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Detox Basics. Compulsion: loss of control The user cant not do it s/he is compelled to use. Compulsion is not rational and is not planned. Continued use.

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Presentation on theme: "Detox Basics. Compulsion: loss of control The user cant not do it s/he is compelled to use. Compulsion is not rational and is not planned. Continued use."— Presentation transcript:

1 Detox Basics

2 Compulsion: loss of control The user cant not do it s/he is compelled to use. Compulsion is not rational and is not planned. Continued use despite adverse consequences An 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 disease The 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 craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using. Definition of Addiction

3 Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation is the brains 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.

4 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.

5 Kindling In tolerant users: Progressive nervous system arousal causing withdrawal symptoms to worsen each time drug use is discontinued. Also called withdrawal sensitization.

6 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.

7 Physical Dependence When the user stops the drug, physical illness results. Abstinence Syndrome Name of the illness caused by withdrawal symptoms. Tolerance Neuroadaptation 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.

8 C I M Model Treatment Causes of Craving EWMS 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

9 Withdrawal Management Detoxification Use of medications to treat withdrawal symptoms. Goals: Evaluation Stabilization Foster readiness for and entry into treatment

10 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

11 C I M Model Treatment Withdrawal Management PRINCIPLES Calculate the dose equivalent per 24 hours Push medications to achieve symptom capture Maintain Diastolic BP <90 and Pulse <90 Decrease substitute medication in 10% increments Slow rate of taper to maintain Diastolic BP <90 and Pulse <90 Tremor free SUBSTITUTION TAPER

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13 Opiate Effects Analgesia Euphoria Anxiolytic- calming Sleep Inducing Sensation of warmth Constipation Dry mucous membranes Pupils constrict Sedation/Sleepiness (nodding) Depresses respiration

14 Effects and Withdrawal Opiates Effects 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

15 Opiate Withdrawal Pain Dysphoria Anxiety Insomnia Diarrhea Rhinorrhea Chills Pupils dilate Increases heart rate & blood pressure

16 Prescription Opiates Generic: Brand NameNon Tolerant 24 hr. dose Codeine w/acetaminophen500 mg Hydrocodone:Vicodin, Lortab, Norco20mg-60 mg Hydromorphone: Dilaudid20 mg-60 mg Oxycodone: Percodan, OxyContin20 mg-60 mg Morphine sulfate: MS Contin30 mg-60 mg Fentanyl: Duragesic (transdermal), Actiq25 mcg-50 mcg Tolerant Users onlyTolerant 24 hr. dose Morphine sulfate: MS Contin60 mg-upward Fentanyl: Duragesic (transdermal)75 mcg-300 mcg Methadone: Methadose60 mg-300 mg Buprenorphine: Suboxone, Subutex6 mg-32 mg

17 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

18 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

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21 OPTIMUM ANALGESIC DOSE The best dose of opiate is the dose that first, best relieves pain, and second, relieves pain without sedation.

22 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 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.

23 Withdrawal Management Opiate Oral Dose Equivalents Buprenorphine (Suboxone®)8 mg (sublingual) Hydrocodone (Vicodin®) mg Methadone (Methadose®)20 mg Morphine sulfate (immediate release)30 mg Morphine sulfate (MS Contin®)15 mg Oxycodone (Percodan®) (Oxycontin®) mg Propoxyphene (Darvon®) mg Adapted from Goodman and Gilman, 9th ed., page 535.

24 Withdrawal Management Opiate 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: alcohol illicit drugs prescription medications over-the-counter preparations Determine if client requires other detoxification

25 Withdrawal Management Substitution 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 hours.

26 Withdrawal Management Completion of Substitution Phase Substitution 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.

27 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

28 A 33-year follow-up of narcotics addicts.

29 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

30 Stimulant Withdrawal Dysphoria Boredom Anergia Disordered sleep Anxiety Depression Hypofrontality

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32 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

33 Medications for Stimulant Dependence Antidepressants (anhedonia/anergia) Effexor XR mg Cymbalta60 mg Wellbutrin XL mg Desipramine mg Anti-Craving Medications Modafinil mg Methylphenidate LA mg Buproprion mg Concerta18-54 mg Dexedrine SR20-30 mg Disorders of Sleep Trazedone mg Seroquel mg Imipramine mg Disorders of Thought Abilify2-10 mg Haldol1-2 mg Risperdal1-3 mg

34 GABA Scale

35 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

36 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

37 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.

38 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

39 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

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41 Withdrawal Management Sedative-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 >90 Repeat 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 hours. Hold Phenobarbital for slurred speech, ataxia, or lethargy. Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer

42 Withdrawal Management Sedative-Hypnotic Uncovering Uncovering: the re-appearance of withdrawal symptoms after initial stabilization, necessitating re-titration of the dose.

43 Withdrawal Management Completion of Substitution Phase Substitution 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.

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46 Effects of Increasing Dosage in the Non-tolerant User Gamma-Hydroxy-Butyrate: GHB Dose (mg/kg) Coma Loss of Consciousness Loss of Consciousness Euphoria Somnolence Vertigo Euphoria Somnolence Vertigo Amnesia Sedation Amnesia Sedation

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49 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

50 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

51 REFERENCES --- Responsibility and choice in addiction. Psychiatric Services. 53(6): (2002). Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005) Dackis C, OBrien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005). Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 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: (2003). Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.


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