Clinical Opiate Withdrawal – Symptom Management Protocol <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllAnswers /> Clinical Opiate Withdrawal – Symptom Management Protocol Estimated Length: 9 minutes April 2015

Northwestern Ontario vs. Ontario Student Drug use - Northwestern Ontario versus Ontario Substance Northwestern Ontario Ontario Alcohol 66.7% 62% Cocaine 6.0% 4.4% Crack 3.3% 2.0% Oxycontin 4.5%

Thunder Bay and IV Drug-Use On average, Superior Points (Thunder Bay alone) distributes 60,000 needles a month. Walker, B. (2010)

Definitions Substance Abuse - a pattern of harmful use of any substance for mood-altering purposes. Addiction - a strong or harmful need to regularly have something or do something. Tolerance - occurs when the person no longer responds to a drug in the way that they initially responded. Dependence – a compulsive need to use a drug in order to function normally. The Four C’s Craving Continued use – despite harm Compulsion to use Control – loss of

Opioid Withdrawal The discontinuation of an opioid will lead to a constellation of withdrawal symptoms. Withdrawal symptoms occur in stages, depending on time of the last dose and the half-life of opioid used. Heroin reaches a peak in three to four days, where buprenorphine and methadone peak at four to eight days. Weaver, M. Hopper, J. (2013)

Withdrawal stages for heroin: 3 to 4 hours Drug craving Anxiety Fear of withdrawal. Weaver, M. Hopper, J. (2013)

Withdrawal stages for heroin: 8 to 14 hours Anxiety Restlessness Insomnia Yawning Rhinorrhea - runny nose Lacrimation - tearing Diaphoresis - sweating Stomach cramps Mydriasis – dilation of pupils Weaver, M. Hopper, J. (2013)

Withdrawal stages for heroin: 1 to 3 days Tremors Muscle spasms Vomiting Diarrhea Tachycardia Chills Piloerection – goose bumps Weaver, M. Hopper, J. (2013)

Clinical Opiate Withdrawal Scale

Clinical Opiate Withdrawal Scale

Clinical Opiate Withdrawal – Symptom Management Protocol This is a Pre-Printed Direct order that was developed to treat patients with opiate withdrawal and the various symptoms that they might have. The score provided by Clinical Opiate Withdrawal Scale will provide the nurse and physician to adequately treat opiate withdrawal symptoms.

The Clinical Opioid Withdrawal – Symptom Management Protocol The pre-printed direct order will be used in conjunction with the COWS scale to administer appropriate doses of clonidine in order to manage opiate withdrawal effectively. The protocol will also use appropriate medication to manage symptoms, such as nausea, diarrhea, anxiety and insomnia. The physician can determine whether to follow the PPDO or follow another therapy at their discretion.

COWS – Symptom Management

COWS – Initiating Clonidine

Assessments

Opioid Dependence Opioid dependence is a chronic, relapsing illness. Patients that have gone through an acute withdrawal period have only gone through the first step.

Thank you If you have any questions, feel free to contact your Clinical Nurse Specialist

References Mood Disorder Society of Canada (2009) Quick Facts: Mental Illness and Addictions in Canada[3rd Ed.] Sieswerda, L. Starkes, J. Adlaf, E. (2006) http://www.tbdhu.com/NR/rdonlyres/2C52E632-4AB7-414C-AAB2- 66819228AD00/0/05NWOSDUSExecSummary.pdf Walker, B. (2010) Pills knock off cocaine as drug of choice in city http://www.ohsutp.ca/index.php/news/pills- knock-off-cocaine-as-drug-of-choice-in-city/ Weaver, M. Hopper, J. (2013) Medically supervised opioid withdrawal during treatment for addiction http://www.uptodate.com/contents/medically-supervised-opioid-withdrawal-during-treatment-for- addiction?source=search_result&search=opioid+withdrawal&selectedTitle=2%7E94 Wesson, D. Ling, W. (2003) The Clinical Opiate Wtihdrawal Scale (COWS) Journal of Psychoactive Drugs 35,2 P. 253 – 259