therapies Contingency management rewards abstinence (e.g., with vouchers)

or punishes drug taking (e.g., by notification of courts, employers,or family members).

It requires frequent, random, supervised urine, saliva, or hair-folliclemonitoring.

Psychodynamic and interpersonal therapiesThese therapies may facilitate abstinence when combined with other

treatment modalities (e.g., pharmacotherapies and self-help groups).

Psychosocial treatments are an essential component of a comprehensivetreatment program.


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Group therapy Group therapy can be supportive, therapeutic, and educational. This type of therapy increases accountability by providing

opportunities for the group to respond to early warning signs ofrelapse.

Family therapyDysfunctional families are associated with poor short- and long-term

patient outcome. The goals of family therapy include the following: Encourage family support for abstinence. Obtain information about the patients clinical status. Maintain marital relationships. Address interpersonal and family interactions that lead to conflict

or that enable substance use behaviors. Reinforce behaviors that help prevent relapse and enhance the

prospects for recovery.

Self-help groups Participation in self-help groups is an important adjunct to treatment

for some but not all patients. Refusal to participate is not synonymous with resistance to

treatment in general. Patients who require psychoactive medications (e.g., lithium,

antidepressants) should be directed to groups that are supportive ofsuch treatment.


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Choose setting for patients who do not need detoxification.Ongoing treatment usually takes place outside the hospital (e.g.,outpatient treatment, day hospital, or partial hospitalization). Patientswho are unlikely to benefit from less intensive and less restrictivealternatives may occasionally need hospitalization.

1. Alcohol Use Disordersa. Treatment Setting

Naltrexone (ReVia)At 50 mg/day, naltrexone can lead to reduced drinking andresolution of alcohol-related problems. It may be useful in preventing relapse, particularly when combined

with other therapeutic approaches.

It may attenuate some of the reinforcing effects of alcohol.

Disulfiram (Antabuse)Treatment with disulfiram deters subsequent slips by causing ahighly aversive reaction after a patient has even a single drink. The usual dosage is 250 mg/day (range 125 to 500 mg/day). It can be an effective adjunct to a comprehensive treatment

program. It should be used only for reliable, motivated patients whose

drinking may be triggered by events. (Patients with impulsivebehavior, psychotic symptoms, or suicidal thoughts are poor

candidates.) Because it can cause a variety of potentially serious outcomes,

disulfiram should be avoided in the presence of moderate to severehepatic dysfunction, peripheral neuropathy, pregnancy, renalfailure, or cardiac disease.

1. Alcohol Use Disordersb. Pharmacological Treatment

E. Substance-Specific Recommendations


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Specific therapiesSpecific therapies may also be used to treat comorbid psychiatricconditions. For many patients, signs and symptoms of depression and anxiety

may not require pharmacotherapy but instead are related toalcohol intoxication or withdrawal and remit in the first few weeksof abstinence.

For alcoholic hallucinosis during or after cessation of prolongedalcohol use, antipsychotic medication should be considered.

Korsakoffs syndrome (alcohol amnestic disorder) should be treatedvigorously with B-complex vitamins (e.g., thiamine, 50 to 100mg/day i.m. or i.v.).

Potentially helpful psychosocial treatments include the following: Cognitive behavior therapies aimed at improving self-control and

social skills. Behavior therapies. Psychodynamic/interpersonal therapies. Brief interventions (i.e., abbreviated assessments of drinking

severity and related problems and provision of motivationalfeedback and advice).

Marital and family therapy. Group therapies. Aftercare during the period following an intense treatment

intervention (e.g., hospital or residential care). Aftercare, whichmay include partial hospitalization, outpatient care, or involvementin self-help approaches, may help maintain abstinence.

Self-help groups, such as Alcoholics Anonymous.

1. Alcohol Use Disordersc. Psychosocial Treatment


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Assess symptoms of intoxication and withdrawal. Withdrawal symptoms generally begin within 4 to 12 hours after

cessation or reduction of alcohol use, peak in intensity during thesecond day of abstinence, and generally resolve within 4 to 5days.

Laboratory tests should be used to determine whether the presence

of other substances is contributing to the clinical presentation. Gastrointestinal distress, anxiety, irritability, elevated blood

pressure, tachycardia, and autonomic hyperactivity are symptomsof mild to moderate withdrawal.

Fewer than 5% of patients develop severe withdrawal. Symptomsinclude delirium, hallucinations, grand mal seizures, respiratoryalkalosis, and fever.

Determine whether risk factors for withdrawal are present.Moderate risk of withdrawal is associated with the presence of anyof the following: Prior history of delirium tremens Documented history of very heavy alcohol use and high tolerance Concurrent abuse of other drugs Severe comorbid general medical condition or psychiatric disorder Repeated failures at outpatient detoxification

1. Alcohol Use Disordersd. Management of Alcohol Intoxication and Withdrawal


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Treat intoxication and withdrawal. For acute intoxication, monitor and maintain in a safe environment. For mild to moderate withdrawal, provide generalized support,

reassurance, and frequent monitoring. For approximately two-thirdsof patients with mild to moderate withdrawal symptoms, thistreatment is sufficient and can occur in outpatient settings thatprovide for frequent clinical assessment and any needed clinicaltreatments.

Treat moderate to severe withdrawalas follows:

- Arrange for an appropriate setting (residential or hospitaladmission may be needed, with hospitalization required in thepresence of delirium tremens).

- Reduce CNS irritability with benzodiazepines (see Figure 1,p. 20).

- Beta-blockers or clonidine may be used in combination withbenzodiazepines to decrease symptoms of withdrawal.

- Restore physiological homeostasis (e.g., thiamine and fluids).- After patient is clinically stable, taper benzodiazepines and othermedications.

- Observe for reemergence of withdrawal symptoms.

- Observe for emergence of signs and symptoms suggestive of acomorbid psychiatric disorder.- Use an antipsychotic agent (as adjunct) for delirium, delusions, orhallucinations.

Treat or prevent common neurological sequelae of chronic alcohol useby routinely giving thiamine if moderate to severe alcohol use ispresent.


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Calculate the total number of milligrams ofbenzodiazepine required in the first 24 hours.

Give an orally administered benzodiazepine, e.g.,chlordiazepoxide (50 mg every 2 to 4 hours), diazepam(10 to 20 mg every 2 to 4 hours), oxazepam (60 mgevery 2 to 4 hours), or lorazepam (1 to 4 mg every 2 to4 hours), as needed for signs and symptoms of alcoholwithdrawal.

Taper over the next 2 to 5 days, monitoring forreemergence of withdrawal symptoms. (Patients insevere withdrawal and those with a history ofwithdrawal-related symptoms may require up to 10 daysbefore benzodiazepines are completely withdrawn.)

FIGURE 1. Benzodiazepine Treatment ofModerate to Severe Withdrawal

Alcohol use during pregnancy may have adverse effects on thepregnant womans health, the pregnancy course, fetal and early child

development, and parenting behavior.

1. Alcohol Use Disorderse. Treatment of Pregnant Women


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Goals for the treatment of pregnant women include the following:

Eliminate the patients use of alcohol. Treat any comorbid psychiatric or general medical disorders. Guide the patient safely through the pregnancy. Refer the patient for education in parenting skills. Motivate the patient to remain in treatment after delivery to

decrease relapse risk.

Intensive (i.e., more than twice a week) outpatient treatment is mosteffective. The effectiveness of self-help groups is also greatest withregular participation.

2. Cocaine Use Disordersa. Treatment Setting

Pharmacological treatment is not ordinarily indicated as an initialtreatment.

Medications should be considered for patients who have moresevere dependence or fail to respond to psychosocial treatment.

Medications have had limited effectiveness; desipramine andamantadine have shown the most promising results.

2. Cocaine Use Disordersb. Pharmacological Treatment

The best-established effect of in utero exposure to alcohol is fetalalcohol syndrome, which is associated with low birth weight,retarded growth and development, poor coordination, hypotonia,neonatal irritability, craniofacial abnormalities (includingmicrocephaly), cardiovascular defects, mild to moderate retardation,childhood hyperactivity, and impaired school performance.


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Focus on abstinence.

Consider the following specific types of psychotherapiesand self-help groups: Cognitive behavior

Behavior Psychodynamic Self-help groups, including 12-steporiented programs

(e.g., Narcotics Anonymous)

2. Cocaine Use Disordersc. Psychosocial Treatment

Intoxication Cocaine intoxication can produce hypertension, tachycardia,

seizures, and paranoid delusions. Intoxication is usually self-limited and typically requires only

supportive care. Acutely agitated patients may benefit from sedation with

benzodiazepines.

Withdrawal Following cessation of cocaine use, anhedonia and craving are

common. Currently available pharmacotherapy provides no clear benefit.

2. Cocaine Use Disordersd. Management of Cocaine Intoxication and Withdrawal


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Minimize or eliminate cocaine use to prevent increased risk ofprematurity, low birth weight, stillbirth, and sudden infant deathsyndrome (SIDS).

2. Cocaine Use Disorderse. Treatment of Pregnant Women

In addition to drug treatment programs, therapeutic communities areeffective.

3. Opioid Use Disorders

a. Treatment Setting

Methadone or LAAM maintenance treatmentTreatment rationale Reduces the morbidity associated with opioid dependence. Appropriate when history of opioid dependence is prolonged

(>1 year).

Treatment goals Achieve a stable maintenance dose. Facilitate engagement in a comprehensive program of

rehabilitation.(continued)

3. Opioid Use Disordersb. Pharmacological Treatment


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Methadone or LAAM maintenance treatment (continued)

Dosing Methadone

- A dosage of 40 to 60 mg/day is usually sufficient to blockwithdrawal symptoms.

- Higher dosages (average, 70 to 80 mg/day) are associated withbetter outcomes during maintenance treatment and are needed toblock craving for opiates and associated drug use.

- Monitoring of plasma methadone concentrations may be helpful ifhigher doses are used, with the aim of maintaining minimumlevels of 150 to 200 ng/mL.

LAAM- It is usually prescribed in doses of 20 to 140 mg(average, 60 mg).

- Dosing can be as infrequent as three times per week.

3. Opioid Use Disordersb. Pharmacological Treatment (continued)

Naltrexone Naltrexone is an opioid antagonist that blocks the effects of usualstreet doses of opioids.

It can be administered orally three times per week (e.g., 100 mgon Monday and Wednesday, 150 mg on Friday).

Because it can precipitate severe withdrawal symptoms in opioid-dependent patients, naltrexone should be administered only topatients who are withdrawn from opioids under medicalsupervision and are opioid free for at least 5 days after use ofshort-acting opioids, or 7 days after longer-acting opioids.

Utility is often limited by poor adherence and low treatmentretention.

Although abstinence can never be achieved in some patients,important reductions in morbidity and mortality can be achievedthrough efforts to reduce the deleterious effects of opioid use.


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Psychosocial treatments, when combined with opioid antagonist oropiate agonist treatments, can improve treatment adherence andprevent relapse. The following treatments may be helpful: Cognitive behavior therapies Behavior therapies Psychodynamic psychotherapies

Group and family therapies Self-help groups

3. Opioid Use Disordersc. Psychosocial Treatment

Recognize and treat acute intoxication.Patients with opioid use disorders frequently relapse and present withintoxication.

3. Opioid Use Disordersd. Management of Opioid Intoxication

Level of IntoxicationMild to moderate

Severe overdose(may be fatal)

IndicatorsDrowsiness, pupillary

constriction, slurredspeech

Respiratory depression,stupor, coma

TreatmentSpecific treatment is

usually not required

Requires treatment ininpatient or emergencydepartment setting

May require ventilatoryassistance

Use naloxone toreverse


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Reverse respiratory depression by administering naloxone. The usual dose is 0.4 mg (1 mL) i.v. A positive response (with increases in respiratory rate and volume,

increased systolic blood pressure, and pupillary dilation) shouldoccur within 2 minutes.

If there is no response, the same or a higher dose (e.g., 0.8 mg) ofnaloxone can be given twice more at 5-minute intervals.

Failure to respond to naloxone suggests a concurrent, orcompletely different, etiology of the problem (e.g., barbiturateoverdose, head injury).

3. Opioid Use Disordersd. Management of Opioid Intoxication (continued)

Methadone substitution with gradual tapering The daily stabilization dose should be based on the response of

objective signs of withdrawal to a methadone dose of 10 mg every2 to 4 hours as needed.

During the first 24 hours, 10 to 40 mg of methadone will stabilizemost patients and control withdrawal symptoms.

Once the stabilization dosage is determined, methadone can beslowly tapered (e.g., by 5 mg/day).

When the methadone dosage drops below 20 to 30 mg/day,

many patients begin to complain of renewed (but milder)withdrawal symptoms. These may be ameliorated by the additionof clonidine (see the following).

3. Opioid Use Disorderse. Management of Opioid Withdrawal

The goals of withdrawal management are to ameliorate acute symptoms

and facilitate entry into a long-term treatment program.


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Abrupt discontinuation of opioids, with the use of clonidine tosuppress withdrawal symptoms

Clonidine suppresses nausea, vomiting, diarrhea, cramps, andsweating but does little to reduce muscle aches, insomnia, anddrug craving.

Be aware that some patients are extremely sensitive to clonidineand experience profound hypotension, even at low doses.

On day 1, clonidine-aided detoxification involves either a test-doseapproach or a treatment dosage ranging from 0.1 to 0.6 mg inthree divided doses. Thereafter, dosage is adjusted until withdrawalsymptoms are reduced.

If blood pressure falls below 90/60 mm Hg, the next dose shouldbe withheld.

Tapering can be resumed while the patient is monitored for signs ofwithdrawal.

Advantages over methadone:- Clonidine does not produce opioid-like tolerance or physicaldependence.

- It avoids the postmethadone rebound in withdrawal symptoms.- If indicated, an opioid antagonist (e.g., naltrexone) can be usedimmediately after the course of withdrawal.

Disadvantages:- Side effects include insomnia, sedation, and hypotension.- Clonidine will not ameliorate some symptoms of opioidwithdrawal, such as insomnia and muscle pain.

- It is contraindicated in patients with moderate to severehypotension and cardiac, renal, or metabolic disease.

Clonidine-assisted detoxification is easiest to carry out in inpatient

settings. Outpatient detoxification with clonidine is a reasonable approach

with experienced staff; outpatients should not be given more than a3-day supply of clonidine for unsupervised use.


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Clonidine-naltrexone ultrarapid withdrawal Clonidine pretreatment avoids naltrexone-precipitated withdrawal. It is most useful for opioid-dependent patients who are in transition

to narcotic antagonist treatment. It necessitates monitoring of patients for 8 hours on day 1 (because

of the potential severity of naltrexone-induced withdrawal).

It requires careful monitoring of blood pressure throughoutwithdrawal.

Goals for the treatment of pregnant women include the following: Ensure physiological stabilization and avoidance of opioid

withdrawal. Prevent further abuse of illicit drugs or alcohol. Improve maternal nutrition. Encourage participation in prenatal care and rehabilitation. Reduce the risk of obstetrical complications, including low birth

weight and neonatal withdrawal, which can be lethal if untreated. Arrange for appropriate postnatal care when necessary.

3. Opioid Use Disorderse. Management of Opioid Withdrawal (continued)

Opioid use during pregnancy is associated with an increased risk oflow birth weight, prematurity, neonatal abstinence syndrome,stillbirth, and sudden infant death syndrome (SIDS).

3. Opioid Use Disordersf. Treatment of Pregnant Women

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