Detox Basics

• Compulsion: loss of controlThe user can’t not do it s/he is compelled to use.Compulsion is not rational and is not planned.

• Continued use despite adverse consequencesAn addict is a person who uses even though s/he knows it is causing problems.Addiction is staged based on adverse consequences.

• Craving: daily symptom of the diseaseThe user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad.

• Denial/hypofrontality: distortion of cognition caused by cravingUnder the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.

Definition of Addiction

Neuroadaptation, Tolerance, and Withdrawal

• Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and stimulation or intoxication.

• Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation.

• In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy.

• Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy

• Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.

Drug-Specific Neural Dysregulation

Withdrawal

• Withdrawal: Negative symptoms that mirror positive drug effects AND reflect neuroadaptation (tolerance).

• Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy.

• Under unstimulated conditions (without drugs) interference with the ability to experience normal pleasure is profound . When sober, the user feels anhedonia, anxiety, anger, frustration and craving.

• The pleasure system remains impaired for months to years, interfering with learning, impulse inhibition, and sobriety.

KindlingIn tolerant users:

• Progressive nervous system arousal causing withdrawal symptoms to worsen each time drug use is discontinued.

• Also called withdrawal sensitization.

C I M Model Treatment

Tolerance/Withdrawal

• Over-stimulation of brain pathways induces neuroadaptation, requiring the user to escalate the dose to achieve the effects formerly seen at lower doses.

• Whenever there is tolerance to drugs/alcohol, there will always be the appearance of negative symptoms (withdrawal) when the user is sober; these negative symptoms are the mirror image of the drugs’ effects.

Physical Dependence

• Physical DependenceWhen the user stops the drug, physical illness results.

• Abstinence SyndromeName of the illness caused by withdrawal symptoms.

• ToleranceNeuroadaptation forces the user to increase the dose to maintain the effect of the drug.

Using an inadequate dose causes withdrawal: symptoms occur when the amount used is less than the tolerance level.

C I M Model Treatment

Causes of Craving

E W M S

• Environmental cues (Triggers)immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences

• Drug Withdrawal inadequately treated or untreated

• Mental illness symptoms inadequately treated or untreated

• Stress equals craving

Withdrawal Management

Detoxification

Use of medications to treat withdrawal symptoms.

Goals:

Evaluation

Stabilization

Foster readiness for and entry into treatment

C I M Model Treatment

Withdrawal Management

Withdrawal management is the use of medications to treat drug withdrawal symptoms, sometimes called “detox.”

When is withdrawal management needed?• If the pulse is persistently above 90 beats per minute

• If the blood pressure is persistently above 140/90 or below 90/60

• If INSOMNIA interferes with function

• If ANXIETY interferes with function.

• If CRAVING threatens to cause relapse

C I M Model Treatment

Withdrawal Management

PRINCIPLES

Calculate the dose equivalent per 24 hoursPush medications to achieve “symptom capture”Maintain Diastolic BP <90 and Pulse <90

Decrease substitute medication in 10% incrementsSlow rate of taper to maintain Diastolic BP <90 and Pulse <90Tremor free

SUBSTITUTION

TAPER

Opiate Effects

• Analgesia• Euphoria• Anxiolytic- calming• Sleep Inducing• Sensation of warmth• Constipation• Dry mucous membranes• Pupils constrict

• Sedation/Sleepiness (nodding)• Depresses respiration

Effects and Withdrawal

OpiatesEffects• Analgesia

• Euphoria

• Anxiolytic - calming

• Sleep Inducing

• Constipation

• Dry mucous membranes

• Sensation of warmth

• Pupils constricted

Withdrawal• Pain

• Dysphoria

• Anxiety

• Insomnia

• Diarrhea

• Rhinorrhea• Chills• Pupils dilated

Opiate Withdrawal

• Pain

• Dysphoria

• Anxiety

• Insomnia

• Diarrhea

• Rhinorrhea• Chills

• Pupils dilate

• Increases heart rate & blood pressure

Prescription OpiatesGeneric: Brand Name Non Tolerant 24 hr. doseCodeine w/acetaminophen 500 mgHydrocodone:Vicodin, Lortab, Norco 20mg-60 mgHydromorphone: Dilaudid 20 mg-60 mgOxycodone: Percodan, OxyContin 20 mg-60 mgMorphine sulfate: MS Contin 30 mg-60 mgFentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg

Tolerant Users only Tolerant 24 hr. doseMorphine sulfate: MS Contin 60 mg-upwardFentanyl: Duragesic (transdermal) 75 mcg-300 mcgMethadone: Methadose 60 mg-300 mgBuprenorphine: Suboxone, Subutex 6 mg-32 mg

Opiate Progression Pills to the Needle

Historically, untreated dependence on prescription opiates led to a trajectory from

• Pills ingested orally

• Pills crushed and snorted or smoked

• Heroin snorted or smoked

• Heroin used intravenously

Overview of Buprenorphine Suboxone and Subutex

• Highly safe medication (acute & chronic dosing).

• Primary side effects: like other mu agonist opioids (e.g.,nausea, constipation) but may be less severe.

• No evidence of significant disruption in cognitive or psychomotor performance with buprenorphine maintenance.

• No evidence of organ damage with chronic dosing.

Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001

OPTIMUM ANALGESIC DOSE

The best dose of opiate is the dose that first, best relieves pain, and

second, relieves pain without sedation.

Special Problems in Former Opiate Addicts

Persons previously addicted to opiates

• Have low pain tolerance because endogenous analgesic mechanisms are impaired.

• Will “uncover” their previous level of opiate tolerance over 4 - 6 weeks and require upward dosage titration over an extended time (despite years of abstinence).

• Require doses 2 to 4 times higher for analgesia than non-tolerant persons (due to high opiate tolerance).

• Need slower, symptom-driven tapers to discontinue opiates.

Withdrawal ManagementOpiate Oral Dose

Equivalents• Buprenorphine (Suboxone®) 8 mg

(sublingual)• Hydrocodone (Vicodin®) 10 - 20 mg • Methadone (Methadose®) 20 mg• Morphine sulfate (immediate release) 30 mg • Morphine sulfate (MS Contin®) 15 mg • Oxycodone (Percodan®) (Oxycontin®) 10 - 20 mg • Propoxyphene (Darvon®) 130 - 200

mg

• Adapted from Goodman and Gilman, 9th ed., page 535.

Withdrawal ManagementOpiate Substitution

• Query: time since last opiate use • Query: all opiates used in past 7 days. • Calculate client's usual 24 hour opiate dose.

• Query: prior withdrawal experience(s).• Query: other drugs used:

alcoholillicit drugsprescription medicationsover-the-counter preparations

• Determine if client requires other detoxification

Withdrawal ManagementSubstitution Methodology

Opiates• Calculate Suboxone dose using opiate dose equivalents.

• Give first Suboxone dose (2 - 8 mg) when objective and clear signs of withdrawal are evident.

• Record Pulse, BP, and withdrawal SX on Symptom Assessment sheet.

• Recheck Pulse & Blood Pressure after 90 minutes.

• Give 1/4 of estimated daily Suboxone dose when withdrawal symptoms reappear.

• Give the remainder of Suboxone in divided doses every 6 - 8 hours.

Withdrawal ManagementCompletion of Substitution

PhaseSubstitution is complete when the patient feels “normal,” and craving goes away.

Persistence of insomnia, anxiety, pain, or depression indicate need for separate treatment of these symptoms (dual diagnosis).

The patient is now ready for taper or for maintenance.

Withdrawal Management

Taper Phase

There are two variables in tapering: Dose: how much to taper

Time: how often to taper

Dose reductions are adjusted so that the patient does not re-enter withdrawal. If withdrawal symptoms develop during taper, return to previous effective dose, reduce amount of taper (dose) or lengthen the (time) interval. Do not continue until symptoms subside.

• Monitor Pulse and Blood Pressure daily• Complete Symptom Assessment sheet daily.• Adjust amount decreased and time between decreases to maintain

symptom scores at 0-1

A 33-year follow-up of narcotics addicts

.

Stimulant Effects• Improve mood and confidence • Increase interest/alertness• Increase sex drive• Interference with sleep• Increase anger and aggression• Suppress appetite• Pupils dilate• Increases heart rate & blood pressure

• Fever• Arrythmia - irregular heart beat• Seizures

Stimulant Withdrawal

• Dysphoria

• Boredom

• Anergia

• Disordered sleep Anxiety

• Depression

• Hypofrontality

Dual Diagnosis

• Mental Illness symptoms interact with drug effects.

• Intoxication: relieves symptoms of mental illness

• Tolerance: exacerbates symptoms of mental illness

• Withdrawal: exacerbates symptoms of mental illness

Medications for Stimulant Dependence

• Antidepressants (anhedonia/anergia)Effexor XR 150-300 mgCymbalta 60 mgWellbutrin XL 150-300 mg Desipramine 100-200 mg

• Anti-Craving Medications

Modafinil 100-200 mg

Methylphenidate LA 10-40 mg

Buproprion 150-300 mg

Concerta 18-54 mgDexedrine SR 20-30 mg

• Disorders of SleepTrazedone 50-300 mgSeroquel 25-100 mg

Imipramine 100-200 mg

• Disorders of ThoughtAbilify 2-10 mgHaldol 1-2 mg Risperdal 1-3 mg

GABA Scale

Sedative-Hypnotic Effects

• Calm Euphoria• Release of Inhibitions• Sleep Inducing

• Sedation/Sleepiness• Slurred Speech• Unsteady gait (Ataxia)• Confusion• Forgetfulness• Slows heart rate• Decreases blood pressure

Sedative-Hypnotic Effects

Effects• Calm Euphoria• Release of Inhibitions• Sleep Inducing

• Sedation/Sleepiness• Slurred Speech• Unsteady gait (Ataxia)• Confusion• Forgetfulness• Slows heart rate• Decreases blood pressure

* Symptom may continue for months

Withdrawal

• Dysphoria *• Anxiety *• Insomnia *

• Sweating (Diaphoresis) *• Tremor• Tachycardia• Hypertension• Hyperventilation

• Elevated temperature• Hallucinations• Seizures• Delirium tremens

Spectrum of Sedative-Hypnotic Withdrawal

1. Acute withdrawal: hypertension, tachycardia, tremors, sweating, pallor, anxiety/panic, craving

2. Withdrawal seizures: preceded by increasing tremors and myoclonic jerks

3. Delirium Tremens: medical emergency presentation of combative, hallucinating, confused; all sedative-hypnotic withdrawal can yield DTs.

Sedative-Hypnotic Withdrawal

• Dysphoria * * May continue for months

• Anxiety *

• Insomnia *

• Sweating (Diaphoresis)

• Tremor• Increases heart rate & blood pressure

• Hyperventilation

• Elevated temperature

• Hallucinations

• Seizures

• Delirium tremens

Prescription Tranquillizers

Dose Equivalent To Alcohol (2oz liquor or 2 glasses of wine or 2 cans of beer)

• Alprazolam (Xanax®) 0.5- 1mg• Diazepam (Valium®) 10mg• Chlordiazepoxide (Librium®) 25mg• Clonazepam (Klonopin®) 1-2mg• Lorazepam (Ativan®) 2mg• Temazepam (Restoril®) 30mg

• Butalbital (in Fiorinal®) 100mg• Carisoprodol (Soma ®) 350mg• Zolpidem (Ambien®) 10 mg

Withdrawal ManagementSedative-Hypnotics

Substitution

• Obtain seizure history.• Question client regarding all sedative-hypnotic use:

alcohol / prescription medications / over-the-counter preparations• Determine client's usual 24 hour sedative-hypnotic dose.

Acute Withdrawal

STAT Phenobarbital 60mg for Pulse >90 or diastolic BP >90Repeat dose every 2 hours until Pulse <90 & diastolic BP <90

• Calculate Phenobarbital 30mg based on the 24-hour Phenobarbital total.• Complete sedative-hypnotic Symptom Assessment flow sheet with each dose. • Give Phenobarbital in divided doses every 6 - 8 hours.

• Hold Phenobarbital for slurred speech, ataxia, or lethargy.

Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer

Withdrawal ManagementSedative-Hypnotic

“Uncovering”

Uncovering: the re-appearance of withdrawal symptoms after initial stabilization, necessitating re-titration of the dose.

Withdrawal ManagementCompletion of Substitution

PhaseSubstitution is complete when the patient feels “normal,” and craving goes away.

Persistence of insomnia, anxiety, pain, or depression indicate need for separate treatment of these symptoms (dual diagnosis).

The patient is now ready for taper or for maintenance.

Effects of Increasing Dosage in the Non-tolerant User

Gamma-Hydroxy-Butyrate: GHB

0 10 20 30 40 50 60Dose (mg/kg)

ComaComaLoss of

ConsciousnessLoss of

Consciousness

EuphoriaSomnolenceVertigo

EuphoriaSomnolenceVertigo

AmnesiaSedationAmnesiaSedation

Cannabis effects

EFFECTS• Sleep inducing• Appetite stimulation• Induces calm• Induces ‘mellow’

feelings• Elevates mood• Reduces muscle tone• Produces pleasure

WITHDRAWAL• Insomnia/nightmares

• Anorexia

• Anxiety

• Irritability/anger

• Depression

• Tremor

• Anhedonia

Nicotine Effects

Receptor Activation• Increase arousal• Heighten attention• Influence stages of sleep• Produce states of pleasure• Decrease fatigue• Decrease anxiety• Reduce pain• Improve cognitive function

Withdrawal Symptoms• Mentally sluggish• Inattentive• Insomnia• Boredom and dysphoria• Fatigue• Anxiety• Increase pain sensitivity• Worsen cognitive function

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13 (2002).• Bechara A. Decision making, impulse control and loss of willpower to

resit drugs: a neurocognitive perspective. Nature Neuroscience. 8:1458-63 (2005)

• Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11):1431-6 (2005).

• Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004.

• Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006

• Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10:1444-51 (2003).

• Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.