1. MEDICATIONS DETOX

2. Why Medicate withdrawal ? To prevent seizures (Etoh, barbiturates, benzodiazepines) To prevent DTs To make the client comfortable enough to consider engagement in treatment. To prevent psychiatric Decompensation

3. THE BENZODIAZEPINES ARE THE PRIMARY SEDATIVES/ANXIOLYTICS IN DETOX Minimal sedation/anxiolysisModerate sedation. The goal in detox is to achieve a state of Minimal sedation/anxiolysis to Moderate sedation. The patient should be easily arousable, with ability to maintain his/her airway, with no drop in blood pressure.

4. BZD = Benzodiazepine They are commonly used for : – Insomnia = hypnotic – Acute anxiety, = anxiolytic – Anticonvulsants – Muscle relaxants – Agitation /anxiety in AXIS I disorders= sedative They enhance the effect of GABA in the brain. Which contains/controls brain talk

5. BZDs: Long half-life vs Short half-life SHORT T ½ : Lorazepam/oxazepam T ½ between 8 -30 hrs LONG T ½ : Librium/Valium T1/2 between 30- 100 hrs. Long acting: Like librium less frequent dosing, less variation in plasma concentration Less severe withdrawal phenomena …but – they accumulate, increase risk of daytime psychomotor impairment, increased daytime sedation

6. LIBRIUM First BZD released in 1960 Librium half Life: 3-100 hours + Active metabolites: Desmethyldiapepam : half life: 30-200 hrs Dependent on Liver metabolism Librium 10 mg = Ativan 1 mg

7. 7 Benzodiazepines Short-acting Oxazepam & Lorazepam Advantages – They can be administered IM or IV (in monitored settings) – They have no significant active metabolites – They are metabolized & excreted principally through kidneys (& do not jeopardize already-damaged liver) Disadvantages – They need to be administered more frequently.

8. Benzodiazepines--contraindication Alcohol Intoxication, Narrow Angle Glaucoma Pregnancy ** Respiratory Depression Sleep Apnea**

9. Managing clients with: Hepatic Encephalopathy –DELIRIUM. Severe Chronic Obstructive Pulmonary Disease, Severe Hepatic Disease BILI-jaundice PT AST/ALT,, platelets—bruising, petechiae ALBUMIN, ascites, edema AVOID MEDICATIONS THAT ALTER CNS STATUS/RESIRATORY DRIVE Benzodiazepines Anti-histamines which have an anti-cholinergic affect

10. BZD side affects Drowsiness/confused/slurred speech Dizziness/ Ataxia Dyspnea Decreased reflexes Dis-inhibition / Paradoxical increase in aggression (in persons with preexisting brain damage)

11. DURING THE WEEK OF DETOX CLIENTS ARE SEDATED WITH BZDs If a patient requests a SMOKE BREAK If a patient requests a SMOKE BREAK – CONSIDER – Risk of falling due to unsteadiness with BZDs – Risk of seizures highest during the first 48 hrs. of detox. – CIWA score- – Delay smoke break if they have just been medicated with BZD, have mod/severe CIWA, or are unsteady on feet. – Offer Nicotine Patch – Offer Nicotine Patch / Nicotine Inhalers may be used (not gum or lozenges: risk of aspiration in the sedated)

12. Drug interactions BZD: can increase the plasma concentrations of dilantin and digoxin Kava OTC can potentiate the action of BZDs through synergistic overactivation of GABA receptors. Antacids and food can decrease the plasma concentration of BZDs Smoking can increase the metabolism of BZDs. Use the DRUG INTERACTION CHECKER on MEDSCAPE!!!

13. Antihistamines BENADRYL/HYDROXYZINE Anxiolytic Not proved effective for long term therapy Neuroleptic induced parkinsonism-HELPFUL Neuroleptic acute dystonia--HELPFUL Neuroleptic induced akathisia- HELPFUL Hypnotics: Safe, but not superior to BZD

14. The antihistamines Additive with other depressants like alcohol, or sedative hypnotic drugs, and psychotropic drugs BUT THERE ARE SIDE AFFECTS: Sedation, dizziness, hypotension, all of which can be severe in elderly persons Anticholinergic: dry mouth, urinary retention, burred vision, constipation: Not the 1 st choice in someone dehydrated, or men with prostatic hypertrophy, or someone severely agitated Paradoxical excitement and agitation GI : Epigastric distress, nausea, vomiting, diarrhea, constipation. Benadryl: CNS excitation: delirium Opiate abusers add antihistamines to enhance the euphoria.

15. SLEEP AIDES TRAZADONE: Antidepressant – Inhibits neuronal uptake of serotonin (but not NE) – T1/2 : 4-9 hrs. – Metabolized by liver – + SSRI increased risk of GI bleeds – Don’t combine with antipsychotics / cardiac drugs that prolong QT c – SEROTONIN SYNDROME – DON’T USE IN SOMEONE RECENTLY ABUSING COCOAINE which also blocks the re-uptake of serotonin.

16. MORE on Trazodone >10% Blurred vision (11-15%) Dizziness (20-28%) Drowsiness (24-40%) Dry mouth (15-34%) Fatigue (11-15%) Headache (16-20%) Nausea/vomiting (11-15%) Frequency Not Defined Sedation Priapism—in men protracted erections.

17. And in 1-10% 1-10% Constipation Edema Confusion Disorientation Incoordination Nasal congestion Orthostatic hypotension Syncope Tremor Weight change This is a drug with interactions with multiple drugs. MEDSCAPE DRUG INTERACTION CHECK IS IMPORTANT. WE WILL BE DISCONTINUING ITS USE IN DETOX

18. OTHER ALTERNATIVES TO ASSIST SLEEP Melatonin—hormone produced by pineal gland – 3-5 mg @ HS. Increasing sedation when combined with hydroxyzine/BZDs. – It’s been used with Alzheimer's disease, benzodiazepine or nicotine withdrawal, cancer (adjunctive treatment), headache (prevention), insomnia, jet lag, shift-work disorder, sleep disorders, thrombocytopenia (chemo- induced), winter depression, tardive dyskinesia Abdominal cramps Alertness decreased Circadian rhythm disruption Daytime fatigue Depression (transient) Dizziness Drowsiness Dysphoria in depressed patients Headache Irritability

19. SAFE FOR SLEEP Hydroxyzine – Safe Hypnotic: 25-50 mg @ HS BENZODIAZEPINES – Ativan—short acting : 1 mg @ HS

20. ANTI-EMETICS PHENERGAN: 12.5-25 mg PO/IV/IM/PR q4-6hr PRN: Time of onset 20 minutes (po/im) Blocks dopamine receptors Blocks alpha-adrenergic receptors in the brain Antihistaminic effect: blocking H1-receptors CONTRAINDICATIONS: Subq/IV=tissue necrosis BPH Narrow angle glaucoma Pyloroduodenal obstruction, stenosing peptic ulcer, bladder neck obstruction

21. PHENERGAN: Because it blocks DOPAMINE receptors in the Mesolimbic area has been reported to cause Hallucinations, nervousness, irritability), involuntary movements (e.g., fixed upward stare, neck twisting, tongue movements), restlessness, shaking (tremor)

22. PHENERGAN: Because it blocks dopamine receptors PHENERGAN has been reported to cause NEUROLEPTIC MALIGNANT SYNDROME Sudden confusion, extreme drowsiness), very high fever, seizures, irregular/fast heartbeat, increased sweating, muscle rigidity

23. PHENERGAN IS SEDATING due to Anti-histamine effect! Severe CNS depression Coma Severe respiratory depression IF A CLIENT IS SEDATED BUT NAUSEATED DON’T ADD PHENERGAN TO THE MIX!! IF A CLIENT IS HAVING DIFFICULTY BREATHING, AND ASKS FOR SOMETHING FOR NAUSEA, DON’T GIVE PHENERGAN

24. zofran Selective 5-HT3 receptor antagonist Ondansetron has no effect on dopamine receptors, therefore doesn't cause EPS Can prolong the QTc interval Do not give in Severe Hepatic Impairment (Child-Pugh score 10 or greater): No more than 8 mg/day

25. >10% Headache (6-27%) Malaise/fatigue (9-13%) Diarrhea (8-16%) Dizziness (7-12%) Constipation (3-11%) 1-10% Hypoxia (9%) Drowsiness (8%) Fever (7-8%) Gynecological disorder (7%) Anxiety (6%) Urinary retention (5%) Pruritus (1-5%) Injection site pain (4%) Paresthesia (2%) Cold sensation (2%) LFT's increased ondansetron

26. DIARRHEA LOMOTIL : diphenoxylate/atropine Diphenoxylate: act on smooth muscle of intestinal tract, inhibiting GI motility & excessive GI propulsion similar to morphine Atropine: subtherapeutic quantity of atropine is added to discourage deliberate overdose of diphenoxylate – 13-16 years old: 5 mg PO TID

27. LOMOTIL 1-10% Anticholinergic effects Blurred vision Sedation Nausea Vomiting Abdominal discomfort Dryness of skin/mouth

28. IMODIUM/Kaopectate 1-D/ 1-10% Anticholinergic effects Blurred vision Sedation Nausea Vomiting Abdominal discomfort Dryness of skin/mouth

29. HYPER ADRENERGIC FLOW CATAPRESS—Alpha Agonist- PVR, BP, PULSE – Off-label Uses EtOH withdrawal: 0.3-0.6 mg PO q6hr Smoking Cessation: 150-400 mcg/day PO OR 100-200 mcg/day patch q7Days Restless Legs Syndrome: 100-300 mcg/day, up to 900 mcg/day Menopausal Flushing: Apply 100 mcg/day patch change q7Days, OR 50 mcg PO BID initially, may increase up to 400 mcg BID Heroin withdrawal

30. CATAPRESS Hypotension Avoid in clients with; Severe CAD, recent MI, conduction disturbances, cerebrovascular disease, chronic renal failure Rebound hyptertension, with sudden cessation Don’t give to a client withdrawing from heroin who is dehydrated!! Remember it drops BP!!

31. 31 Thiamine & Multivitamins 30-80% of patients are deficient Thiamine does not reduce risk of seizures or delirium tremens Thiamine does reduce risk of Wernicke’s encephalopathy

32. IM Thiamine Patients with WKS should be with thiamine 100 mg IV, followed by 10 0 mg IM daily for 7-10 days and then 100 mg by mouth daily Give with magnesium, which is necessary for thiamine metabolism

33. MUSCLE RELAXANTS FLEXERIL – related to cyclic antidepressants – norepinephrine potentiation, – potent anticholinergic – sedation – Reduces motor activity – Use caution in urinary retention, narrow-angle glaucoma or other anticholinergic drugs

34. GABAPENTINE Restless Legs Syndrome Indicated for moderate-to-severe primary restless legs syndrome 600 mg PO qDay with food at about 5 PM Muscle Cramps (Off-label) 100-300 mg PO qHS; titrate to 300-400 mg TID PRN Anxiety (Off-label) Initial 300 mg PO qHS, THEN 300 mg PO TID, further increase as tolerated Diabetic Neuropathy (Off-label) Initial 900 mg/day PO; increase to 1800-3600 mg/day

35. THE ANALGESICS TYLENOL & LIVER NEVER exceed 4 grams/day Smaller amounts can cause hepatic damage Motrin & Gut/Kidney Can cause gastritis Can result in GI bleeding Can decrease renal function Don’t combine with other NSAIDs/ASA

36. ANTIELEPTICS TEGRETOL As effective as oxazepam Dose: 200mg TID x 10 days Low abuse potential Minimal Cognitive Effects Used in BZD withdrawal MILD AND MODERATE WITHDRAWAL