4 Physical In This Chapter… Detoxification Psychosocial and Services for Biomedical Screening and Assessment Withdrawal From Alcohol Intoxication and Specific Substances Withdrawal Opioids This chapter highlights specific treatment regimens for specific sub- Benzodiazepines stances and provides guidance on the medical, nursing, and social ser- and Other vices aspects of these treatments. It also includes considerations for spe- Sedative- cific populations. Although it is written principally for healthcare profes- Hypnotics sionals, some professionals without medical training may find it of use. Stimulants To accommodate a broad audience, the chapter includes definitions for Inhalants/Solvents technical terms that may be unfamiliar to some readers—for example, “the patient was afebrile (without fever).” Nicotine Marijuana and Other Drugs Psychosocial and Biomedical Containing THC Screening and Assessment Anabolic Steroids This section covers more complex psychosocial and biomedical assess- Club Drugs ments that may occur after initial contact as an individual undergoes Management of detoxification. Psychosocial and biomedical screening and services are Polydrug Abuse: closely associated: neither is likely to succeed without the other, as the An Integrated case study below illustrates. Approach Although the medical issues in this case indicate that the patient could Alternative successfully be managed as an outpatient, careful assessment of psy- Approaches chosocial and biomedical aspects of the patient’s condition, including lack of transportation, the risk of violence, and his inability to carry out Considerations for routine medical instructions, strongly indicated that the patient remain Specific in a 24-hour supervised setting such as a residential detoxification or Populations treatment program. For an illustration of some of the fundamental

47 Case Study

A 44-year-old Caucasian male with a fifth-grade education presented to an emergency clinic in mild alcohol withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia; blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) (see below) score = 12, indicating mild withdrawal. A treatment plan was recommended that called for an outpatient 3-day fixed-dose taper of lorazepam (a benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that there was no reliable transportation to the clinic, there had been domestic violence on the parts of both spouses, and the patient’s ability to carry out routine medical instructions was questionable.

aspects of the patient’s health and psychosocial rehabilitation, and treatment are being status that should be covered in screening and promoted. assessment, see Figure 3-1, p. 25. Clinicians also can use the presentation of Figure 4-1 lists several instruments useful in information from biochemical markers to characterizing the intensity of specific with- patients as an effective tool in motivational drawal states (see appendix C for more infor- enhancement. For example, information mation on these instruments and how to obtain regarding liver transaminases (specific kinds them). of enzymes that perform chemical reactions within the liver) helps provide the patient with objective information on the level of Biochemical Markers and recent alcohol use and potential acute hepatic Their Use damage. This may help the patient move from This section focuses on biochemical laborato- contemplating treatment to actually beginning ry tests that detect the presence or absence of treatment. For a more detailed discussion of alcohol or another substance of abuse, may biological markers in substance abuse, see be able to quantify the level of present use, or Javors and colleagues (1997). may be able to quantify cumulative use over the past few weeks. Tests in all of these areas Blood alcohol content are reasonably well developed and validated for alcohol. This is not the case for most Blood alcohol content (BAC) can be determined other substances of abuse. Biochemical mark- by highly sensitive laboratory procedures that ers are not adequate screening or assessment generally are available in most emergency instruments alone, but rather are used to departments, hospitals, and clinical chemistry support a more comprehensive clinical assess- laboratories. Alcohol elimination undergoes, ment. Common uses of these biochemical for the most part, zero-order kinetics (decreas- markers are: ing a set amount per unit of time rather than a set percentage), so the concept of half-life is not 1. In the initial screening setting to support really accurate. However, first-order kinetics or refute other information that leads to and half-life do occur when BAC is low (i.e., proper diagnosis, assessment, and manage- below 10mg percent), and the half-life is on the ment. order of about 15 minutes at that point. 2. For forensic purposes (e.g., evaluating a Though disappearance rates of 15mg percent driver after an automobile accident). per hour are probably average for moderate 3. In detecting occult (secretive or hidden) drinkers, higher values were seen in a group of use of alcohol and other substances in Swedish drivers apprehended for driving while therapeutic settings where abstinence, intoxicated (19mg/dL/hr) (Jones and Andersson

48 Chapter 4 Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and Specific Illicit Drugs

Drug of Dependence Instrument Reference Notes

Alcohol CIWA-Ar Sullivan et 10 items that take 2 to 5 minutes to com- al. 1989 plete; scores 0–67, with 10 or greater as clinically significant; requires training to administer

Cocaine Cocaine Selective Kampman et 18 items that take 10 minutes to com- Severity al. 1998 plete; high scores correlated with poor Assessment (CSSA) outcome

Opioids Subjective Opiate Handelsman 16-item questionnaire; using a scale of Withdrawal Scale et al. 1987 0–4, respondents rate to what extent (SOWS) they are currently experiencing each of 16 characteristics; higher scores indicate more severe withdrawal

Objective Opiate Handelsman Rater observes patient for about 10 min- Withdrawal Scale et al. 1987 utes and indicates if any of 13 manifesta- (OOWS) tions of withdrawal are present; scores can range from 0 to 13, with higher scores indicating more severe withdraw- al; staff must be familiar with withdraw- al signs

1996). The rate of metabolism of alcohol range (about 15 or higher), the clinician can increases with dependence—some alcoholics reasonably predict that the withdrawal will be can metabolize 20–25mg/dL/hr (Jones and relatively severe. As noted, however, the rate Andersson 1996), and Jones and Sternebring of metabolism of alcohol increases with (1992) have found that alcohol-dependent dependence. The diagnosis of alcohol intoxi- patients may metabolize 22mg/dL/hr during cation is a clinical diagnosis and not based detoxification. simply on a BAC. A person with a BAC of 200mg percent could be in withdrawal, intoxi- When knowledge of BAC is combined with cated (showing related signs and symptoms), clinical information, the healthcare provider or showing no signs and symptoms of either can make some predictions regarding the intoxication or withdrawal. A BAC above acuteness of withdrawal. For example, in an 100mg percent does not necessarily indicate individual whose blood alcohol level is 200mg clinical intoxication. Like all laboratory pro- percent but who is already showing tremu- cedures, the blood alcohol levels test has limi- lousness (shakiness of the hands), brisk tations. Usually, patient permission must be reflexes, tachycardia (rapid heart rate), obtained prior to testing, the testing itself can diaphoresis (excessive sweating), and perhaps be expensive, and forensic testing may be a CIWA-Ar score in the moderate or high subject to specific legal procedures.

Physical Detoxification Services for Withdrawal From Specific Substances 49 Reading Blood Alcohol Concentrations

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. This figure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BAC of .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.

Source: Center for Substance Abuse Treatment (CSAT) 1995a.

Breath alcohol levels chromatography, urine alcohol concentration, and gas chromatography-mass spectrometry. Although the initial cost of small breath alcohol instruments may be relatively high, the recur- Informed clinicians also should be aware of ring costs (of disposable mouthpieces and peri- which drugs are screened for by the laboratory odic recalibration) are low. The technique is they use, the relative time window of detection less invasive than blood testing and health (a substance’s metabolic half-life, or approxi- providers can follow breath alcohol levels mately how long a drug can be detected once repeatedly at low expense during the course of ingested), and whether cross-reactivity with assessment and detoxification. The detection of other interfering substances may alter out- rapidly rising, high levels of alcohol over a comes. Many laboratories perform more specif- short period of time may indicate alcohol poi- ic confirmation testing on positive screening soning overdose. Breath alcohol levels provide tests, which can largely eliminate false-posi- useful guidance in determining whether to hos- tives. It is important to clarify which type of pitalize these patients. test result is being reported. Interfering and cross-reactive substances leading to false-posi- Limitations on breath alcohol determinations tive tests frequently are discussed in bulletins are that patient cooperation is required and and publications periodically published by the that some patients with lung diseases are not National Institute on Drug Abuse (NIDA) and able to muster a sufficient tidal volume (force- the Centers for Disease Control and Prevention ful breath) to give an accurate reading to the (CDC). Usually, the senior laboratory supervi- machine. On occasion, patients whose breath sor has up-to-date information in this area and alcohol levels indicate recent alcohol use will often can be consulted via e-mail or telephone assert that they have recently gargled with in an emergency. Limitations of urine drug mouthwash that contained alcohol. Having the screening include consent and privacy issues, patient rinse his mouth with water several expense, the inability to screen for some drugs times and then making another breath alcohol of abuse, and the inability of urine drug determination in 15 to 30 minutes usually will screens to provide information on the current resolve whether the patient’s assertion is valid. level of intoxication.

Urine drug screens Urine testing should at a minimum test for the presence of Urine drug screens vary widely in their meth- •Benzodiazepines ods of detection, sensitivity and specificity, expense, and availability. The healthcare •Barbiturates provider assessing patients for detoxification •Cocaine should be familiar with the type of assay (test •Amphetamines measurement) being used; some examples are •Opioids enzyme multiple assay techniques, thin layer chromatography, high performance liquid •PCP

50 Chapter 4 It also should be noted that current testing for insults to the liver from toxins (such as chemi- opioids primarily refers to “organic” drugs that cals, alcohol, prescribed or over-the-counter are derived from opium (i.e., heroin, codeine, medications). In any form of hepatitis, GGT and morphine). Synthetic opioids like may be elevated, indicating damage to liver hydrocodone and methadone are not detected cells. Therefore, GGT elevation does not by the usual tests; this is true of oxycodone as automatically mean liver damage from alcohol well. If the use of these drugs is suspected, spe- use, although this is certainly one of the most cial tests can be ordered. Most important, each common reasons for elevated GGT levels in program should tailor its urine screening tests patients hospitalized in North America. The to reflect the substance use patterns prevalent use of GGT levels along with carbohydrate- in the community. deficient transferrin (CDT) levels is a rela- tively sensitive and specific indicator of alco- hol use. The CDT test is discussed below. Gamma-glutamyltransferase (GGT) Carbohydrate-deficient GGT has been measured in serum (the portion of the blood that has neither red nor white transferrin blood cells) for many years as a marker for CDT has been developed over the past 20 years liver damage. More recently, GGT has been as a marker of cumulative alcohol consumption advocated as a measure of cumulative alcohol but is just now becoming widely available as a use (Dackis 2001). Sensitivity of the test is in clinical tool. Sensitivities appear to be in the 70 the 60 to 70 percent range and specificity (its to 80 percent range, and specificities of greater ability not to misidentify or confuse alcohol use than 90 percent have been found. Sensitivity with other disorders) is in the 40 to 50 percent and specificity are somewhat lower among range. In general, both sensitivity and specifici- females than males. Most therapeutic drugs or ty are lower in females than males. GGT does drugs of abuse do not appear to affect CDT correlate with alcohol intake but often requires levels. When CDT and GGT levels are com- heavy drinking (more than six drinks per day) bined, sensitivity and specificity rise to more to elevate it, and only about half of individuals than 90 percent (Anton 2001). CDT testing is will show elevations. The half-life of elevated limited by its relatively high cost, lack of clini- serum GGT after the onset of abstinence is said cal availability in some laboratories, and false- to be 2 to 3 weeks with alcoholic liver disease. positive results in abstaining individuals who Chlorpromazine, phenobarbital, and have endstage liver disease from causes other acetaminophen can all raise serum GGT levels. than alcohol use (DiMartini et al. 2001).

GGT is limited by its expense and its relative- ly low specificity, which sometimes leads to Mean corpuscular false-positive evaluations. GGT is helpful as a volume (MCV) motivational enhancer in patients with a high degree of denial during detoxification. Erythrocyte (red blood cell) size is measured in Evidence of liver damage, as measured by the a Coulter counter and often is part of a com- GGT, provides patients with objective feed- plete blood count; therefore, it is widely avail- back concerning the consequences of their able to clinicians. Sensitivity and specificity are alcohol use and thus plays a very important in the 30 to 50 percent range. Hence, caution role in enhancing motivation. should be exercised when interpreting an ele- vated MCV in relation to drinking behavior. Hepatitis is a general term that refers to This lab test should be considered complemen- inflammation of the liver with damage to liver tary to other biological markers that are more cells (hepatocytes). Hepatitis may be due to specific and sensitive, such as GGT or CDT. viruses (such as in hepatitis A, B, C) or Advanced age, nutritional status, cigarette

Physical Detoxification Services for Withdrawal From Specific Substances 51 smoking, and co-occurring disease states with- in monitoring vital functions, protecting respi- out the presence of alcoholism may make test ration, and observing aspiration, hypo- results abnormal. glycemia, and thiamin deficiency. Screening for other drugs that may contribute to the coma, as well as other sources of coma induction, Alcohol Intoxication should be done. Agitation is best managed with and Withdrawal interpersonal and nursing approaches rather than additional medications, which may only complicate and delay the elimination of the Intoxication Signs and alcohol. Symptoms The clinical presentation of intoxication from Withdrawal Signs and alcohol varies widely depending in part on Symptoms blood alcohol level and level of previously developed tolerance. At alcohol concentrations Hippocrates, writing around 400 B.C., gave us between 20mg percent and 80mg percent, loss our first written clinical picture of alcohol with- of muscular coordination, changes in mood, drawal when he wrote that if the patient is “in personality alteration, and [increases in motor the prime of life and if from drinking he has activity] begin. At levels from 80 to 200mg per- trembling hands,” it may well be the case that cent, more progressive neurologic impairment the patient is showing withdrawal signs and occurs with ataxia (inability to coordinate mus- symptoms. To this day, alcohol withdrawal cular activity) and slurring of speech being remains underrecognized and undertreated. prominent. A variety of cognitive functions also The signs and symptoms of acute alcohol with- are impaired. At blood alcohol levels between drawal generally start 6 to 24 hours after the 200 and 300mg percent nausea and vomiting patient takes his last drink. Alcohol withdrawal may occur, which along with sedation may may begin when the patient still has significant place patients at grave risk for aspiration of blood alcohol concentrations. The signs and stomach contents. At levels greater than 300mg symptoms may include the following: percent, hypothermia (low body temperature) •Restlessness, irritability, anxiety, agitation with impairment of level of consciousness is •Anorexia (lack of appetite), nausea, vomiting likely except in all but the most tolerant indi- viduals. Coma begins to be seen at levels of 400 •Tremor (shakiness), elevated heart rate, to 600mg percent, but this is variable, again increased blood pressure depending on tolerance. Although exceptions •Insomnia, intense dreaming, nightmares are found, BACs between 600 and 800mg per- •Poor concentration, impaired memory and cent are fatal. At this point, respiratory, car- judgment diovascular, and body temperature controls •Increased sensitivity to sound, light, and tac- fail. See Figure 4-2 for more symptoms of alco- tile sensations hol intoxication. •Hallucinations (auditory, visual, or tactile) Since the elimination rate of alcohol from the •Delusions, usually of paranoid or persecutory body generally is 10 to 30mg percent per hour, varieties the goals for the treatment of alcohol intoxica- tion are to preserve respiration and cardiovas- •Grand mal seizures (grand mal seizures rep- cular function until alcohol levels fall into a resent a severe, generalized, abnormal elec- safe range. Patients who are severely intoxicat- trical discharge of the major portions of the ed and comatose as the result of alcohol use brain, resulting in loss of consciousness, brief should be managed in the same manner as all cessation of breathing, and muscle rigidity comatose patients, with particular care taken followed by muscle jerking; a brief period of

52 Chapter 4 Figure 4-2 Symptoms of Alcohol Intoxication*

Blood Alcohol Level Clinical Picture

20–100mg percent •Mood and behavioral changes •Reduced coordination •Impairment of ability to drive a car or operate machinery

101–200mg percent •Reduced coordination of most activities •Speech impairment •Trouble walking •General impairment of thinking and judgment

201–300mg percent •Marked impairment of thinking, memory, and coordination •Marked reduction in level of alertness •Memory blackouts •Nausea and vomiting

301–400mg percent •Worsening of above symptoms with reduction of body temperature and blood pressure •Excessive sleepiness •Amnesia

401–800mg percent •Difficulty waking the patient (coma) •Serious decreases in pulse, temperature, blood pressure, and rate of breath- ing •Urinary and bowel incontinence •Death

*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood alcohol level).

Source: Consensus Panelist Robert Malcolm, M.D.

sleep, awakening later with some mild to even the heading Management of Delirium and severe confusion, generally occurs) Seizures (p. 63).

•Hyperthermia (high fever) Mild alcohol withdrawal generally consists of •Delirium with disorientation with regard to anxiety, irritability, difficulty sleeping, and time, place, person, and situation; fluctua- decreased appetite. Severe alcohol withdrawal tion in level of consciousness usually is characterized by obvious trembling of the hands and arms, sweating, elevation of For a discussion of seizures and delirium, pulse (above 100) and blood pressure (greater including delirium tremens, see below under

Physical Detoxification Services for Withdrawal From Specific Substances 53 than 140/90), nausea (sometimes with vomit- the number of previous withdrawals (treated ing), and hypersensitivity to noises (which seem or untreated) experienced, with three or four louder than usual) and light (which appears being a particularly significant number for brighter than usual). Brief periods of hearing the appearance of severe withdrawal reac- and seeing things that are not present (auditory tions unless adequate medical care is provid- and visual hallucinations) also may occur. A ed. This assumption that this phenomenon fever greater than 101° F also may be seen, will manifest itself, which has been referred though care should be taken to determine to as the “kindling hypothesis,” is well-estab- whether the fever is the result of an infection. lished in the research literature (Booth and Seizures and true delirium tremens, as dis- Blow 1993; Wojnar et al. 1999). cussed elsewhere, represent the most extreme Uncomplicated or mild to moderate with- forms of severe alcohol withdrawal. Moderate drawal is characterized by restlessness, irri- alcohol withdrawal is defined more vaguely, tability, anorexia (lack of appetite), tremor but represents some features of both mild and (shakiness), insomnia, impaired cognitive severe withdrawal. functions, and mild perceptual changes. Complicated or severe medical withdrawal The course of these symptoms is extremely has one or more elements of delirium, halluci- variable. An individual may progress partial- nations, delusions, seizures, and disturbances ly through some of the symptoms noted above of body temperature, pulse, and blood pres- and then have a slow improvement. Other sure. individuals may have mild to moderate symp- toms with almost abrupt resolution. Yet another group may present with a grand mal Medical Complications of seizure or with hallucinations. Some people Alcohol Withdrawal: Possible with alcohol dependence, regardless of their pattern of drinking or the extent of drinking, Fatal Outcomes appear to develop minor symptoms or show Seizures; delirium tremens (severe delirium no symptoms of withdrawal. Infrequent binge with trembling); and dysregulation of body drinkers seem less likely to have withdrawal temperature, pulse, and blood pressure are symptoms than individuals who are heavy outcomes in severe alcohol dependence that can regular users of alcohol who then abruptly lead to fatal consequences. Other medical com- cease their alcohol use, but this is not well plications of alcohol withdrawal include infec- substantiated. As previously discussed in the tions, hypoglycemia, gastrointestinal (GI) assessment section, the use of a standardized bleeding, undetected trauma, hepatic failure, clinical rating instrument for withdrawal such cardiomyopathy (dilation of the heart with as the CIWA-Ar is valuable because it guides ineffective pumping), pancreatitis (inflamma- the clinician through multiple domains of tion of the pancreas), and encephalopathy alcohol withdrawal and allows for semi-quan- (generalized impaired brain functioning). The titative assessment of nausea, tremor, auto- suspicion of impending complications or their nomic hyperactivity, anxiety, agitation, per- appearance will require hospitalization of the ceptual disturbances, headache, and disorien- client and possible intensive care unit level of tation. Age, general health, nutritional fac- management. Consultation with internists spe- tors, and possible co-occurring medical or cializing in infectious disease, pulmonary care, psychiatric conditions all appear to play a and hepatology; surgeons; neurologists; psychi- role in increasing the severity of the symp- atrists; anesthesiologists; and other specialists toms of alcohol withdrawal. also may be warranted, depending on the nature of the complications. The most useful clinical factors to assess the likelihood and the extent of a current with- drawal is the patient’s last withdrawal and

54 Chapter 4 Management of Withdrawal withdrawal. The consensus panel has found Without Medication that in actual practice, social detoxification programs vary greatly in their approach and The management of an individual in alcohol scope. Some programs offer some medical and withdrawal without medication is a difficult nursing onsite supervision, while others pro- matter because the indications for this have not vide access to medical been established firmly through scientific stud- and nursing evalua- ies or any evidence-based methods. tion through clinics, For alcohol, Furthermore, the course of alcohol withdrawal urgent care pro- is unpredictable and currently available tech- grams, and emergen- sedative-hypnotic, niques of screening and assessment do not cy departments. allow us to predict with confidence who will or Some social detoxifi- and opioid with- will not experience life-threatening complica- cation programs only tions. Severe alcohol withdrawal may be associ- offer basic room and ated with seizures due to relative impairment of board for a “cold drawal syndromes, gamma-aminobutyric acid (GABA) and relative turkey” detoxifica- over-activity of N-methyl-D-aspartate systems tion, while other pro- hospitalization (or (a subtype of the excitatory glutamate receptor grams offer super- system) (Moak and Anton 1996). The failure to vised use of medica- some form of treat incipient convulsions is a deviation from tions. Sometimes the established general standard of care. medications are pre- 24-hour medical scribed at the onset of Positive aspects of the nonmedication withdrawal by health- care) is generally the approach are that it is highly cost-effective care professionals in and provides inexpensive access to detoxifica- an outpatient setting, preferred setting for tion for individuals seeking aid. Observation while the staff in the is generally better than no treatment, but social detoxification detoxification, based people in moderate to severe withdrawal will program supervises be best served at a higher level of care. Young the administration of individuals in good health, with no history of these medications. on principles of previous withdrawal reactions, may be well Whatever the partic- served by management of withdrawal without ular situation might safety and humani- medication. However, personnel supervising be, there should in this setting should possess assessment abili- always be medical tarian concerns. ties and be able to summon help through the surveillance, includ- emergency medical system. Methods of with- ing monitoring of drawal management without medication vital signs, as part of every social detoxification include frequent interpersonal support, pro- program. vision of adequate fluids and food, attention to hygiene, adequate sleep, and the mainte- The consensus panel agrees that for alcohol, nance of a no-alcohol/no-drug environment. sedative-hypnotic, and opioid withdrawal syn- dromes, hospitalization (or some form of 24- Social Detoxification hour medical care) is generally the preferred setting for detoxification, based on principles of Social detoxification programs are defined as safety and humanitarian concerns. When hos- short-term, nonmedical treatment services for pitalization cannot be provided, a setting that individuals with substance use disorders. A provides a high level of nursing and medical social detoxification program offers room, backup 24 hours a day, 7 days a week is desir- board, and interpersonal support to intoxicat- able. The panel readily acknowledges that ed individuals and individuals in substance use social detoxification programs are, for some

Physical Detoxification Services for Withdrawal From Specific Substances 55 communities, the only available resources for The consensus panel acknowledges that, for a uninsured, homeless individuals. Social detoxi- substantial group of individuals, substance fication is preferable to detoxification in unsu- use withdrawal syndromes do not lead to fatal pervised settings such as the street, shelters, or outcomes or even significant morbidity. jails. The panel also notes that in some large Determining which individuals will have urban areas, social detoxification programs benign outcomes often is difficult, and in fact have longstanding, excellent reputations of pro- this determination prior to social detoxifica- viding high-quality supervision and nurturance tion referral frequently is not made. Some for their clients. incorrect beliefs have sprung up in the con- Social detoxification text of social detoxification: Individuals programs are orga- undergoing opioid withdrawal often are con- For a substantial nized and funded by sidered to require hospitalization to alleviate a variety of sources, suffering, while individuals undergoing alco- group of including faith-based hol withdrawal sometimes are, for a variety of organizations, com- reasons, denied hospital-level treatment for individuals, munity charities, detoxification, even though alcohol withdraw- and municipal and al produces suffering and may have fatal con- substance use other local govern- sequences. ments. The consensus panel agreed on several guide- withdrawal The genesis of social lines for social detoxification programs: detoxification is syndromes do not •Such programs should follow local govern- complex. Often, mental regulations regarding their licensing these programs grew and inspection. lead to fatal out of community •It is highly desirable that individuals entering needs when no other social detoxification be assessed by primary outcomes or even alternatives were care practitioners (physicians, physician available. Early assistants, nurse practitioners) with some reports (Whitfield et significant experience in substance abuse treatment. al. 1978) indicated •Such an assessment should determine morbidity. that many individu- als in alcohol with- whether the patient currently is intoxicated drawal could be and the degree of intoxication, the type of managed successful- withdrawal syndrome, severity of the with- ly without medications in a social detoxification drawal, information regarding past with- setting. Subsequent reviews that have revisited drawals, and the presence of co-occurring the topic (Lapham et al. 1996) have reached psychiatric, medical, and surgical conditions similar conclusions. Critical analysis of these that might well require specialized care (see reports by the consensus panel indicates that chapter 3, Figure 3-1, p. 25). some of the scientific issues were oversimplified •Particular attention should be paid to those and misleading. A number of these studies, in individuals who have undergone multiple fact, excluded many seriously ill clients from withdrawals in the past and for whom each their surveys prior to referral to social detoxifi- withdrawal appears to be worse than previ- cation. Some of these surveys had a very high ous ones—this is the so-called “kindling staff-to-client ratio during social detoxification, effect” (Ballenger and Post 1978; Booth and thus providing an unusually high level of psy- Blow 1993; Malcolm et al. 2000; Shaw et al. chological support. This level of staffing is not 1998; Wojnar et al. 1999; Worner 1996). frequently found today in social detoxification Subjects with a history of severe with- programs. drawals, multiple withdrawals, delirium

56 Chapter 4 tremens, or seizures are not good candidates sion, been abstinent for a few hours and have for social detoxification programs. not developed signs or symptoms of withdraw- •All social detoxification programs should al. A decision regarding medication for this have an alcohol- and drug-free environment, group should be in part based on age, num- have personnel who are familiar with the fea- ber of years of alcohol dependence, and the tures of substance use withdrawal syn- number of previously treated or untreated dromes, have training in basic life support, severe withdrawals (three or four appears to and have access to an emergency medical sys- be a significant threshold in predicting future tem that can provide transportation to emer- serious withdrawal) (Shaw 1995). If there is gency departments and other sites of clinical an opportunity to observe the patient in the care. emergency department of the clinic or similar setting over the next 6 to 8 hours, then it is Management of Withdrawal possible to delay a decision regarding treat- ment and periodically reevaluate a client of With Medications this category. If this is not possible, then the Over the last 15 years several reviews and posi- return of the patient to a setting in which tion papers (Fuller and Gordis 1994; Lejoyeux there is some supervision by family, signifi- et al. 1998; Mayo-Smith 1997; Nutt et al. 1989; cant others, or in a social detoxification pro- Shaw 1995) have asserted that only a minority gram is desirable. of patients with alcoholism will in fact go into The decision as to whether to give the patient significant alcohol withdrawal requiring medi- a single medication dose prior to discharge cations. Identifying that significant minority and perhaps provide one or two additional sometimes is problematic, but there are signs medication doses to be administered in the and symptoms of impending problems that can referral setting rests on adequacy of supervi- alert the caretaker to seek medical attention. sion, the probability of whether the patient Deciding on whether to use medical manage- will drink while undergoing treatment, and ment for the treatment of alcohol withdrawal whether the patient can or will return for requires that patients be separated into three assessments the following day. In some cir- groups. The first and most obvious group cumstances, no treatment may be safer than comprises those clients who have had a previ- treatment with medication. Mayo-Smith ous history of the most extreme forms of with- (1997) has shown that benzodiazepines confer drawal, that of seizures and/or delirium. This protection against alcohol withdrawal seizures group is discussed in more detail below, but and thus patients with previous seizures in general, the medication treatment of this should be treated early. The same applies to group in early abstinence, whether or not delirium. Both of these topics will be explored they have had the initiation of withdrawal in greater detail in the next section. symptoms, should proceed as quickly as pos- Extremely heavy drinking in the weeks prior sible. to complete cessation also predicts more severe withdrawal (Lejoyeux et al. 1998), but The second group of patients requiring imme- confirming such a history often is difficult. diate medication treatment includes those patients who are already in withdrawal and A less accepted and more controversial posi- demonstrating moderate symptoms of with- tion on the indications for medication treat- drawal. ment for alcohol withdrawal springs from studies that attempt to measure oxidative The third group of patients includes those stress, which is the formation of oxidative who may still be intoxicated and therefore free radicals (chemicals that damage pro- have not had time to develop withdrawal teins), and stress hormones during alcohol symptoms or who have, at the time of admis- withdrawal (Dupont et al. 2000; Tsai et al.

Physical Detoxification Services for Withdrawal From Specific Substances 57 1998). These studies have asserted that indi- benzodiazepines have side effects and limita- viduals who are undergoing mild withdrawal tions. These limitations are far more prominent without treatment still have the formation of when treating alcohol withdrawal in an outpa- toxic oxidative products which have the hypo- tient setting. thetical potential of producing neuronal dam- age and perhaps some cell death. Lending Loading dose of a benzodiazepine support to this argument is the fact that alco- Medical or nursing administration of a slowly hol withdrawal appears to be progressive in metabolized benzodiazepine, frequently intra- that it worsens with each successive episode venously, but sometimes orally, may be carried (Malcolm et al. 2000) and that some patients out every 1 to 2 hours until significant clinical dependent on alcohol develop evidence of improvement occurs (such as reducing the dementia over time. On the other hand, age, CIWA-Ar score to 10 or less) or the patient nutritional status, trauma, co-occurring con- becomes sedated (Sellers and Naranjo 1985). ditions, and other unspecified events also Patients at grave risk for the most severe com- probably contribute to this process. plications of alcohol withdrawal or who are already experiencing severe withdrawal should The decision to treat a patient in alcohol be hospitalized and can be treated with this withdrawal or at potential risk for alcohol regimen. In general, patients with severe with- withdrawal will in great part rest on the clini- drawal may receive 20mg of diazepam or cal judgment of the practitioner, relying on 100mg of chlordiazepoxide every 2 to 3 hours the factors noted above in addition to the until improvement or sedation prevails. issue of whether treatment may in fact actual- Oversedation, ataxia (lack of muscular coordi- ly do more harm than good. This topic is dis- nation), and confusion, particularly in elderly cussed below under the heading Limitations patients, may occur with this protocol. The of Benzodiazepines in Outpatient Treatment treatment staff should closely monitor hemody- (p. 60). For more information about medica- namic (blood pressure and pulse) and respira- tion-assisted treatment, see TIP 43, tory features. They should particularly be pre- Medication-Assisted Treatment for Opioid pared to detect and rapidly treat apnea (no Addiction in Opioid Treatment Programs breathing) with assisted ventilation. Having (CSAT 2005d). experienced staff with adequate time to fre- quently monitor the patient and provide intra- Benzodiazepine treatment of venous medication is necessary. alcohol withdrawal Symptom-triggered therapy Depending upon the clinical setting and the Using the CIWA-Ar or similar alcohol with- patient circumstances, there are several accept- drawal rating scales, medical personnel can be able regimens for treating alcohol withdrawal trained to recognize signs and symptoms of that make use of benzodiazepines. These drugs alcohol withdrawal, make a rating, and based remain the medication class of choice for treat- on that rating administer benzodiazepines to ing alcohol withdrawal. The early recognition their patients only when signs and symptoms of alcohol withdrawal and prompt administra- reach a particular threshold score. Studies tion of a suitable benzodiazepine usually will have demonstrated that appropriate training of prevent the withdrawal reaction from proceed- nurses in the application of the CIWA-Ar dra- ing to serious consequences. Patients suspected matically reduces the number of patients who of alcohol withdrawal should be seen promptly need to receive symptom-triggered medication by a primary care provider (physician, nurse (Saitz et al. 1994; Wartenberg et al. 1990). This practitioner, physician assistant) who has expe- regimen has been used successfully with short, rience in diagnosing and managing alcohol intermediate, and long half-life benzodi- withdrawal. Practitioners are reminded that azepines.

58 Chapter 4 The training of staff in a standardized proce- drug response) according to severity of symp- dure of administering rating scales is impor- toms. An alternative regimen might be the tant and periodic retraining to ensure contin- administration of 1 to 2mg lorazepam two or ued reliability among raters is essential. A three times a day the first day, followed by typical routine of administration of symptom- gradual reduction over the next 3 to 5 days. triggered therapy is as follows: Administer The general approach to tapering is to estab- 50mg of chlordiazepoxide (Librium) for lish an acute dose in the first 24 hours, then CIWA-Ar > 9 and reassess in 1 hour. to reduce it over the next three days: for Continue administering 50mg chlordiazepox- example, 400 chlordiazepoxide total on day 1, ide every hour until CIWA-Ar is < 10. Dosage then 300, 200, 100, amount and frequency can be modified and off on day 5. depending on the individual clinical situation This has to be as determined by the medical provider. extended if Patients with a history of withdrawal seizures lorazepam is used. should receive scheduled doses of a long-act- Doses of withdrawal Benzodiazepines ing benzodiazepine (e.g., diazepam [Valium], medication are omit- 20mg every 6 hours for 3 days) regardless of ted if the patient is remain the CIWA-Ar score, and should receive addition- sleeping soundly, al doses if indicated by elevated CIWA-Ar showing signs of medication class score. It must be noted here that symptom- oversedation, or triggered therapy is not recommended for exhibiting marked of choice for outpatient detoxification. Symptom-triggered ataxia. therapy requires monitoring and decision- making by a healthcare professional. The use of gradual, treating alcohol tapering doses is Gradual, tapering doses appealing in settings withdrawal. Before beginning any tapering regimen, the where trained nurs- patient must be fully stabilized; that is, all signs ing or medical and symptoms of withdrawal must be observations cannot improved. Without proper stabilization, no be made frequently; tapering scheme will succeed. Once the patient however, this in has been stabilized, oral benzodiazepines can itself is a pitfall. be administered on a predetermined dosing Under- or overmedication with this regimen schedule for several days and gradually can occur depending on benzodiazepine toler- tapered over time. This is a commonly used ance; the presence of chronic cigarette smok- regimen. ing, which induces benzodiazepine metabolism; liver function; age; and the pres- Dosing protocols vary widely among treat- ence of co-occurring medical or psychiatric ment facilities based on the needs of the conditions. The use of this regimen may be patient population. One example is that problematic in the outpatient settings in patients might receive 50mg of chlordiazepox- which it frequently is applied. Supplying the ide or 10mg of diazepam every 6 hours during patient with 4 to 5 days of a benzodiazepine the first day of treatment and 25mg of chlor- and facing the probability that the patient diazepoxide or 5mg of diazepam every 6 may drink and take the benzodiazepine is a hours on the second and third days. This hazard. It is important to enforce strict limi- approach to dosing, that is, every 6 hours, is tations on driving automobiles, climbing, or not as accurate in tailoring medications to operating hazardous machinery. counter symptoms; a more precise dosing reg- imen is titrating (adjusting dosage in light of

Physical Detoxification Services for Withdrawal From Specific Substances 59 Single daily dosing protocol ataxia, and on rare occasions, confusion may Jauhar and Anderson (2000) compared single ensue. daily dosing of diazepam to multiple daily dos- Lorazepam ing of chlordiazepoxide in inpatients being treated for alcohol withdrawal. Patients in the Lorazepam (Ativan) has an intermediate half- diazepam single daily dose group did as well as life of about 8–15 hours, and although it usual- the chlordiazepoxide multiple dosing group. ly is administered in multiple doses each day, it The authors suggest that this regimen might be can be given approximately twice per day. attractive in community or social detoxification Lorazepam, with its shorter half-life and lack settings, particularly if patients could be moni- of storage in adipose (fatty) tissue, actually has tored between administered doses. Further to be given more frequently than the long-act- study with a larger group of patients is needed. ing preparations, not less. It is absorbed easily orally, intramuscularly, and intravenously. The choice of the specific benzodiazepine for Older patients and patients with severe liver any particular regimen depends on a number disease tolerate it well and it is an effective of factors, but the most significant factor is that anticonvulsant in blocking a second alcohol the clinician administer one that she has the withdrawal seizure (D’Onofrio et al. 1999). most experience using. Despite 30 years of However, it has been suggested that seizures research, no single benzodiazepine has emerged may occur late in detoxification with short-act- as the number one drug of choice in treating ing benzodiazepines such as lorazepam and alcohol withdrawal. All benzodiazepines stud- oxazepam (Shaw 1995). ied have worked better than placebo but have been roughly equivalent with each other. Many Oxazepam clinicians prefer long half-life benzodiazepines Oxazepam (Serax) often is favored by internists such as chlordiazepoxide and diazepam, desir- and hepatologists treating alcohol withdrawal ing less frequent daily dosing, relatively steady in patients with severe liver failure. It has a rel- serum levels, and the ability of these drugs to atively short half-life of 6 to 8 hours. Its self-taper based on their long half-lives. metabolism is very simple and it has no metabolites. The agent is relatively limited in Diazepam and chlordiazepoxide that its oral absorption is quite slow compared Both diazepam and chlordiazepoxide have to other benzodiazepines, it must be given excellent rapid oral absorption and are avail- three to four times a day, and is only available able for intravenous (IV) use. Intramuscular in the United States in an oral form. use of these drugs is to be discouraged since muscle absorption is erratic. One study sug- Ultimately, the experience of the treating clini- gests that if chlordiazepoxide (Librium) is cian, characteristics of the patient, and the set- taken in overdose with alcohol, it is less likely ting in which he will be treated will determine to be fatal than diazepam (Valium) (Serfaty the choice of drug. Although all benzodi- and Masterton 1993). Detractors of the use of azepines are now generic in the United States, these two drugs point out that they have long costs vary and this too may be a factor in half-lives (although some clinicians see this as choice. an advantage because it prevents the emer- Limitations of benzodiazepines in gence of withdrawal symptoms between doses), outpatient treatment have multiple active metabolites, and go through many oxidative metabolic steps in the Although benzodiazepines remain the mainstay liver. Older patients or patients with liver dis- of treatment for alcohol withdrawal, they have ease are likely to accumulate these medications limitations that are particularly pronounced quickly without being able to metabolize them. when treating outpatients. Benzodiazepines’ Possible consequences include oversedation or potential interactions with alcohol can lead to coma and respiratory suppression, motor inco-

60 Chapter 4 ordination (leading to falls and automobile the majority of these studies, patients were accidents), and abuse of the medications. treated with benzodiazepines, although in a Abuse usually is in the context of the concur- few, phenobarbital was used. rent use of alcohol, opioids, or stimulants. A second, and at present more hypothetical, There are two other limitations of benzodi- concern about benzodiazepine use to treat out- azepines that may be relevant in some clinical patients in alcohol withdrawal is that they may settings for some patients. First, although ben- “prime” or reinstate alcohol use during their zodiazepines have been studied for more than administration. Two preclinical studies support 30 years and are effective for suppressing alco- this premise (Deutsch and Walton 1977; hol withdrawal symptoms at any one episode, Hedlund and Wahlstrom 1998). A recent ran- their ability to halt the progressive worsening domized, blinded, clinical trial comparing car- of each successive alcohol withdrawal reaction bamazepine to lorazepam for the outpatient is in question. There are now at least nine stud- treatment of alcohol withdrawal found that the ies that have found that an ever-increasing outpatients on lorazepam were three times as number of previous alcohol withdrawals likely to drink as those on carbamazepine. The increases the severity of withdrawal, particu- lorazepam group drank about twice as much larly seizures and delirium tremens, and alcohol in the immediate post-detoxification decreases responsiveness to benzodiazepines period than the carbamazepine group (Malcolm (Ballenger and Post 1978; Booth and Blow et al. 2002). 1993; Brown et al. 1988; Gross et al. 1972; Lechtenberg and Worner 1990, 1992; Malcolm For a list of potential contraindications to using et al. 2000; Shaw et al. 1998; Worner 1996). A benzodiazepines to treat alcohol withdrawal in tenth study (Wojnar et al. 1999) found that certain patients, see Figure 4-3. increasing severity of alcohol withdrawal symp- toms was observed only in a minority (22 per- Other medications cent) of 418 repeatedly treated clients. However, within this group of one in five indi- Barbiturates viduals, seizures were three times more com- Barbiturates have been used for nearly a cen- mon than in the larger, nonprogressive group tury for the treatment of alcohol withdrawal. and premature age of death was 7 years Most barbiturates, other than phenobarbital, younger than for the nonprogressive group. In have fallen into disfavor because of severe

Figure 4-3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal

•Previous allergic reaction •Previous paradoxical disinhibition (e.g., violence, agitation, self-harm) •Previous serious adverse outcomes that could have medico-legal consequences if they re-occur (e.g., fractured hip, status epilepticus [continuous seizures of several minutes]) •Severe alterations in mental status with low dose of benzodiazepines (e.g., confusion, delirium) •An outpatient setting where benzodiazepine use with alcohol has occurred previously with extreme intox- ication leading to injuries, coma, or apnea

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 61 lethal interactions Other agents Delirium and with alcohol, death Beta blockers and alpha adrenergic agonists from overdose of the such as clonidine have been used in the treat- agents alone, rapid seizures are the ment of alcohol withdrawal. They do not pre- tolerance, and high vent seizures in delirium and have only modest abuse potential. two most benefits for ameliorating symptoms of with- Barbiturates are drawal. However, some patients will have highly addictive. In tachycardia (rapid heartbeat) and hyperten- pathological clinical practice, the sion (high blood pressure) that will not be con- medication is effec- trolled by benzodiazepines, and beta blockers responses seen in tive both for the and alpha adrenergic agonists can be of use in treatment of alcohol these patients. Calcium channel antagonists will alcohol withdrawal and also ameliorate some symptoms of alcohol with- sedative-hypnotic drawal. As with beta blockers and clonidine, withdrawal. withdrawal although calcium channel antagonists should be consid- few controlled trials ered adjunctive therapy primarily to manage have been conduct- extreme hypertension during withdrawal. ed with it (Wilbur and Kulik 1981). Phenobarbital has a long Antipsychotics half-life and may rapidly accumulate. Antipsychotics have long been used to control Overdoses with phenobarbital also can be fatal. extreme agitation, hallucinations, delusions, Members of the consensus panel recommend its and delirium during alcohol withdrawal. Older, use only in highly supervised settings. low-potency drugs such as chlorpromazine gen- Anticonvulsants erally are avoided since they can reduce the seizure threshold. High-potency drugs such as Anticonvulsants have been used in Europe for haloperidol (Haldol) also can reduce the a quarter of a century for the treatment of seizure threshold, but less commonly. alcohol withdrawal. Carbamazepine (Atretol, Haloperidol and related agents are available Tegretol) has been shown in at least three trials for oral, intramuscular, and IV administration. to be as effective as various benzodiazepines in Clinicians should note that since antipsychotics mild to moderate alcohol withdrawal (Malcolm can lower the seizure threshold, their use dur- et al. 2001). Although less well studied, val- ing alcohol withdrawal should be undertaken proic acid also has been shown to be effective with great care and close supervision of the (Reoux et al. 2001). Older, first-generation patient is required. anticonvulsants have limitations in that they only have been studied in mild to moderate Relapse prevention agents withdrawal, can on rare occasions have serious Relapse prevention agents such as naltrexone hepatic and bone marrow toxicities, interact and acamprosate are under consideration as with several other classes of medication, and additional therapies during late withdrawal are only available in oral forms. They are not, treatment, although they are not effective for however, controlled substances, are not alcohol detoxification. Since one-third to one- abused, and as previously noted, carba- half of outpatients detoxifying with benzodi- mazepine may have the propensity to reduce azepines will either drink or leave treatment some of the indices of drinking behavior imme- prematurely, naltrexone and acamprosate may diately in the post-withdrawal treatment of out- be valuable in assisting in reducing the proba- patients. Newer drugs such as tiagabine, oxcar- bility of the individual drinking during late bazepine, and gabapentin do not appear to detoxification. High-dose naltrexone therapy have these liabilities, but sufficient studies have has been associated with some liver toxicity, not been done to confirm their effectiveness but this has not been reported in individuals and safety. taking therapeutic doses to enhance relapse

62 Chapter 4 prevention. Acamprosate may produce diar- weeks prior to treatment, the severity of the rhea and this may be already present in some last withdrawal episodes, and the number of individuals in alcohol withdrawal. Thus far no previously treated or untreated withdrawal well-controlled studies have been conducted to episodes. Other factors such as increasing age; provide guidelines as to when these medications the patient’s general health, including nutri- should be introduced during detoxification or tional status; the presence of co-occurring med- whether it would be better to wait until the ical, surgical, and psychiatric disorders; and early phase of rehabilitation. For an extended the use of medications (prescription, over-the- review, see Kranzler and Jaffe (2003). counter, or herbal) also can amplify severity of withdrawal symptoms. Early proper medical Other medications management of alcohol withdrawal reduces the Abecarnil (Anton et al. 1997), and more recent- probability of these complications, assuming ly baclofen (Addolorato et al. 2002), have both early recognition. shown promise in the treatment of alcohol with- drawal. However, insufficient information has For patients with a history of DTs or seizures, been accumulated on these drugs, and there- early benzodiazepine treatment is indicated at fore they are not recommended for use in clini- the first clinical contact setting (e.g., doctor’s cal patient settings. Their use in alcohol with- office, clinic, urgent care, emergency depart- drawal should be considered experimental and ment). Patients with severe withdrawal symp- premature for the present. toms, multiple past detoxifications (more than three), and co-occurring unstable medical and psychiatric conditions should be managed simi- Management of Delirium and larly. Seizures Once an initial clinical screening and assess- Delirium and seizures are the two most patho- ment have been made, and the diagnosis is rea- logic responses seen in alcohol withdrawal. The sonably certain, medication should be given. major goal of medical management is to avoid Giving the patient a benzodiazepine should not seizures and a special state of delirium called be delayed by waiting for the return of labora- delirium tremens (DTs) with aggressive use of tory studies, transportation problems, or the the primary detoxification drug (e.g., higher availability of a hospital bed. Early thiamine doses of a benzodiazepine). Prevention is and multivitamin administration also should be essential where DTs are concerned. DTs do not done at this time. Once full DTs have devel- develop suddenly but instead progress from oped, they tend to run their course despite earlier withdrawal symptoms. Properly admin- medication management, and there is little evi- istered symptom-triggered medication dence in the medical literature to suggest that approaches will prevent DTs and limit over- any medication treatment can immediately medication that can occur when high-dose ben- abort DTs. zodiazepines are administered without regard to clinical response. It can be challenging clini- Patients presenting in severe DTs should have cally to differentiate impending DTs versus emergency medical transport to a qualified benzodiazepine toxicity on day 3 of detoxifica- emergency department and generally will tion. When in doubt, in most cases it is safer to require hospitalization. If the DTs are severe, overmedicate than to undertreat and allow DTs patients may need to be placed in an intensive to develop. Flumazenil (Romazicon) can be care unit (ICU), and in such settings continu- used to reverse benzodiazepine overdose. ous monitoring of cardiac rhythm, pulse, blood pressure, oxygen saturation, temperature, and Death and disability may result from DTs or respiration rates begins with the emergency seizures without medical care. Several factors medical system and continues in the emergency are related to severity of alcohol withdrawal: department and ICU. high amounts of alcohol being consumed in the

Physical Detoxification Services for Withdrawal From Specific Substances 63 Early care will depend on medical and surgical sists of jerking of head, neck, arms, and legs. complications and may involve protocols from Breathing resumes during this clonic phase of advanced cardiac life support (ACLS) and/or the seizure but may be irregular. During the advanced trauma life support. Correction of clonic phase, the lips, tongue, or inside of the fluids and electrolytes (salts in the blood), cheeks may be bitten. Involuntary urination or hyperthermia (high fever), and hypertension a bowel movement may occur. Immediately are vital. Loading doses (rapid administration after the jerking ceases, the patient generally of initial high doses) of IV diazepam or has a period of what appears to be sleep with lorazepam are recommended, as are IV thi- more regular breathing. Vomiting may occur at amine (prior to IV glucose) and multiple vita- this time. The period of sleep may be a few sec- mins. The physician should consider intramus- onds with awakening or a few minutes. Rarely, cular or intravenous haloperidol (Haldol and the patient may appear not to waken at all and others) to treat agitation and hallucinations. have a second period of rigidity followed by Nursing care is vital, with particular attention muscle jerking. This is known as status epilep- to medication administration, patient comfort, ticus. Upon awakening, the individual usually soft restraints, and frequent contact with ori- is mildly confused as to what has happened and enting responses and clarification of environ- may be disoriented as to where she or he is. mental misperceptions. This period of post-seizure confusion generally lasts only for a few minutes but may persist for Alcohol withdrawal seizures represent another several hours in some patients. Headache, management challenge (Ahmed et al. 2000), sleepiness, nausea, and sore muscles may per- since no large-scale clinical studies have been sist in some individuals for a few hours. See the conducted to establish firmly best treatment text box on the next page for what to do in the practices. The majority of alcohol withdrawal event of a seizure. seizures occur within the first 48 hours after cessation or reduction of alcohol, with peak Patients who start to retch or vomit should be incidence around 24 hours (Victor and Adams gently placed on their side so that the vomitus 1953). Most alcohol withdrawal seizures are (stomach contents vomited) may exit the mouth singular, but if more than one occurs they tend and not be taken into the lungs. Vomitus taken to be within several hours of each other. While into the lungs is a severe medical condition alcohol withdrawal seizures can occur several leading to immediate difficulty breathing and, days out, a higher index of suspicion for other within hours, severe pneumonia. causes is prudent. Someone experiencing an alcohol withdrawal seizure is at greater risk for Predicting who will have a seizure during alco- progressing to DTs, whereas it is extremely hol withdrawal cannot be accomplished with unlikely that a patient already in DTs will also any great certainty. There are some factors then experience a seizure. that clearly increase the risk of a seizure, but even in individuals with all of these factors, The occurrence of an alcohol withdrawal most patients will not have a seizure. Out of seizure happens quickly, usually without warn- 100 people experiencing alcohol withdrawal ing to the individual experiencing the seizure or only two or three of them will have a seizure. anyone around him. The patient loses con- The best single predictor of a future alcohol sciousness, and if seated usually slumps over, withdrawal seizure is a previous alcohol with- but if standing will immediately fall to the floor. drawal seizure. Individuals who have had three The patient’s body is rigid, and breathing ceas- or more documented withdrawal episodes in es. This part of the seizure is called the tonic the past are much more likely to have a seizure phase, which usually lasts for a few seconds regardless of other factors including age, gen- and rarely more than a minute. der, or overall medical health. However, cer- tain other factors may increase the risk of The next part of the seizure (more dramatic seizures for all patients: and generally remembered by witnesses) con-

64 Chapter 4 What To Do in the Event of a Seizure

•At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel. •Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for the clinic or hospital unit. •While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt to prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s head and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen by anyone. •In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from extreme head-banging by placing a soft object under the head and neck. Sometimes placing one’s hand or shoe under the head is adequate. •No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades). Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially swallowed and obstruct the airway. •Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia. •Even if the individual appears to become fully awake, alert, and oriented without any harm following a seizure, it is strongly recommended that he be referred for medical evaluation. •Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages to reorient them as to what happened and where they are.

•Having drunk for more than two decades preferably with IV administration. The study •Having poor general medical health and poor by D’Onofrio and colleagues (1999) indicated nutritional status that a single dose of 1mg of IV lorazepam reduced recurrent seizure risk, reduced rates •Having had previous head injuries of return to emergency departments, and low- •Having had disturbances of serum calcium, ered hospitalization rates. Despite this sodium, potassium, or magnesium report, the consensus panel agrees that hospi- talization for further detoxification treatment Patients having a witnessed seizure can be is strongly advised to monitor and ameliorate treated with IV diazepam or lorazepam and other withdrawal symptoms, reduce suffering, ACLS protocol procedures. This reduces but and stabilize the patient for rehabilitation does not completely prevent the likelihood of a treatment. second seizure (D’Onofrio et al. 1999). In the rare patient with recurrent multiple seizures or The addition of anti-epileptic drugs (AEDs) status epilepticus (continuous seizures of sever- has not been established as effective (Chance al minutes) an anesthesiology consultation may 1991; Hillbom and Hjelm-Jager 1984; Rathlev be required for general anesthesia. Evaluation et al. 1994). This is primarily based on evalu- of electrolyte disturbances, central nervous sys- ations of phenytoin (Dilantin and others). tem (CNS) trauma, and consideration of seda- Newer AEDs have not been studied extensive- tive-hypnotic withdrawal should be reviewed. ly for preventing alcohol withdrawal seizures. The consensus panel suggests that AED thera- Patients who have had a single witnessed or py should be considered in alcohol withdraw- suspected alcohol withdrawal seizure should al patients with multiple past seizures (of any be immediately given a benzodiazepine, cause), a history of recent head injury, past

Physical Detoxification Services for Withdrawal From Specific Substances 65 meningitis, encephalitis, or family history of mine whether the patient is using aspirin or seizures. Further evaluation of a first seizure nonsteroidal anti-inflammatory medications often warrants neurologic evaluation (com- (for example, Motrin or Advil, both containing puterized tomography and electroencephalo- ibuprofen) in conjunction with alcohol use. gram), even if the seizure may be suspected to Antidiabetic agents in concert with alcohol may have been due to alcohol withdrawal. produce hypoglycemia (low blood sugar) and lactic acidosis (blood that has become too acidic). The therapeutic efficacy and margin of Patient Care and Comfort safety for the use of anti-anxiety medications, Interpersonal support and hygienic care along antidepressants, and antipsychotic medication with adequate nutrition should be provided. is thought by some to be lessened by alcohol Staff assisting patients in detoxification should use, but this is based largely on anecdotal provide whatever assistance is necessary to information. Alcohol interacts with numerous help get patients cleaned up after entering the other classes of medications that lead to less facility and bathed thoroughly as soon as they serious results. Some important examples are have been medically stabilized. Attention to the sedatives, tranquilizers, antiseizure medica- treatment of scabies, body lice, and other skin tions, and anticoagulants (blood thinners) such conditions should be given. Screening for as Coumadin. Patients who may be taking such tuberculosis should be done. Dental and oral medications need to be carefully observed and care should be made available. The patient have their medications carefully monitored. should be screened for physical trauma, including bruises and lacerations. Tetanus immunization may be necessary. Patients with Opioids an altered mental status or altered level of con- Opioids are highly addicting, and their chronic sciousness should be seen in emergency depart- use leads to withdrawal symptoms that, ments, evaluated, and possibly hospitalized. although not medically dangerous, can be high- Staff should continue to observe patients for ly unpleasant and produce intense discomfort. head injuries after admission because some All opioids (e.g., heroin, morphine, hydromor- head injuries, such as subdural hematomas, phone, oxycodone, codeine, and methadone) may not immediately be evident and cost con- produce similar effects by interacting with siderations may preclude obtaining a brain endogenous (produced by the body itself) opi- scan in some settings. oid (:, *, and 6) receptors (that is, specific sites on cells where these substances bind to the Other Immediate Concerns cell). Opioid agonists stimulate these receptors and opioid antagonists block them, preventing Alcohol may interact with several classes of their action. medicine to produce serious CNS depression. Some examples include benzodiazepines, barbi- turates, meprobamate, and other sedative hyp- Opioid Withdrawal Symptoms notic groups. Metoclopramide and sedating All opioid agents produce similar withdrawal antipsychotic medicines such as phenothiazines signs and symptoms with some variance in also can produce CNS suppression. A disulfi- severity, time of onset, and duration of symp- ram-like (Antabuse) reaction characterized by tomatology, depending on the agent used, the flushing, sweating, tachycardia, nausea, and duration of use, the daily dose, and the interval chest pain has been reported for metronidazole between doses. For instance, heroin withdrawal and several antibiotics including, but not limit- typically begins 8 to 12 hours after the last ed to, cefamandole, cefoperazone, and cefote- heroin dose and subsides within a period of 3 tan. Acetaminophen in low doses may act to 5 days. Methadone withdrawal typically acutely with alcohol to produce hepatotoxicity begins 36 to 48 hours after the last dose, peaks (liver damage). Clinicians also should deter-

66 Chapter 4 after about 3 days, and gradually subsides over the opioid withdrawal syndrome, after which a period of 3 weeks or longer. Physiological, dose reductions can be made gradually. genetic, and psychological factors can signifi- cantly affect intoxication and withdrawal sever- Medical complications associated with opioid ity. Figure 4-4 summarizes many of the com- withdrawal can develop and should be quick- mon signs and symptoms of opioid intoxication ly identified and treated. Unlike alcohol and and withdrawal. sedative withdrawal, uncomplicated opioid withdrawal is not life-threatening. Rarely, The clinician uses intoxication and withdraw- severe gastrointestinal symptoms produced by al measures as guides to avoid under- or over- opioid withdrawal, such as vomiting or diar- medicating patients during medically super- rhea, can lead to dehydration or electrolyte vised detoxification; the number and intensity imbalance. Most individuals can be treated of signs determine the severity of opioid with- with oral fluids, especially fluids containing drawal. It is important to appreciate that electrolytes, and some might require intra- untreated opioid withdrawal gradually builds venous therapies. In addition, underlying in severity of signs and symptoms and then cardiac illness could be made worse in the diminishes in a self-limited manner. Repeated presence of the autonomic arousal (increased assessments should be made during detoxifi- blood pressure, increased pulse, sweating) cation to determine whether symptoms are that is characteristic of opioid withdrawal. improving or worsening. Repeated assess- Fever may be present during opioid with- ments also should address the effectiveness of drawal and typically will respond to detoxifi- pharmacological interventions. Detoxification cation. Other causes of fever should be evalu- strategies should aim to establish control over ated, particularly with intravenous users,

Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal

Opioid Intoxication Opioid Withdrawal

Signs Signs Bradycardia (slow pulse) Tachycardia (fast pulse) Hypotension (low blood pressure) Hypertension (high blood pressure) Hypothermia (low body temperature) Hyperthermia (high body temperature) Sedation Insomnia Meiosis (pinpoint pupils) Mydriasis (enlarged pupils) Hypokinesis (slowed movement) Hyperreflexia (abnormally heightened reflexes) Slurred speech Diaphoresis (sweating) Head nodding Piloerection (gooseflesh) Increased respiratory rate Symptoms Lacrimation (tearing), yawning Euphoria Rhinorrhea (runny nose) Analgesia (pain-killing effects) Muscle spasms Calmness Symptoms Abdominal cramps, nausea, vomiting, diarrhea Bone and muscle pain Anxiety

Source: Consensus Panelist Charles Dackis, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 67 because HIV infec- Management of Withdrawal tion, viral hepati- With Medications Methadone is the tis, abscesses, infected injection The management of opioid withdrawal with sites, and pneumo- medications is most commonly achieved most frequently nia occur common- through the use of methadone (in addition to ly in this popula- adjunctive medications for nausea, vomiting, used agent tion and always diarrhea, and stomach cramps). Federal regu- require medical lations restrict the use of methadone for opioid approved for attention. Anxiety withdrawal to specially licensed programs, disorders, especial- except in cases where the patient is hospitalized detoxification by ly those involving for treatment of another acute medical condi- panic anxiety, also tion. Methadone is the most frequently used the FDA, and a might show agent approved for detoxification by the Food increased intensity and Drug Administration (FDA), and a new new medication, during opioid with- medication, buprenorphine (discussed below), drawal. Finally, has been approved for use. Methadone can be used for detoxification from heroin and all opi- buprenorphine, any condition involving pain is oid agonists. likely to worsen has been Another commonly used agent is clonidine during opioid with- α drawal because of a (Gold et al. 1984), an -adrenergic agonist approved for use. reduced pain that relieves most opioid withdrawal symp- threshold and the toms without producing opioid intoxication or lack of analgesia drug reward. However, since clonidine detox- (pain relief) afford- ification is less effective against many opioid ed by opioid use. withdrawal symptoms, adjunctive medicines This phenomenon is particularly common often are necessary to treat insomnia, muscle with dental pain and chronic back pain. pain, bone pain, and headache. Adjunctive agents should not be used in the place of an adequate detoxification dosage. Additional Management of Withdrawal opioid agonists could be used theoretically for Without Medications detoxification but would have to be adminis- tered “off label,” because the FDA has It is not recommended that clinicians attempt approved only methadone for this purpose. to manage significant opioid withdrawal symp- Off-label use (prescribing an agent approved toms (causing discomfort and lasting several for another condition) could be difficult to hours) without the effective detoxification justify, given the efficacy of methadone in agents discussed below. Even mild levels of opi- reversing opioid withdrawal. oid use commonly produce uncomfortable lev- els of withdrawal symptomatology. Detoxification is indicated for treatment-seek- Management of this syndrome without medica- ing persons who display signs and symptoms tions can produce needless suffering in a popu- sufficient to warrant treatment with medica- lation that tends to have limited tolerance for tions and for whom maintenance is declined physical pain. or for some reason is not indicated or practi- cal. In addition, individuals dependent on opioids sometimes are hospitalized for other health problems and may require hospital- based detoxification even though they are not

68 Chapter 4 seeking substance abuse treatment. Such and endocrinologic defects caused by long-term patients also can be maintained on methadone heroin addiction. This is one of many impor- during the course of hospitalization for any tant reasons to consider conversion to mainte- condition other than opioid addiction. The nance during most methadone detoxification hospital does not have to be a registered opi- admissions. oid treatment program, as long as the patient was admitted for a detoxification treatment Once the dose requirement for methadone has for some substance other than opioids. On been established, methadone can be given the other hand, some persons may not have once daily and generally tapered over 3 to 5 used sufficient amounts of opioids to develop days in 5 to 10mg daily reductions. The initial withdrawal symptoms, and for others suffi- dose requirement is determined by estimating cient time may have elapsed since their last the amount of opioid use and gauging the dose to extinguish withdrawal and eliminate patient’s response to administered the need for detoxification. methadone. Clinicians should take care not to underdose patients with methadone; adequate dosage is vitally important. Patients some- Methadone times exaggerate their daily consumption to This section discusses methadone as an agent receive greater dosages of methadone. For for detoxification. For detailed information this reason, history is no substitute for a on methadone maintenance, readers are physical examination that screens for signs of referred to TIP 43 Medication-Assisted opioid withdrawal. Treating clinicians should Treatment for Opioid Addiction in Opioid not only be familiar with the intoxication and Treatment Programs (CSAT 2005d). While withdrawal signs that are set forth in Figure methadone is one of the more common medi- 4-4 (p. 67), but also should be skilled in dis- cations for opioid detoxification, its use is cerning these features of opioid withdrawal. highly regulated and it can only be prescribed Avoidance of overmedicating is crucial during for withdrawal by a doctor at a Substance methadone detoxification because excessive Abuse and Mental Health Services doses of this agent can produce overdose, Administration (SAMHSA)-certified whereas opioid withdrawal does not constitute methadone clinic or if the patient is being a medical danger in otherwise healthy adults. hospitalized for another medical condition. For more information on methadone and (Detoxification programs may become certi- other medications used to treat opioid addic- fied to prescribe methadone by undergoing tion, see TIP 43, Medication-Assisted the process described in TIP 43.) Federal reg- Treatment for Opioid Addiction in Opioid ulations allow for the use of methadone in Treatment Programs (CSAT 2005d). both a short-term detoxification treatment of Patients with significant opioid dependence less than 30 days and a long-term treatment may require a starting dose of 30 to 40mg per of 30 to 180 days. The regulations also specify day; this dose range should be adequate for that if a patient has failed two detoxification even the most severe withdrawal. If the attempts in a 12-month period he or she must degree of dependence is unclear, withdrawal be evaluated for a different course of treat- signs and symptoms can be reassessed 1 to 2 ment (e.g., ongoing opioid substitution hours after giving a dose of 10mg of therapy). methadone. The practice of giving a dose of Methadone is a long-acting agonist at the :-opi- methadone and later assessing its effect (also oid receptor site that, in effect, displaces hero- termed a challenge dose) is an important in (or other abused opioids) and restabilizes the intervention of detoxification. Sedation or site, thereby reversing opioid withdrawal symp- intoxication signs after a methadone challenge toms. If maintained for long enough, this stabi- dose indicate a lower starting dose. Similarly, lizing effect can even reverse the immunologic intoxication at any point of the detoxification

Physical Detoxification Services for Withdrawal From Specific Substances 69 signals the need to hold or more rapidly wean muscle aches, and drug craving. Completion (reduce to a zero dose) the methadone. Care rates for opioid detoxification using clonidine should be taken to avoid giving methadone to have been low (ranging from 20 to 40 per- newly admitted patients with signs of opioid cent); those patients who complete the proce- intoxication, since overdose could result. dure are more likely to be dependent on opi- Note that methadone stabilization is the treat- oids other than heroin, have private health ment of choice for patients who are pregnant insurance, and report lower levels of subjec- and opioid dependent. tive withdrawal symptoms than those who do not complete (Strobbe et al. 2003).

Clonidine (Catapres) An appropriate protocol for clonidine is Clonidine was originally marketed and 0.1mg administered orally as a test dose. A approved for the treatment of high blood pres- dose of 0.2mg might be used initially for sure but also has been used for opioid detoxifi- patients with severe signs of opioid withdraw- cation since 1978. While clonidine is not FDA al or for those patients weighing more than approved for treatment of opioid withdrawal, it 200 pounds. The sublingual (under the is widely used “off label” for this purpose tongue) route of administration also may be (Alling 1992) because the research literature used. Clinicians should check the patient’s substantiates its effectiveness for this condition. blood pressure prior to clonidine administra- Advantages of clonidine over methadone in the tion and clonidine should be withheld if sys- treatment of opioid withdrawal are as follows: tolic blood pressure is lower than 90 or dias- tolic blood pressure is below 60. These •Clonidine does not produce opioid intoxica- parameters can be relaxed to 80/50 in some tion and is not reinforcing. cases if the patient continues to complain of •The FDA does not classify clonidine as having withdrawal and is not experiencing symptoms abuse potential. Yet some abuse has been of orthostatic hypotension (a sudden drop in reported. (See p. 107 under the section on blood pressure caused by standing). pregnant women and opioids.) Clonidine (0.1 to 0.2mg orally) can then be •Since clonidine does not interact with the given every 4 to 6 hours on an as-needed :-opioid receptor, detoxification occurs basis. Clonidine detoxification is best con- without opioids. ducted in an inpatient setting, as vital signs and side effects can be monitored more close- •No special licensing is required for the dis- ly in this environment. In cases of severe pensing of this medication. withdrawal, a standing dose (given at regular One disadvantage to methadone detoxification intervals rather than purely “as needed”) of with naltrexone (an opioid antagonist), com- clonidine might be advantageous (Alling pared with clonidine, is that naltrexone, when 1992). The daily clonidine requirement is it is prescribed for abstinence, can precipitate established by tabulating the total amount opioid withdrawal if given too soon after the administered in the first 24 hours, and divid- last methadone dose. This problem does not ing this into a three or four times per day exist with clonidine, making this agent particu- dosing schedule. Total clonidine should not larly beneficial in a drug-free treatment pro- exceed 1.2mg the first 24 hours and 2.0mg gram or a therapeutic community. after that, with doses being held in accor- dance with parameters noted above. The Nevertheless, patients addicted to opioids standing dose is then weaned over several generally prefer methadone over clonidine days. Clonidine must be tapered to avoid detoxification. Although clonidine alleviates rebound hypertensions. some symptoms of opioid withdrawal, it usu- ally is relatively ineffective for insomnia, The clonidine transdermal (administered through the skin) patch, FDA approved in

70 Chapter 4 1986 for the treatment of hypertension (high Buprenorphine is available in oral form as blood pressure), also is used in opioid detoxi- Subutex, which contains only buprenorphine, fication. However, the safety of the patch for and is meant for patients who are starting treatment of opioid withdrawal has not been treatment for drug dependence. Another sufficiently studied in controlled clinical tri- form, Suboxone, contains buprenorphine and als. The transdermal route of administration naloxone and is intended for persons depen- has the disadvantage of continued clonidine dent on opioids who have already started and action even after the patch has been removed. are continuing medication therapy. Blood pressure effects of clonidine can there- Buprenorphine has great affinity for the fore be prolonged, leading to undesirable and :-opioid receptor, in persistent reductions of blood pressure. For spite of being only a this reason, it has been recommended that the partial agonist, and patch be used only if the patient’s blood pres- can displace other One advantage of sure is monitored regularly (Alling 1992). opioids such as hero- in. This feature gives buprenorphine is The clonidine patch is available in three buprenorphine the sizes that deliver a total daily oral equivalent ability to precipitate 2 that it can be clonidine dose of 0.2mg (3.5 cm ), 0.4mg (7.0 opioid withdrawal cm2), or 0.6mg (10.5 cm2). The patch supplies when administered to dispensed at a clonidine for up to 7 days and one patch patients who have application usually is sufficient. The conve- recently used heroin nience of one application allows the clinician (Kosten and physician’s office, to avoid the disruption that multiple dosing McCance-Katz 1995). might have during rehabilitative program- unlike methadone, ming. In particular, patients can focus on An advantage to rehabilitative treatment without being dis- buprenorphine is its which can be tracted by the need to ask repeatedly for oral safety. Because of clonidine doses. Vital signs should be moni- the partial agonist dispensed only at tored at least four times daily to assess persis- action, buprenor- tent signs and symptoms of withdrawal or phine has a “ceiling undesirable effects of clonidine on blood pres- effect” with regard to designated treat- sure. overdose potential (Walsh et al. 1994). ment centers. That is, unlike Buprenorphine methadone, which Buprenorphine, a partial α-opioid agonist that produces increasing is FDA approved in an injectable form respiratory suppression with increasing dose, (Buprenex) for the treatment of pain, has respiratory effects of buprenorphine tend to recently been approved as a detoxification level off due to its partial agonist action. agent and for opioid maintenance treatment as Another advantage of buprenorphine is that an alternative to methadone maintenance. A it can be dispensed at a physician’s office, number of clinical trials have reported it to be unlike methadone, which can be dispensed effective for heroin detoxification (Becker et al. only at designated treatment centers. This 2001; Bickel et al. 1988; Diamant et al. 1998), makes access to this medication for opioid and the medication should play an important dependence much more convenient for both role in gradually removing patients from patient and clinician. See TIP 40, Clinical methadone maintenance (Amass et al. 2004; Guidelines for the Use of Buprenorphine in Banys et al. 1994; Johnson et al. 2000). the Treatment of Opioid Addiction (CSAT 2004a).

Physical Detoxification Services for Withdrawal From Specific Substances 71 Unlike methadone, buprenorphine may be described above for heroin. The methadone prescribed by physicians who are not con- dose should be tapered gradually by 5 to nected with a certified opioid treatment pro- 10mg/week until a daily dose of 30 to 40mg has gram. However, there is a still a specific been attained. At that time, detoxification with training and certifi- either clonidine or smaller doses of methadone cation process can be instituted. The use of clonidine has the Inpatient physicians must advantage of brevity as a complete clonidine undergo in order to detoxification usually can be conducted within prescribe the medi- 2 to 3 weeks (Gold et al. 1984). treatment can cation. Information on the legal aspects Once the daily dose requirement has been provide additional of prescribing established by using the principles outlined buprenorphine and above, the patient can be placed on a stand- support, medical rules for carrying ing dose of clonidine. The dose required usu- out detoxification in ally is in the range of 0.2mg, three to four supervision, and the physician’s times daily, although titration (adjustment of office can be found dosage in light of drug response) is necessary rehabilitative at www.buprenor- based on the information gathered during the phine.samhsa.gov/. clinical examination. Additional doses as needed (sometimes abbreviated “PRN”) of treatment that Information given at the site includes 0.2mg clonidine also can be given and blood pressure parameters must be followed prior serve as the following on the Drug Addiction to the administration of standing and PRN Treatment Act doses to avoid orthostatic hypotension. The disincentives to (DATA) of 2000: initial standing dose can be reduced to 0.1mg, “[DATA 2000] given three to four times daily, after one week relapse. expands the clinical of detoxification, with PRN doses of 0.1mg context of medica- available. After a period of 1 week on this tion-assisted opioid reduced dosage, clonidine is given for an addiction treatment by allowing qualified additional week only if needed. Because cloni- physicians to dispense or prescribe specifical- dine does not reverse all opioid withdrawal ly approved Schedule III, IV, and V narcotic symptoms, especially insomnia, adjunctive medications for the treatment of opioid addic- medications for symptom relief of insomnia, tion in treatment settings other than the tra- nausea, diarrhea, etc. usually are required. ditional Opioid Treatment Program (i.e., Clonidine detoxification is best conducted on methadone clinic). In addition, DATA 2000 an inpatient basis to ensure appropriate vital reduces the regulatory burden on physicians sign monitoring. Inpatient treatment also who choose to practice opioid addiction ther- reduces the impulse to relapse, especially if apy by permitting qualified physicians to the detoxification is difficult. apply for and receive waivers of the special Methadone detoxification can be continued registration requirements defined in the once a daily dose of 30 to 40mg is achieved, as Controlled Substances Act” (SAMHSA 2002). described above. The dose can be reduced to 20mg per day by a reduction of 5 to Terminating Methadone 10mg/week. Once the patient is on 20mg/day, methadone can be reduced by 1 to 2mg daily, Maintenance Treatment depending on clinical measures of withdraw- Individuals seeking the discontinuation of al. As with clonidine detoxification, the final methadone maintenance require a much more 2 to 3 weeks of methadone detoxification is lengthy detoxification process than that associated with recidivism (relapsing).

72 Chapter 4 Inpatient treatment, if available, can provide and shortened during the 1980s (Charney et additional support, medical supervision, and al. 1982, 1986; Kleber et al. 1987; Riordan rehabilitative treatment that serve as disin- and Kleber 1980; Vining et al. 1988) so that a centives to relapse. blocking dose of naltrexone—at least 25mg— usually was used by the second or third day of treatment. The rate-limiting factor of this Rapid and Ultrarapid rapid clonidine-naltrexone method is its Detoxification capacity to adequately relieve the precipitat- Although there are few data showing that the ed withdrawal symptoms in the conscious rapid or ultrarapid methods of opioid detoxifi- patient. Golden and Sakhrani (2004) found cation show a positive correlation with the like- that 25 percent of the 20 patients they studied lihood of a patient’s being abstinent a few who were undergoing rapid detoxification months later, efforts persist to make the detoxi- using clonidine and naltrexone developed fication process shorter and easier. This stems delirium and had to discontinue the proce- in part from the desire of the person addicted dure after the first day, and another patient to opioids for a rapid, painless procedure, and dropped out before completion. in part from an attempt to coax more such per- The 1990s witnessed a variety of attempts to sons into treatment (fewer than one in five peo- overcome this barrier by using general anes- ple with substance use disorders in the United thesia or heavy sedation. Although the ultra- States are in treatment at any time) (Office of rapid procedure under anesthesia has National Drug Control Policy 2002). Another received wide publicity, controlled studies contributing factor is the American culture’s that would make it possible to evaluate the search for rapidity in most endeavors. Finally, risk/benefit ratio are absent. The procedure the desire for rapid opioid detoxification is a is still unproven and controversial. For a remnant of the belief system of a century ago, brief review of studies done in this area, see when detoxification often was erroneously Stine and colleagues (2003). equated with cure. Rapid methods of detoxification have at their Patient Care and Comfort core the use of narcotic antagonists; for exam- ple, naloxone, naltrexone, or nalmefene, to Opioid detoxification, when properly conduct- precipitate narcotic withdrawal by displacing ed, usually can be concluded without signifi- exogenous opioids (those not produced by the cant patient discomfort. Aside from the com- body itself) from the receptor sites. The ensu- passionate goal of preventing unnecessary suf- ing severe symptoms then are managed by a fering, appropriate opioid detoxification variety of medications and techniques. This strengthens the therapeutic alliance between procedure was tried in the mid-1970s (Blachly the patient and clinician and prevents patients et al. 1975; Resnick et al. 1977), using naloxone from leaving treatment prematurely. combined with benzodiazepines or propranolol Discomfort also can indicate that too low a dose to ameliorate symptoms, but relief was insuffi- of the detoxification agent is being adminis- cient for the technique to be considered useful. tered. Mere symptomatic treatment is not a substitute for reversing opioid withdrawal With the discovery of clonidine as a nonopi- and care should be taken to avoid masking oid that could successfully treat much of the symptoms that would better respond to withdrawal syndrome (Gold et al. 1978), the detoxification. method became more successful, but was still problematic. Using combinations of clonidine, Nevertheless, patients receiving adequate naltrexone, benzodiazepines, and other detoxification doses still may complain of adjunct medications, the method was refined symptoms that can be treated with adjunctive

Physical Detoxification Services for Withdrawal From Specific Substances 73 medications. Insomnia can be treated with Benzodiazepines diphenhydramine (Benadryl) 50 to 100mg, trazodone (Desyrel) 75 to 200mg, or hydrox- and Other Sedative- yzine (Vistaril) 25 to 50mg at bedtime. Benzodiazepines should be avoided unless Hypnotics required for concomitant alcohol or sedative detoxification. Headache, muscle aches, and Intoxication and Withdrawal bone pain can be managed with acetamin- Symptoms Associated With ophen (e.g., Tylenol), aspirin, or ibuprofen Benzodiazepines and Other (e.g., Motrin) as needed. Abdominal cramps are rare when the detoxification dose is suffi- Sedative-Hypnotics cient but can be ameliorated with dicyclomine Patients intoxicated with sedative-hypnotics (e.g., Bentyl) 10 to 20mg every 6 hours. appear similar to individuals intoxicated with Mylanta or Maalox can be administered for alcohol. Slurred speech, ataxia, and poor phys- epigastric complaints and bismuth subcar- ical coordination are prominent. If benzodi- bonate (e.g., Pepto-Bismol) 30 cc can be given azepines are used alone, breath and blood alco- every 2 to 3 hours for diarrhea. Constipation, hol levels should be zero. It should be remem- a frequent complaint during methadone main- bered that benzodiazepines, when ingested tenance, usually can be managed with milk of alone, intentionally, or accidentally in over- magnesia at 30 cc daily. dose, rarely lead to death by themselves. Unfortunately, most individuals who ingest Opioid dependence, particularly intravenous benzodiazepines also may be using alcohol, heroin dependence, is associated with a num- other sedative-hypnotics, or other drugs of ber of medical conditions. For this reason, a abuse, which in combination with benzodi- complete physical examination, review of sys- azepines could be fatal if not managed appro- tems, and laboratory evaluation (when indi- priately. cated) should be conducted. The patient should be screened for tuberculosis as well as Management of benzodiazepines and other for commonly encountered medical complica- sedative-hypnotics in overdose is in part sup- tions. These include HIV/AIDS, viral hepati- ported following principles of ACLS with par- tis (especially B and C), other sexually trans- ticular attention to ventilation. Additionally, mitted diseases, and opportunistic infections. removal of the benzodiazepine from the gas- Injection sites should be examined for infec- trointestinal tract using lavage and a cathar- tion or abscess and patients should be tic is generally carried out, particularly if the queried about night sweats, chills, nutritional overdose is recent. Flumazenil (Romazicon) is intake, diarrhea and gastrointestinal distress, a competitive antagonist that acts at the ben- fever, and cough. History or evidence of trau- zodiazepine receptor. It can reverse the seda- ma also should be elicited as part of a com- tive and overdose effects of benzodiazepines prehensive assessment upon which a full but not of alcohol or other sedative-hyp- treatment plan will be based. In general, notics. The medication is administered via IV patients should be ambulatory and able to by slow push (2 to 3 minutes) and dosage participate in rehabilitative activities during varies, depending on whether one is treating detoxification. However, during the first 24 sedation reversal or overdose coma-reversal. hours they may require bed rest or reduced Flumazenil is only effective in benzodiazepine activity. overdose and is not an effective antidote against other drugs. Clinicians should be aware that in chronic benzodiazepine users who are physically dependent, flumazenil may induce seizures, high blood pressure,

74 Chapter 4 and delirium. So patients who are comatose diazepine are at risk for falls and myocardial from benzodiazepines and are benzodiazepine infarctions. Delirium without marked auto- dependent may move quickly from coma to nomic hyperactivity (no elevations of pulse, acute benzodiazepine withdrawal symptoms blood pressure, or temperature) also may be when flumazenil is administered. seen in the elderly. The management of benzo- diazepine withdrawal is not recommended Assessing the potential or actual severity of a without medical supervision. All benzodi- benzodiazepine and other sedative-hypnotic azepines should be tapered rather than stopped abstinence syndrome is based primarily on abruptly, regardless of dose or duration of clinical information obtained from the patient, use—unless it is a significant others, and physical assessment. matter of use for only Confirmation of length of benzodiazepine treat- a few days (Ashton ment with significant others, local pharmacies, 2002). Patients and treating physicians is useful. Specific name of medication, dose, and duration of therapy intoxicated with are vital. The presence or absence of alcohol Management use is also important to know, as with the use of of other sedative-hypnotics, such as medications sedative-hypnotics for sleep. The existence of co-occurring psychi- Withdrawal atric disorders such as panic disorder also are With appear similar to important factors and should be investigated. Medications Cigarette smoking tends to induce the individuals metabolism of some benzodiazepines and this There are a limited number of controlled can be a factor in scheduling a taper. Physical intoxicated with assessment, with particular attention to mental trials that can pro- vide guidance regard- status, and neurologic exams are important. alcohol. Slurred Determination of vital signs also provides guid- ing the management of benzodiazepine ance. A urine drug screen may confirm the speech, ataxia, presence of benzodiazepines but otherwise will and other sedative- not be particularly helpful. Although sedative- hypnotic withdrawal. hypnotic withdrawal scales have been used in For reviews, see and poor physical research studies, they are not widely available Rickels and col- for clinical practice. leagues (1999) and coordination are Eickelberg and Mayo- Medical complications of withdrawal from ben- Smith (1998). One prominent. zodiazepines include problems similar to those strategy that is appro- seen in alcohol withdrawal. Seizures are partic- priate is to begin with ularly worrisome and may occur without being a slow taper of the preceded by other evidence of withdrawal. As benzodiazepine that the patient already is tak- in alcohol withdrawal, seizures and delirium ing. This taper may be conducted over several represent the most extreme pathology seen. weeks or perhaps even months. This may be Anecdotal reports appearing in the literature effective in cases of long-acting benzodiazepines also have described distortions in taste, smell, but often is not effective in detoxification from and other perceptions. Since many individuals short half-life benzodiazepines. Sometimes who take benzodiazepines have underlying switching to another benzodiazepine in a anxiety disorders, it often is difficult during patient who has had serious loss of control and periods of withdrawal to determine whether abuse problems with his primary agent is ther- symptomatology is related to withdrawal or the apeutic. Another strategy is to switch the emergence of panic attack symptoms. Elderly patient to another benzodiazepine with a long patients who are being withdrawn from benzo- half-life. Frequently chlorodiazepoxide and

Physical Detoxification Services for Withdrawal From Specific Substances 75 clonazepam are recommended. Figures 4-5 and that, in more severe withdrawal syndromes, 4-6 (p. 78) give the equivalent doses of these they do not decrease symptoms. Imipramine medicines along with numerous other sedative- can lower the seizure threshold and therefore hypnotics and benzodiazepines. is not recommended. The use of anticonvul- sants is probably best reserved as an adjunc- Another alternative is phenobarbital substitu- tive medicine to the long-acting benzodi- tion. For patients who have used high doses of azepine or phenobarbital. The use of bus- benzodiazepines for an extended period of pirone for benzodiazepine detoxification is time, hospitalization is always prudent. ineffective and should not be considered. For Outpatient detoxification should be reserved patients with major autonomic symptoms dur- for patients whose doses of benzodiazepines ing withdrawal that cannot be controlled by were mainly in therapeutic ranges, who do not the primary treating agent, consideration of have polysubstance dependence, and who are the use of a low dose of clonidine or propra- reliable and have reliable significant others to nolol may be helpful. aid in monitoring and supervising their progress. In the outpatient setting, patients and Preparing patients and starting detoxification families need to be informed that even with during a period of low external stressors, with sound withdrawal treatment, seizures and patient commitment to tapering, and a plan to delirium are possible. The individual should be manage underlying anxiety disorders, also are instructed not to drive or operate dangerous important in detoxification. A flexible detoxi- machinery during treatment and perhaps for fication schedule is advised. During periods several weeks thereafter. Recurring assessment of increased withdrawal symptoms, dosage will be necessary, particularly around times of should be stabilized or even increased for a dosage reductions. Pregnant patients will need period of days. Frequent in-person or phone to be detoxified slowly and in consultation with contact with the patient is vital. Patients an obstetrician. being detoxified in the outpatient setting may need to be seen several times per week, espe- A variety of cognitive and behavioral tech- cially at times of dosage reductions. niques have been proposed to assist in the pres- ence of a medication taper. These techniques alter negative cognitions regarding medication Stimulants cessation, provide patient education, and pro- vide alternative cognitive and behavioral tech- Cocaine and amphetamines (such as metham- niques for anxiety reduction and sleep phetamine) are the most frequently abused cen- enhancement during detoxification (Spiegel tral nervous system stimulants. These agents 1999). are intensely rewarding and are self-adminis- tered by laboratory animals to the point of Anticonvulsants such as carbamazepine and death. Individuals dependent on stimulants valproate, as well as sedating antidepressants experience profound loss of control over stimu- such as trazodone and imipramine, have been lant intake, presumably in response to the advocated for use in withdrawal (Dickinson et stimulation and disruption of endogenous (orig- al. 2003). Rickels and colleagues (1999) assert inating internally) reward centers (Dackis and that these drugs have some beneficial effect in O’Brien 2001). They often use stimulants in a the management of relatively low-dose benzo- binge pattern that is followed by periods of diazepine discontinuation in their ability to withdrawal. It is not clear whether craving reduce patients’ subjective complaints, but occurs predominantly during stimulant with-

76 Chapter 4 Figure 4-5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents

Generic name Trade name Therapeutic dose Dose equal to Phenobarbital range (mg/day) 30mg of pheno- conversion barbital for with- constant drawal (mg)**

Benzodiazepines

alprazolam Xanax 0.75–6 1 30

chlordiazepoxide Librium 15–100 25 1.2

clonazepam Klonopin 0.5–4 2 15

clorazepate Tranxene 15–60 7.5 4

diazepam Valium 4–40 10 3

estazolam ProSom 1–2 1 30

flumazenil Mazicon *** *** ***

flurazepam Dalmane 15–30* 15 2

halazepam Paxipam 60–160 40 0.75

lorazepam Ativan 1–16 2 15

midazolam Versed *** *** ***

oxazepam Serax 10–120 10 3

prazepam Centrax 20–60 10 3

quazepam Doral 15* 15 2

temazepam Restoril 15–30* 15 2

triazolam Halcyon 0.125–0.50* 0.25 120

* Usual hypnotic dose. ** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dose withdrawal signs and symptoms. *** Not applicable.

Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.

Physical Detoxification Services for Withdrawal From Specific Substances 77 Figure 4-6 Other Sedative-Hypnotics and Their Phenobarbital Withdrawal Equivalents

Generic name Trade Common Dose equal Phenobarbital Conversion name(s) therapeutic to 30mg of for with- constants indication therapeutic drawal (mg)** dose range (mg/day)

Barbiturates

amobarbital Amytal sedative 50–150 100 0.33

butabarbital Butisol sedative 45–120 100 0.33

butalbital Fiorinal, sedative/ 100–300 100 0.33 Sedapap analgesic*

pentobarbital Nembutal hypnotic 50–100 100 0.33

secobarbital Seconal hypnotic 50–100 100 0.33

Others

buspirone Buspar sedative 15–60 *** ***

chloral hydrate Noctec, hypnotic 250–1,000 500 0.06 Somnos

ethchlorvynol Placidyl hypnotic 500–1,000 500 0.06

glutethimide Doriden hypnotic 250–500 250 0.12

meprobamate Miltown, sedative 1,200–1,600 1,200 0.025 Equanil, Equagesic

methylprylon Noludar hypnotic 200–400 200 0.15

* Butalbital usually is available in combination with opioid or non-opioid analgesics. ** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dose withdrawal signs and symptoms. *** Not cross-tolerant with barbiturates.

Source: APA 1990; Wesson and Smith 1985.

78 Chapter 4 drawal or after these symptoms have largely or amphetamine withdrawal and, in part, a disappeared. While the processes that govern reaction to individuals’ acute realization of the addiction to cocaine and amphetamines are devastating psychosocial consequences after a believed to be similar, recent animal research binge ends. While both cocaine and suggests that there are also subtle differences in amphetamine users may experience depression the ways in which these two types of drugs cre- during withdrawal, the period of depression ate sensitization (and perhaps addiction) in reg- experienced by amphetamine users is more ular users (Li et al. 2005). prolonged and may be more intense. Amphetamine users, in particular, should be monitored closely during detoxification for Stimulant Withdrawal signs of suicidality and treated for depression if Symptoms appropriate.

Stimulants are associated with withdrawal Although the literature on cocaine withdrawal symptoms that differ markedly from those seen is controversial, reasonable consensus supports with opioid, alcohol, and sedative dependence the constellation of symptoms depicted in (see Figure 4-7). While most clinicians believe Figure 4-7 (Coffey et al. 2000; Cottler et al. that alcohol and heroin withdrawal should be 1993). These symptoms often disappear after treated aggressively with detoxification, there several days of stimulant abstinence but can has been little emphasis on treating symptoms persist for 3 to 4 weeks (Coffey et al. 2000). In of stimulant withdrawal. Consequently, no addition, since individuals addicted to stimu- medications have been developed for this pur- lants often fail to achieve abstinence, withdraw- pose. This situation is understandable because al symptoms can be a persistent component of stimulant withdrawal usually does not involve active addiction. In addition, individuals medical danger or intense patient discomfort. addicted to stimulants may experience impair- However, if stimulant withdrawal predicts poor ment in hedonic function (ability to experience outcome, it may be a reasonable target for clin- pleasure) that has been ascribed to stimulant- ical interventions. induced disruptions of endogenous reward cen- An often overlooked but potentially lethal ters (Dackis and O’Brien 2002). Research on “medical danger” during stimulant withdrawal animals has found that exposure to high doses is the risk of a profound dysphoria (depres- of methamphetamine results in changes to both sion, negative thoughts and feelings) that may the dopaminergic and serotonergic systems of include suicidal ideas or attempts. This may the brain (Nordahl et al. 2005) and dopamine be, in part, a physiological response to cocaine abnormalities among animals and humans who had been ingesting cocaine (Schuckit 2000).

Figure 4-7 Stimulant Withdrawal Symptoms

•Depresion •Poor concentration •Hypersomnia (or insomnia) •Psychomotor retardation •Fatigue •Increased appetite •Anxiety •Paranoia •Irritability •Drug craving

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 79 Researchers have also observed abnormalities electrocardiogram (between the q wave and the in regions of the brain that govern attention t wave), while QTc is the relative (or “correct- and memory in animals that were regularly ed”) QT interval. Some conditions and many administered methamphetamine (Nordahl et al. drugs (LAAM, other opioids, and even antibi- 2005). otics) can cause the interval to lengthen and this can result in cardiac rhythm disturbances. Although cocaine withdrawal has traditionally Anterior chest pain or cardiac symptoms been viewed as relatively mild (Satel et al. should therefore be fully evaluated in these 1991; Weddington et al. 1990), evidence sug- individuals. Seizures also may be a complica- gests that individuals dependent on cocaine tion of stimulant abuse and can occur during with severe stimulant withdrawal are more like- detoxification. Persistent headaches could rep- ly to have a poor clinical outcome (Kampman resent a subdural, subarachnoid, or intracere- et al. 2001a). The level of withdrawal symp- bral bleed (bleeding in or around the brain) toms, therefore, may be clinically significant and should be appropriately evaluated. It also and should be monitored and recorded for should be emphasized that people who abuse future treatment (Kampman et al. 2001b). stimulants usually become addicted to other Kampman reported significantly higher substances, such as alcohol, sedatives, or opi- dropout rates in individuals dependent on oids, and therefore can experience any of the cocaine who scored high on the Cocaine complications ascribed to detoxification from Selective Severity Assessment (CSSA), a reli- these substances. Covert (secretive) use of able and valid structured interview designed to other substances should be suspected and capture cocaine withdrawal symptoms assessed with urine toxicology. (Kampman et al. 1998). Patients with high scores on the CSSA were five times more likely to leave treatment and four times more likely to Management of Withdrawal resume cocaine use than those with low scores Without Medications (Mulvaney et al. 1999). The CSSA is an easily administered 18-item questionnaire. Each item The most effective means of treating stimulant is a 7-point rating scale, so that a person can withdrawal involves establishing a period of score a number of points on any given ques- abstinence from these agents. Access to brief tion. Scores in excess of 22 indicate the pres- hospitalization, a level of care previously avail- ence of significant cocaine withdrawal. See able for those who abuse stimulants, has been appendix C for more information on the CSSA. largely eliminated by managed care initiatives. Given the poor prognosis associated with In its place, intensive outpatient treatment can cocaine withdrawal, it is reasonable that more assist the patient to cease use long enough for clinical attention be directed toward this phe- withdrawal symptoms to abate entirely. nomenon. Rehabilitative approaches to achieve stimulant abstinence have been reviewed elsewhere (Dackis and O’Brien 2001). The avoidance of Medical Complications of cue-induced craving is particularly important Stimulant Withdrawal in these individuals, especially in light of research that shows limbic activation (activity As previously noted, stimulant withdrawal is in a certain part of the brain) in response to not usually associated with medical complica- cue-induced craving (Childress et al. 1999). It tions. However, patients with recent cocaine also is important that individuals dependent on use can experience persistent cardiac complica- stimulants abstain from other addictive sub- tions, including prolonged QTc interval and stances. vulnerability for arrhythmia and myocardial infarction (Chakko and Myerburg 1995). QT is an interval of time that can be measured on an

80 Chapter 4 Management of Withdrawal or hydroxyzine (Vistaril) 25 to 50mg at bed- With Medications time. Benzodiazepines should be avoided unless required for concomitant alcohol or sedative There are no medications with proven efficacy detoxification. As stimulant withdrawal symp- to treat stimulant withdrawal. However, toms wane, patients are best treated with an researchers have investigated some medications active rehabilitative approach that combines for cocaine detoxification. Amantadine may entry into substance abuse treatment with sup- help reduce cocaine use in patients with more port, education, and changes in lifestyle. severe withdrawal symptoms (Kampman et al. 2000). Modafinil, an antinarcolepsy agent with stimulant-like action, is currently under inves- Other Immediate Concerns tigation by one research group as a cocaine Central nervous system stimulants exert most detoxification agent (Dackis and O’Brien of their toxic effects through vasoconstriction 2002). One small study in Thailand found the (constriction of the blood vessels). antidepressant mirtazapine (Remeron) was Consequently, a number of medical conditions effective at reducing a number of the symptoms can arise from associated with amphetamine withdrawal ischemia (lack of (Kongsakon et al. 2005). None of these medica- proper blood supply) Intensive tions, however, are approved for use in treating or infarction (death stimulant withdrawal and further research is of tissue as the result outpatient needed. Gorelick and colleagues (2004) review of lack of blood sup- the full range of clinical literature on pharma- ply) as a result of cological intervention for cocaine addiction. stimulant use. treatment can Myocardial (heart assist the patient Patient Care and Comfort muscle) infarction and stroke are widely Since stimulant withdrawal is not associated recognized complica- to cease use long with severe physical symptoms, adjunctive tions of stimulant use. medications are seldom required. These However, other prob- enough for patients often are sleep deprived and might be lems such as sponta- unable to benefit from therapeutic activities neous abortion, bowel withdrawal during the first 24 to 36 hours of abstinence. necrosis (tissue They often are hungry and in need of large death), and renal symptoms to abate meal portions initially as their food intake may (kidney) infarction have been inadequate during active addiction. also have been Stimulant users also may be irritable and care reported from entirely. should be taken to avoid needless confrontation cocaine-induced vaso- during the initial withdrawal phase. Headaches constriction. Cardiac often are reported and can be treated symp- arrhythmias also are common. Other medical tomatically. Persistent headaches should be problems that are associated with stimulant evaluated, as cocaine can produce cerebrovas- dependence include dental disease, neuropsy- cular disease. Similarly, chest pain of possible chiatric abnormalities, and movement distur- cardiac origin should be evaluated medically bances/disorders. with electrocardiography, cardiac enzymes, and appropriate medical attention. On occa- Antidepressants, such as selective serotonin sion, patients undergoing withdrawal from reuptake inhibitors, can be prescribed for the cocaine or amphetamines report insomnia and depression that often accompanies metham- may benefit from diphenhydramine (Benadryl) phetamine or other amphetamine withdrawal. 50 to 100mg, trazodone (Desyrel) 75 to 200mg,

Physical Detoxification Services for Withdrawal From Specific Substances 81 Inhalants/Solvents There are no specific assessment instruments available to measure inhalant withdrawal symptoms. A patient who presents with a his- Withdrawal Symptoms tory of inhalant use and symptoms of seda- Associated With tive-like withdrawal should alert the clinician Inhalants/Solvents to the possibility of inhalant withdrawal. These patients require a complete history and The term “inhalants” is used to describe a physical exam. Additionally, a blood alcohol large and varied group of psychoactive sub- level and urine drug screen are helpful in the stances that all share the common characteris- cases of suspected polydrug abuse. tic of being inhaled for their effects. They are commonly found in household, industrial, and medical products. These drugs are used pri- Medical Complications of marily by adolescents, although some, especial- Withdrawal From ly the nitrates, are used by adults as well Inhalants/Solvents (NIDA 2000). Figure 4-8 presents some of the more commonly abused inhalants. There are a large number of medical complica- tions associated with inhalant abuse and intoxi- Dependence on inhalants and subsequent cation. Many of these complications are not the withdrawal symptoms are both relatively result of withdrawal but may still be seen when uncommon phenomena (Balster 2003). There the patient presents to the clinician. Most is no specific or characteristic withdrawal inhalants produce some neurotoxicity with cog- syndrome that would include all drugs in the nitive, motor, and sensory involvement. inhalant class. Intoxication with the solvents, Additionally, damage to internal organs includ- aerosols, and gases often produces a syn- ing the heart, lungs, kidneys, liver, pancreas, drome most like that of alcohol intoxication and bone marrow has been reported. but lasting only 15 to 45 minutes (Miller and Gold 1990). Rarely, symptoms similar to sedative withdrawal have been described, Management of Withdrawal including “fine tremors, irritability, anxiety, Without Medications insomnia, tingling sensations, seizures and It is crucial to provide the patient with an envi- muscle cramps” (Miller and Gold 1990, p. ronment of safety that removes him from access 87). Toluene withdrawal has been reported to to inhalants. This can pose a challenge due to cause delirium tremens (Miller and Gold the almost universal availability of these drugs 1990). Longtime users also may exhibit weak- in society. Many of the medical consequences of ness, weight loss, inattentive behavior, and inhalant usage will remit once the patient depression (NIDA 2005). It has been reported achieves abstinence (Balster 2003). The patient that withdrawal symptoms can occur with as should be monitored for withdrawal symptoms little as 3 months of regular usage (Ron 1986). and changes in mental status. When present, the withdrawal typically lasts 2 to 5 days (Evans and Raistrick 1987). Most patients presenting for treatment of inhalant dependence will be adolescents. In addition to their short-term intoxicating Ideally, they should be entered into an age- affects, nitrates are used to enhance sexual appropriate treatment program that meets pleasure by vasodilation (dilation of blood their medical and psychosocial needs. vessels) that produces a rush and sensation of Supportive care, including helping them to get warmth. There is no withdrawal syndrome enough sleep and a well-balanced diet, usually that has been associated with nitrate abuse. will be sufficient to get patients safely through withdrawal (Frances and Miller 1998).

82 Chapter 4 Figure 4-8 Commonly Abused Inhalants/Solvents Type Example Chemicals in Inhalant/Solvent

Adhesives Airplane glue Toluene, ethyl acetate Other glues Hexane, toluene, methyl chloride, acetone, methyl ethyl ketone, methyl butyl ketone Special cements Trichloroethylene, tetrachloroethylene Aerosols Spray paint Butane, propane (U.S.), fluorocarbons, toluene, hydro- carbons, “Texas shoe shine” (a spray containing toluene) Hair spray Butane, propane (U.S.), chlorofluorocarbons (CFCs) Deodorant; air freshener Butane, propane (U.S.), CFCs Analgesic spray CFCs Asthma spray CFCs Fabric spray Butane, trichloroethane PC cleaner Dimethyl ether, hydrofluorocarbons Anesthetics Gaseous Nitrous oxide Liquid Halothane, enflurane Local Ethyl chloride Cleaning agents Dry cleaning Tetrachloroethylene, trichloroethane Spot remover Xylene, petroleum distillates, chlorohydrocarbons

Degreaser Tetrachloroethylene, trichloroethane, trichloroethylene

Management of Withdrawal has been established, although some clinicians With Medications have found phenobarbital useful (CSAT 1995d). The usefulness of benzodiazepines is Patients presenting with only inhalant with- unknown but would seem a reasonable alter- drawal are unusual. Clinicians should prompt- native given our current understanding of ly ascertain if the patient has been abusing any inhalant withdrawal (Brouette and Anton other substances and proceed with appropriate 2001). No other medications have been rou- detoxification as clinically indicated. When a tinely used for inhalant withdrawal. patient presents with (1) a history of extensive inhalant usage, (2) a sedative-like withdrawal syndrome, and (3) no significant history or lab- Patient Care and Comfort oratory data that supports other substances, For patients who have only been abusing then the clinician can assume that the patient is inhalants, treatment of insomnia during with- in inhalant withdrawal. drawal is not usually necessary. Sedative sub- stitution during the period of detoxification As noted before, withdrawal from inhalants is may allow the patient to sleep. However, a similar to withdrawal from sedative-hyp- period of postdetoxification insomnia should notics. No systematic detoxification protocol be expected and usually can be treated by the

Physical Detoxification Services for Withdrawal From Specific Substances 83 Figure 4-8 (continued) Commonly Abused Inhalants/Solvents Solvents and gases Nail polish remover Acetone, ethyl acetate

Paint remover Toluene, methylene chloride, methanol acetone, ethyl acetate Paint thinner Petroleum distillates, esters, acetone

Correction fluid and thinner Trichloroethylene, trichloroethane

Fuel gas Butane, isopropane

Lighter Butane, isopropane

Fire extinguisher Bromochlorodifluoromethane

Food products Whipped cream Nitrous oxide

Whippets Nitrous oxide

“Room odorizers” Locker Room, Rush, Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal), Poppers cyclohexyl Source: Balster 2003.

recommendation of good sleep hygiene prac- Nicotine tices such as avoiding caffeine, daytime nap- ping, and overstimulation in the evening. In 2004, approximately 44.5 million adults were cigarette smokers (23.4 percent were If the patient is able to refrain from inhalant men and 18.5 percent were women) (CDC (and other substance) use and has no serious 2005a). Nicotine addiction in the form of psychiatric or medical consequences, then cigarette smoking accounts for more deaths outpatient treatment should be the first each year than AIDS, alcohol, cocaine, hero- option. Inpatient or residential treatment in, homicide, suicide, motor vehicle crashes, should be used for those patients who cannot and fires combined (U.S. Department of achieve abstinence or have serious co-occur- Health and Human Services [U.S. DHHS] ring medical or psychiatric disorders. 2000b). Between 1995 and 1999, there were Hospitalized patients will need a thorough 490,000 smoking-related premature deaths history and physical exam. Therapy to annually, and smoking cost the country at address denial, addiction, and pertinent psy- least $157 billion yearly in health-related eco- chosocial issues should be initiated as soon as nomic losses. This amounts to approximately possible during the hospitalization. $7.18 per pack of cigarettes (Fellows et al. Supportive care and abstinence will resolve 2002), a truly staggering figure. most medical problems associated with chron- ic inhalant usage (Balster 2003). Smokers are at increased risk for several medical problems, including myocardial infarction, coronary artery disease, hyperten- sion, stroke, peripheral vascular disease,

84 Chapter 4 chronic obstructive lung disease, chronic drink, and others have shown that continued bronchitis, and several types of cancer (lung, nicotine dependence may be a relapse trigger stomach, head and neck, and bladder). Other for resumption of drinking (Stuyt 1997). The problems associated with nicotine addiction concern that smoking cessation may precipi- include gastro-esophageal reflux disease and tate relapse to other substances of abuse has gastric ulcerations, cataracts, and premature not been supported in the literature (Hughes wrinkling of the skin. There also appears to 1995). be an antiestrogen effect (suppression of an important hormone) that may lead to early Treatment programs that have attempted to development of osteoporosis in women treat nicotine dependence in conjunction with (Okuyemi et al. 2000). other drugs of addiction have met with limit- ed success (Bobo and Davis 1993; Burling et In 1988, the U.S. Surgeon General’s Report al. 1991; Hurt et al. 1994) and have generat- concluded that nicotine is the principal addic- ed increased interest in smoking cessation as tive agent in tobacco. Nicotine binds to nico- a part of a patient’s overall substance abuse tinic acetylcholine receptors in the brain and treatment (Sees and Clark 1993). One study has the direct ability to stimulate the release reported that forcing unmotivated patients of dopamine in the nucleus accumbens area. (or patients who did not consider smoking a The nucleus accumbens has long been consid- problem) to quit was countertherapeutic ered the “reward center” in the brain. This (Trudeau et al. 1995). increase in dopamine is similar to what occurs when patients use stimulants and is felt to be Moreover, it has traditionally been accepted an essential element in the reward process of that nicotine detoxification concurrent with addiction (Glover and Glover 2001). detoxification from other substances makes the undertaking more difficult. Several fac- As many as 90 percent of patients entering tors are involved including the following: (1) treatment for substance abuse are current patient ambivalence and/or lack of interest in nicotine users (Perine and Schare 1999). smoking cessation; (2) physician ambivalence There has long been controversy in the field about the importance of smoking cessation of addiction medicine as to how best to handle early in treatment; (3) staff’s use of nicotine; the problem of nicotine dependence in (4) staff’s ambivalence about the importance patients seeking treatment for other types of of nicotine cessation early in treatment; (5) substance abuse. Traditionally, it has been easy availability of cigarettes from peers, argued that patients would find that trying to family, visitors, staff, and at 12-Step meet- stop smoking while also contending with other ings; (6) lack of sufficient training and exper- (more pressing) addiction problems would be tise on the part of physicians and staff in too difficult and distracting in early absti- managing nicotine withdrawal; and (7) staff nence. However, others argue that nicotine resistance to patient smoking cessation dependence is a lethal disease and that physi- because withdrawal symptoms include irri- cians have the responsibility to intervene in tability, anxiety, and depression, all of which this addiction with the same aggressiveness can make patients more difficult to manage. they show toward other addictive substances. This pro-intervention position has received increasing attention from clinicians, inasmuch Withdrawal Symptoms as it is now understood that alcohol consump- Associated With Nicotine tion is associated with increased nicotine The Diagnostic and Statistical Manual of usage (Henningfield et al. 1984). Gulliver and Mental Disorders, 4th edition, text revision colleagues (1995) have demonstrated that the (DSM-IV-TR) (APA 2000) notes that typically, urge to smoke is correlated with the urge to a person in nicotine withdrawal will have four

Physical Detoxification Services for Withdrawal From Specific Substances 85 or more of the signs presented in Figure 4-9, 4-10) has been reduced to six questions though some clinicians believe that three or (Giovino et al. 1995; Heatherton et al. 1991). more is sufficient to make the diagnosis of Scores greater than seven are consistent with nicotine withdrawal. Furthermore, it should nicotine dependence. be noted that symptoms vary in duration and intensity, with decreased heart rate and light- While both the FTQ and FTND are very use- headedness resolving in 48 hours, while ful for estimating a patient’s physical depen- increased appetite may remain present for dence on nicotine, there is still a need to weeks to months (Glover and Glover 2001). assess more accurately the degree to which Smokers who have severe craving during smoking behavior plays a role in maintaining withdrawal are less likely to be successful in addiction. The Glover-Nilsson Smoking their attempt at quitting (Hughes and Behavioral Questionnaire (GN-SBQ) is an 11- Hatsukami 1992). Depression during with- question, self-administered test that evaluates drawal also has been linked to relapse to the impact of behaviors and rituals associated smoking (Covey et al. 1993). with smoking (see Figure 4-11, p. 88). It was designed to assist clinicians in identifying and quantifying behavioral aspects of smoking Assessing Severity that play a role in maintaining nicotine Since 1978, the standard instrument used to dependence, which can then help the clinician measure physical dependence on nicotine has develop a cessation strategy that takes into been the eight-item Fagerstrom Tolerance account both physical dependence and behav- Questionnaire (FTQ) (Fagerstrom 1978). A ioral dependence (Glover et al. 2002). later revision known as the Fagerstrom Test for Nicotine Dependence (FTND) (see Figure

Figure 4-9 DSM-IV-TR on Nicotine Withdrawal

A. Daily use of nicotine for at least several weeks. B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by 4 or more of the following signs: 1. Dysphoric or depressed mood 2. Insomnia 3. Irritability, frustration, or anger 4. Anxiety 5. Difficulty concentrating 6. Restlessness 7. Decreased heart rate 8. Increased appetite or weight gain C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Source: APA 2000, pp. 244–245.

86 Chapter 4 Figure 4-10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence

Questions Answers Points

1. How soon after you wake up do you smoke your Within 5 minutes 3 first cigarette? 6–30 minutes 2 31–60 minutes 1 After 60 minutes 0

2. Do you find it difficult to refrain from smoking in Yes 1 places where it is forbidden (e.g., in church, at the No 0 library, in the cinema, etc.)?

3. Which cigarette would you hate most to give up? The first thing in the morning 1 All others 0

4. How many cigarettes/day do you smoke? 10 or less 0 11–20 1 21–30 2 31 or more 3

5. Do you smoke more frequently during the first Yes 1 hours of waking than during the rest of the day? No 2

6. Do you smoke if you are so ill that you are in bed Yes 1 most of the day? No 0

Source: APA 1996.

To better understand a patient’s level of nico- tine replacement therapy and patients often tine dependence, providers can assess bio- find it a helpful motivator in their attempt to chemical markers including nicotine, coti- maintain abstinence (Benowitz 1983). nine, and carbon monoxide. Nicotine and its metabolite cotinine can be measured in urine, blood, or saliva. Cotinine continues to be pre- Medical Complications of sent in bodily fluids for up to 7 days after ces- Withdrawal From Nicotine sation. Clinicians should use caution when There are no major medical complications pre- interpreting the meaning of nicotine and coti- cipitated by nicotine withdrawal itself. nine assays, as they are not specific to tobac- However, patients frequently experience co-derived nicotine and may indicate the uncomfortable withdrawal symptoms starting patient’s compliance with nicotine replace- within a few hours of cessation. In addition to ment therapy rather than smoking. the symptoms previously noted, patients may Carbon monoxide is easily measured in complain of increased coughing, a desire for expired breath and can show whether the sweets, and difficulty concentrating (Hughes patient has been smoking within a few hours and Hatsukami 1992). Clinicians should be prior to the test. It can be used to monitor aware that withdrawal symptoms can masquer- smoking cessation for patients receiving nico-

Physical Detoxification Services for Withdrawal From Specific Substances 87 Figure 4-11 The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ)

Please indicate your choice by circling the number that best reflects your choice. 0 = Not at all; 1 = Somewhat; 2 = Moderately so; 3 = Very much so; 4 = Extremely so

How much do you value the following (Specific to Questions 1–2)? 1. My cigarette habit is very important to me. 0 1 2 3 4

2. I handle and manipulate my cigarette as part of the ritual of smoking. 0 1 2 3 4

Please indicate your choice by circling the number that best reflects your choice. (Specific to Questions 3–11). 0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always

3. Do you place something in your mouth to distract you from smoking? 0 1 2 3 4

4. Do you reward yourself with a cigarette after accomplishing a task? 0 1 2 3 4

5. If you find yourself without cigarettes, will you have difficulties in concentrating before attempting a task? 0 1 2 3 4

6. If you are not allowed to smoke in certain places, do you then play with your cigarette pack or a cigarette? 0 1 2 3 4

7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa, room, car, or drinking alcohol)? 0 1 2 3 4

8. Do you find yourself lighting up a cigarette routinely (without craving)? 0 1 2 3 4

9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick, chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or frustration, etc.? 0 1 2 3 4

10. Does part of your enjoyment of smoking come from the steps (ritual) you take when lighting up? 0 1 2 3 4

11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe, secure, or more confident if you are holding a cigarette? 0 1 2 3 4

TOTAL______Scoring for Behavioral Dependence <12 Mild 12–22 Moderate 23–33 Strong >33 Very Strong

Source: Glover et al. 2002

88 Chapter 4 ade as other psychiatric conditions, especially lent pharmaceutical guide. Figure anxiety and depression (see Figure 4-12). 4-13 (p. 90) shows the effects of abstinence from smoking on blood levels of a number of Smoking cessation also may affect the medications. metabolism of other drugs primarily through the Cytochrome P 450 (CYP450) system. This system is one of many hepatic liver enzyme sys- Management of Withdrawal tems that is responsible for the metabolic Without Medications breakdown of various drugs into inactive com- pound products. Different drugs and com- About one third of current smokers attempt pounds have varying affinities for the CYP450 to quit smoking each year and more than 90 system. The higher the affinity, the faster the percent of these try to do so without any for- breakdown of the drug or compound in the mal nicotine cessation treatment. Most smok- body. Some compounds can slow the ers will make several attempts on their own to metabolism or breakdown of other drugs with a quit and ultimately, only about 50 percent are lower affinity, leading to a buildup of that drug successful over a lifetime (U.S. DHHS 2000b). or compound in the body. While some smokers are able to quit on their own, others may require intervention in the During detoxification from nicotine, some form of behavioral treatment and/or pharma- medications will have their metabolism cotherapy. altered, including theophylline, caffeine, tacrine, imipramine, haloperidol, penta- There are insufficient data available to deter- zocine, propranolol, flecainide, and estradiol; mine who will benefit most from a particular in general, these effects are short-lived and type of treatment. Some patients may prefer seldom drastic. Nicotine also reduces beta to stop smoking without the use of medica- blockers’ ability to lower blood pressure and tion. An elevated score on the GN-SBQ would heart rate and decreases the amount of seda- indicate a strong behavioral component to tion from benzodiazepines as well as de- smoking that might guide the clinician in rec- creases the amount of pain relief provided by ommending behavioral treatment as a prima- some opioids, most likely because of its stimu- ry intervention. Patients who also have ele- lant effects (Zevin and Benowitz 1999). A vated FTQ scores may benefit by a combina- complete discussion of nicotine’s effects on tion of behavioral and pharmaceutical inter- medications is beyond the scope of this TIP vention. and physicians are encouraged to consult the Physicians’ Desk Reference (2004) or equiva-

Figure 4-12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With Other Psychiatric Conditions

Anxiety Depression Increased REM (rapid eye movement) sleep Insomnia Irritability Restlessness Weight gain

Source: APA 1996.

Physical Detoxification Services for Withdrawal From Specific Substances 89 Figure 4-13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications

Abstinence Increases Blood Abstinence Does Not Increase Effect of Abstinence on Blood Levels Blood Levels Levels Is Unclear

Clomipramine Amitriptyline Alprazolam Clozapine Chlordiazepoxide Chlorpromazine Desipramine Ethanol Diazepam Desmethyldiazepam Lorazepam Doxepin Midazolam Fluphenazine Triazolam Haloperidol Imipramine Oxazepam Nortriptyline Propranolol

Source: APA 1996.

The U.S. Public Health Service’s Treating interventions alone have not been very suc- Tobacco Use and Dependence: Clinical cessful at helping people achieve abstinence Practice Guideline is a comprehensive review from tobacco. The Guideline suggests, howev- of the smoking cessation literature (Fiore et er, that self-help can be a useful adjunct to al. 2000a). It discusses a range of nonphar- other forms of treatment (Fiore et al. 2000a). macological interventions for the management of withdrawal from nicotine; these can be sep- One type of self-help intervention that shows arated into two basic categories: self-help some promise is the use of computer-generat- interventions and behavioral interventions ed personalized written feedback for patients. (Anderson and Wetter 1997). The computer makes recommendations based on an individual’s response to standardized questions about her smoking (Etter and Self-help interventions Perneger 2001; Shiffman et al. 2000). Many tobacco users prefer to attempt to quit without any assistance from professionals. A Behavioral interventions number of self-help products are available that can assist them in their cessation The U.S. Public Health Service study noted attempts. These include a wide array of pam- that when physicians took as little as 3 min- phlets, manuals, video- and audiotapes (e.g., utes to advise their patients to stop smoking, from the American Lung Association and the long-term quit rates were modestly improved National Cancer Institute), 12-Step self-help from 7.9 percent to 10.2 percent (Fiore et al. support groups, and telephone helplines. The 2000a). Westmaas and colleagues note that U.S. Public Health Service’s Guideline, which “simple, clear advice from a physician can be analyzed all types of self-help interventions considered an easy, cost-effective intervention together, found that the self-help approach to that not only moves smokers closer to the cessation yielded results only slightly better decision to quit, but also may motivate some than no intervention at all. To date, self-help smokers to make an actual attempt”

90 Chapter 4 (Westmaas et al. 2000, p. 58). The greater the effective but not routinely recommended amount of time in face-to-face interventions, (Fiore et al. 2000a). the higher the success rate for patients, but interventions as short as 3 minutes have been found to be effective (Fiore et al. 2000a). A Management of Withdrawal counseling session of longer than 10 minutes With Medications produced a cessation rate of 20.1 percent A U.S. Public Health Service panel recom- compared to a rate of 10.9 percent for no mends that all primary care physicians pro- treatment. The guideline also indicated that if vide a five-step intervention, known as the “5 cessation information is given by multiple A’s,” to all tobacco users. The panel recom- types of providers (e.g., physician, psycholo- mends that all smokers who want to quit gist, dentist, nurse, and pharmacist) it can should be offered active medication that has have a dramatic effect on cessation rates, been approved for assisting in smoking cessa- increasing the rate to 23 percent compared to tion unless there is a medical contraindication 10.8 percent for patients who had no (Fiore et al. 2000a). Figure 4-14 provides a provider contact. summary of the “5 A’s” for brief intervention. A review of behavioral intervention studies concluded that both supportive care by a Nicotine Replacement clinician and the ability of patients to develop problemsolving and coping skills improved Therapy (NRT) success rates for smoking cessation (Anderson Nicotine polacrilex gum was approved by the and Wetter 1997). Other components such as FDA in 1984. In the 1990s other NRTs received cigarette fading (gradually decreasing the FDA approval, including the nicotine transder- number of cigarettes smoked over a period of mal patch, the nicotine nasal spray, and the time), establishing a quit date, enhanced envi- nicotine inhaler. Nicotine gum and nicotine ronmental support, improved diet and transdermal patch are now available over the increased exercise, relaxation training, and counter. After the acute withdrawal period, contingency contracting were not associated patients are then weaned off the medication with improved outcome. Aversive condition- until they become nicotine free. All NRTs are ing, such as rapid smoking techniques, is

Figure 4-14 The “5 A’s” for Brief Intervention

Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.

Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacother- apy to help him or her quit.

Arrange followup. Schedule followup contact, preferably within the first week after the quit date.

Source: Fiore et al. 2000a, p. 26.

Physical Detoxification Services for Withdrawal From Specific Substances 91 effective, with 1-year quit rates between 11 and Bupropion SR 34 percent (Okuyemi et al. 2000). Bupropion SR (Sustained Release) was initially There has been some concern about the manufactured under the name Wellbutrin as a addictive potential of NRTs, and it has been treatment for major depressive disorder. In reported that 5 to 20 percent of patients using 1997, the FDA approved bupropion SR for nicotine polacrilex gum continue to use it for smoking cessation, and it has been marketed more than 1 year (Hughes 1989). There was under the name Zyban. Bupropion is a novel also initial concern that the nicotine nasal antidepressant that is involved primarily with spray, with its rapid onset of action and high dopamine but also affects adrenergic mecha- plasma concentrations, might become a drug nisms in the central nervous system. Its exact of abuse. This has not been reported in the mechanism of action is unknown, but it is not a literature, and it nicotine substitute or replacement like the could be speculated NRTs. The recommended dose is 150mg daily that this is because for 3 days and then 150mg twice daily for 7 to of the nasal spray’s 12 weeks. Typically patients set their quit date relatively uncom- 1 to 2 weeks from the time they start the medi- Patients should be fortable side effects cation in order to get the drug to therapeutic that cause many levels. This is an ideal time for the patient to encouraged to use patients to dislike focus on making behavioral changes and enlist- the product (Schuh ing social support to augment his quit attempt. combined NRT et al. 1997). In gen- Bupropion SR has proven useful in smoking eral, withdrawal cessation with a 12-month abstinence rate of treatments if they symptoms from 35.5 percent compared to a placebo at 15.6 NRTs are mild com- percent and the nicotine patch at 16.4 percent are unable to quit pared to those that (Westmaas et al. 2000). The most commonly occur in smoking reported side effects include dry mouth and using a single type cessation, and con- insomnia. Bupropion SR should not be used in tinued use of these patients with a history of seizures, heavy alco- hol use, head trauma, or with anorexia or of first line products may be the result of patients’ bulimia. fear of returning to pharmacotherapy. active smoking Other nonnicotine (APA 1996). For those patients who pharmacotherapy continue to use Covey and colleagues examined nonnicotine NRTs, providers pharmaceutical products that have been evalu- should balance the patient’s continued depen- ated in controlled trials of smoking cessation dence on nicotine with the considerable (Covey et al. 2000). These drugs include the health benefit of decreasing active tobacco following: usage. It is clear that constituents of tobacco •The alpha-2 agonist antihypertensive, other than nicotine are responsible for caus- clonidine ing cancer. No ill effects have been attributed •The tricyclic antidepressant, nortriptyline to long-term use of nicotine replacement ther- apy (Benowitz and Gourlay 1997). •The monoamine oxidase inhibitor (MAOI) antidepressant, moclobemide •The serotonin 5-HT1A agonist anxiolytic, buspirone

92 Chapter 4 •The antihypertensive CNS nicotinic receptor els, several clinical trials have evaluated the blocker, mecamylamine effectiveness of combining available products. •Oral dextrose tablets The simultaneous use of nicotine gum and the nicotine patch has been evaluated in several Although none of these agents has been studies. Short-term gains in cessation were seen approved by the FDA for smoking cessation, with the combination compared to either medi- clonidine, nortriptyline, and moclobemide have cation alone, but no long-term benefits in absti- all been found to be effective treatments (Covey nence were demonstrated (Anderson and et al. 2000). Clonidine may be a helpful Wetter 1997). Blondal and colleagues (1999) adjunct to nicotine replacement during acute compared the combination of nicotine nasal nicotine withdrawal. Doses of 0.05mg to 0.1mg spray and the nicotine patch to the patch alone three times a day can be tried as tolerated and found that at 3 months 37 percent of the (sedation and low blood pressure are con- patients were smoke free (compared to 25 per- cerns), and the medication needs to be tapered cent for the patch alone). An open-label study when discontinued to avoid rebound hyperten- of the combined use of nicotine inhaler and the sion. nicotine patch found a 12-week cessation rate of 30 percent and good tolerability for the com- The Public Health Service’s Treating bination (Westman et al. 2000). Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al. 2000a) has So-called “combination NRT” involves com- classified nortriptyline and clonidine as sec- bining different types of nicotine replacement ond-line treatments. Clonidine is an antihy- products, such as the patch and gum, on the pertensive and may be appropriate for premise that doing so will boost nicotine patients addicted to certain types of drugs but blood levels. Further rationale for this prac- not appropriate for others. The antidepres- tice is that a “passive” nicotine delivery sys- sant selective serotonin reuptake inhibitor tem (i.e., patch) produces relatively steady (SSRI) fluoxetine has been tested in a number levels of nicotine in the body that prevent the of multisite trials (Cook et al. 2004; Hitsman user from going below a threshold minimum et al. 1999; Niaura et al. 2002) and found to while “active” NRTs (i.e., gum, inhaler, have a small benefit at best, although for spray, sublingual tablet, etc.) permit the user patients who experience mild depressive to respond to situational cravings with ad libi- states it may be a worthwhile adjunctive tum dosing on an acute basis. Several clinical treatment. The usefulness of other SSRIs for trials have evaluated the effectiveness of com- smoking cessation is unknown, but studies bining available NRT products (for a review have generally been unfavorable. More infor- see Silagy et al. 2000). After reviewing avail- mation on smoking cessation for people with able data, the Guideline panel (Fiore et al. co-occurring substance use and other mental 2000a) felt that there was moderately strong disorders can be found in appendix D of TIP evidence to conclude that “Combining the 42, Substance Abuse Treatment for Persons nicotine patch with a self-administered form With Co-Occurring Disorders (CSAT 2005c). of nicotine replacement therapy (either the nicotine gum or nicotine nasal spray) is more efficacious than a single form of nicotine Combination drug therapy replacement, and patients should be encour- Combining NRT products aged to use such combined treatments if they NRT products typically provide less than half are unable to quit using a single type of first- the nicotine plasma levels that cigarette users line pharmacotherapy” (Fiore et al. 2000a, p. achieve through smoking (Benowitz et al. 1997; 77). Dale et al. 1995; Gupta et al. 1995; Lawson et al. 1998). To attempt to increase nicotine lev-

Physical Detoxification Services for Withdrawal From Specific Substances 93 NRT using high-dose nicotine and emotional support to patients attempting patch therapy to quit. Discussing nicotine withdrawal symp- toms can often help allay patient concerns. The highest dose of nicotine available by patch is 22mg. Several studies have evaluated Fear of weight gain is a barrier for many who whether higher doses of nicotine (up to 44mg) want to quit smoking (French et al. 1995). improve abstinence rates. The effect of this This is an especially important issue for strategy has been small and the routine use of women and may deter their attempts to stop higher dose patches is not recommended smoking (Gritz et al. 1989). Though the (Hughes et al. 1999; Killen et al. 1999). health gains of stopping smoking clearly out- weigh the health risks of weight gain, this argument does little to assuage patients’ Combining nicotine patch fears. Dieting during smoking cessation is not and bupropion SR recommended in general and has been shown to increase the likelihood of smoking relapse In a double-blind, placebo-controlled study, (Hall et al. 1992). Physicians should, howev- the combination of bupropion SR and the nico- er, recommend both exercise and proper tine transdermal patch showed higher absti- nutrition for patients attempting to stop nence rates at 12 months (35.5 percent) com- smoking. Patients should be informed that pared to bupropion SR alone (30.3 percent), alcohol use also is considered a risk factor for nicotine patch alone (16.4 percent), or placebo relapse to smoking by most clinicians patch and pill group (15.6 percent) (Jorenby et (Shiffman 1982), and patients who can al. 1999). This combination was well tolerated. abstain from drinking during the withdrawal Clinicians who use this combination should period should do so. first start the patient on bupropion SR 150mg for 3 days and then increase the dosage to Patients generally will find a smoke-free envi- 150mg twice daily for 1 to 2 weeks prior to the ronment helpful during quit attempts. If the day of smoking cessation. On the “quit day,” patient lives in a household where others nicotine patch therapy should be initiated and smoke, household members and friends can the combination treatment continued for 3 to 6 help by not smoking in front of the patient months (Okuyemi et al. 2000). and limiting the number of smoking cues in their residence.

Patient Care and Comfort Patients with more severe nicotine depen- Most smokers attempt cessation on an outpa- dence may benefit from enrollment in a spe- tient basis and without any assistance from cialized smoking cessation program. They professionals. However, if a patient decides might also benefit from more intensive medi- that she or he wants help with smoking cessa- cal management using several drugs (NRT + tion, it is important for the clinician to present anticraving), medication for longer periods of a supportive and nonjudgmental attitude and time, closer followup, and longer enrollment develop a therapeutic alliance with the patient. in treatment. There are a number of cessation It must be emphasized that nicotine depen- programs available from organizations such dence is a chronic relapsing disorder and that as the American Lung Association (www. patients often make several attempts at quitting lungusa.org) and the American Cancer before succeeding. Society (www.cancer.org). Some community and local organizations also sponsor smoking Most smokers who want treatment will seek cessation programs. For the most severely help from their primary care physician. The dependent smokers, there are a limited num- physician has the responsibility of providing ber of residential facilities that treat nicotine pharmaceutical treatment, education about dependence on an inpatient basis (Hurt et al. common problems associated with cessation, 1992). Providers of detoxification services

94 Chapter 4 should be familiar with the programs avail- no immediate medication during the detoxifi- able in their communities in order to make cation period and usually are self-limiting. referrals. However, the clinician should be aware of the potential for more persistent problems. Screening the patient for suicidal ideation or Marijuana and Other other mental health Drugs Containing THC problems is warrant- ed. Some reviews Most experts now Marijuana and hashish are the two sub- have advocated the stances containing THC (delta-9-tetrahydro- use of buspirone as believe that a cannabinol) commonly used today. The field an alternative to of addiction medicine has given considerable benzodiazepines for THC-specific with- attention to the question of whether there is a the management of specific withdrawal syndrome associated with persistent general- drawal syndrome cessation from prolonged THC use. In the ized anxiety (Gatch past, many have stated that there is no acute and Lal 1998). Other does occur in some abstinence syndrome that develops in people common problems who abruptly discontinue THC (CSAT encountered during 1995d). More recently this has been called withdrawal can be patients who are into question and most experts now believe managed with nonad- that a THC-specific withdrawal syndrome dictive, supportive heavy users, does occur in some patients who are heavy medications. For users (Budney et al. 2001), though cannabis patients with more though cannabis withdrawal is not yet included in the APA’s persistent difficulty Diagnostic and Statistical Manual of Mental sleeping, clinical withdrawal is not Disorders. experience suggests that Trazodone may The THC abstinence syndrome usually starts yet included in the be useful. Trazodone within 24 hours of cessation. The amount of can lead to low blood THC that one needs to ingest in order to APA’s Diagnostic pressure upon stand- experience withdrawal is unknown. It can be ing, dizziness, and assumed, however, that heavier consumption may increase falls, and Statistical is more likely to be associated with withdraw- particularly in indi- al symptoms. The most frequently seen symp- viduals over age 60. Manual of toms of THC withdrawal are anxiety, restless- Benzodiazepines and ness and irritability, sleep disturbance, and other addictive medi- Mental Disorders. change in appetite (usually anorexia). Other cations should be symptoms of withdrawal are less frequently avoided. seen and appear to include tremor, diaphore- sis (sweating), tachycardia (elevated heart The patient should be encouraged to maintain rate), and GI disturbances, including nausea, abstinence from THC as well as other addic- vomiting, and diarrhea. Cognitive difficulties tive substances. Some patients will require a including depression also have been reported substance-free, supportive environment to and may persist but usually improve with achieve and maintain abstinence. Clinicians time. There are no medical complications of should educate all patients about the effects withdrawal from THC, and medication is gen- of withdrawal, validate their complaints, and erally not required to manage withdrawal. reassure them that their symptoms will likely improve with time. Symptomatic relief may be Clinicians may see a variety of the symptoms provided in order to increase the patient’s mentioned above, but these generally require comfort.

Physical Detoxification Services for Withdrawal From Specific Substances 95 There are no clinical assessment instruments use. However, neither cessation nor disclo- available that measure THC withdrawal. sure of anabolic steroid use can be assumed Both animal and human studies indicate that when treating these individuals. a withdrawal syndrome starts within 24 hours of cessation and may last for up to a week. Withdrawal Symptoms Associated With Steroids Anabolic Steroids Anabolic steroids can be associated with with- Anabolic steroids, as differentiated from cor- drawal symptoms emerging after their abrupt ticosteroids and female gonadotropic hor- discontinuation. Withdrawal symptoms mones, are androgens (male hormones) and include (in descending order of prevalence) subject to abuse as a means of increasing craving for more steroids, fatigue, depres- muscle mass. These sion, restlessness, anorexia (loss of appetite), agents also can pro- insomnia, reduced libido (sex drive), Interventions duce aggressive, headaches, and nausea (Lukas 1998). It is not manic-like behavior known how commonly this syndrome occurs, directed toward that may include but steroid withdrawal appears more likely in delusions (Lukas heavy users. The clinician’s index of suspi- cessation should 1998). Males cion should be raised when evaluating indi- involved in profes- viduals who are predisposed to steroid misuse involve patient sional sports, and who exhibit these symptoms. Also indica- weight lifting, body tive of possible steroid abuse are certain education regarding building, or other physiological signs of androgen exposure, pursuits that value including hair loss, acne, dysuria (difficult or the dangers and muscular mass are painful urination), small testicles, edema of more likely to use the extremities, and rapid weight gain. medical complica- these substances Females can develop decreased breast size, than are women, acne, virilism (clitoral enlargement, excessive tions of anabolic although use in and abnormal bodily hair growth, male pat- women has been tern baldness) and amenorrhea (suppression steroids, their reported. of menstruation). Males who abuse steroids Adolescents use have been reported to possess a distorted behavioral effects, anabolic steroids to body image and may inaccurately view them- improve their selves as small and weak (Pope et al. 1993). and a thorough appearance and may have increased evaluation of the access to these com- Medical Complications of pounds (Yesalis et Steroid Withdrawal al. 1993). The large patient’s rationale Due to anabolic steroids’ long duration of numbers of anabol- action, side effects that might emerge cannot ic steroid prepara- for misuse. be quickly reversed by the discontinuation of tions that have these substances. Therefore, related side medical and veteri- effects might require medical management nary uses are pri- beyond the simple recommendation that marily obtained illegally through diversion. steroids immediately be discontinued. High doses of anabolic steroids can be medi- Persistent side effects include urinary tract cally dangerous but side effects, usually infections, bladder irritability, skin blistering involving endocrine, liver, central nervous (at the injection site), erythema (abnormal system, and cardiac function, tend to be skin redness) when given as a skin patch, and reversible upon cessation of anabolic steroid

96 Chapter 4 priapism (prolonged erections lasting hours). Patient Care and Comfort The latter condition involves a painful penile erection and constitutes an emergency that Patient comfort during steroid withdrawal can requires specialized medical attention. Edema be achieved by addressing side effects, if pre- (swelling) of the hands or feet, commonly seen sent, that are discussed above. Counseling also with anabolic steroids, can be treated with is a useful intervention and specialized psychi- diuretics (medications that increase urine atric interventions may be necessary. If the flow). Elevated liver function tests and jaun- individual also is using other substances of dice usually resolve with cessation of anabolic abuse, referral to drug or alcohol rehabilitative steroid administration, although hepatic car- treatment should be made. cinoma (cancer of the liver) has been report- ed. Other side effects such as headache, nau- Club Drugs sea, vomiting, acne, insomnia, and lethargy are time-limited and resolve after steroid ces- Club drugs represent diverse classes of drugs sation. Behavioral disturbances, such as psy- that include sedative-hypnotic type agents as chosis or severe aggressiveness, should be well as stimulant/hallucinogens. Club drugs are treated symptomatically with appropriate illicit drugs used in the setting of nightclubs, psychopharmacological interventions. In dance clubs, parties, and “raves.” Raves are extreme cases of psychotic or manic presenta- overnight dance parties, usually with several tions, emergency psychiatric hospitalization hundred people in attendance. might be necessary to address dangerousness Abuse of these drugs by adolescents and to self or others. young adults has risen greatly in recent years. All healthcare professionals need familiarity Management of Steroid with their short- and long-term effects. Withdrawal Although withdrawal syndromes have been reported with some of these drugs, this is not There is no recommended detoxification pro- the most common clinical problem. tocol for anabolic steroids. The key medical Intoxication and severe intoxication with goal is that of persuading the patient to cease overdose are more frequent problems. With steroid misuse. This intervention should be some of these compounds, there appears to be followed by evaluating and treating any side the potential for neurotoxicity (destructive effects (discussed above) that might be pre- effects on the nervous system) and persistent sent. Interventions directed toward cessation psychiatric and neurologic syndromes. At the should involve patient education regarding present time, much of the available informa- the dangers and medical complications of tion regarding club drugs comes from surveys anabolic steroids, their behavioral effects, and anecdotal case reports. Human laborato- and a thorough evaluation of the patient’s ry studies and rigorously controlled clinical rationale for misuse. A family meeting often is trials are not common. helpful if agreed upon by the patient. Unfortunately, education alone often is insuf- One difficulty in assessing the effects of intox- ficient. Patients with distorted body images ication, overdose, withdrawal, and long-term might be especially difficult to dissuade from health consequences of club drugs is that in steroid misuse, and referral to psychotherapy general, there are no baseline evaluations of by a qualified clinician trained in the treat- individuals before they used club drugs. Also, ment of body image disorder should be con- these individuals abuse more than one sub- sidered. Similarly, patients who derive signifi- stance. Some of these patients may have had cant muscle gain from anabolic steroids might moderate to severe psychopathology (includ- be resistant to cessation and may conceal con- ing psychosis) prior to their introduction to tinued steroid use. club drugs. In the past, some club drugs were

Physical Detoxification Services for Withdrawal From Specific Substances 97 referred to as “designer drugs” because of Withdrawal syndromes have not been report- their production in a laboratory rather than ed with hallucinogens; however, considerable being processed from plant products. attention has been paid to residual effects such as delayed perceptual illusions with anx- iety, “flashbacks,” residual psychotic symp- Hallucinogens toms, and long-term cognitive impairment. Hallucinogens are a broad group of sub- Controversies around these issues are not stances that can produce sensory abnormali- important in the clinical setting. The impor- ties and hallucinations. Most hallucinogens tant thing is to determine whether residual have some adrenergic effects as well. symptoms are present and provide an appro- Hallucinogens also are referred to as priate environment and appropriate care for psychedelics and psychomimetics. The more the individual who has them. Generally, staff traditional hallucinogens such as lysergic acid of emergency rooms, clinics that treat people diethylamide (LSD) are considered primarily who abuse substances, and social detoxifica- serotonergic-acting agents. Some of the other tion centers have individuals who are very compounds include phenylethylamines which familiar with “talking down” individuals with have hallucinogenic properties but act like bad hallucinogenic trips. amphetamines as well. These drugs include mescaline and MDMA (3,4-methylenedioxy-N- Acute intoxication and bad trips usually can methylamphetamine). Other drugs include be managed with placement of the individual MDA (3,4-methylenedioxyamphetamine) and in a quiet, nonstimulating environment with DOM (dimethyloxymethylamphetamine). (See immediate and direct supervision so that the section on ecstasy below.) Other hallucinogens patient does not cause harm to herself or to are acetylcholine antagonists. These include others. Occasionally, a low dose of a short- or belladonna, drugs such as benzotrophine intermediate-acting benzodiazepine may be used to treat parkinsonian symptoms, and useful to control anxiety and promote seda- many common over-the-counter antihis- tion. Individuals with chronic depressive-like tamines. reactions may require antidepressant thera- py. Individuals with residual psychotic symp- Hallucinogen intoxication often begins with toms are likely to require antipsychotic medi- autonomic effects, sometimes nausea and cations. On rare occasions, the use of a low vomiting, and mild increases of heart rate, dose, high-potency antipsychotic medication body temperature, and slight elevations of may be required orally or parenterally (any systolic blood pressure. Dizziness and dilated method other than the digestive tract, e.g., pupils may occur. The prominent effects dur- intravenously, subcutaneously, or intramus- ing intoxication are sensory distortions with cularly). Assessment of residual psychiatric illusions and hallucinations. Visual distor- and cognitive symptoms should be made prior tions are more common than auditory or tac- to treatment referral. tile ones. So-called “bad trips” may involve anxiety including panic attacks, paranoid reactions, anger, violence, and impulsivity. Gamma-hydroxybutyrate Either due to delusions or misperceptions, (GHB) individuals may feel they can fly or have spe- GHB use has increasingly been reported in cial powers, and thus injure themselves in night clubs and at raves by adolescents and falls or other accidents. Suicide attempts also young adult populations. GHB is a compound can occur during “bad trips” and possible that is produced in the central nervous sys- suicidal ideation should be carefully evaluat- tem, and it acts as an inhibiting neurotrans- ed, even though it may be quite transient. mitter similar to GABA (Shannon and Quang 2000). In pharmacologic (medication-propor-

98 Chapter 4 tioned) doses, GHB serves as a sedative-hyp- using the substance regularly over a 2-year notic medication. GHB intoxication may look period, and Rosenberg and colleagues (2003) like alcohol or sedative-hypnotic intoxication. note that in severe cases GHB withdrawal may be life-threatening. Although GHB is illegal, psychotropic com- pounds similar to GHB such as gamma- Milder cases of GHB withdrawal syndrome hydroxy lactone (GBL) and 1,4-butanediol may be managed with benzodiazepines such (1,4-BD) are widely available chemical com- as lorazepam and supportive care. However, pounds and may be obtained through catalogs in more severe cases high doses of intra- and the Internet. These compounds produce venous benzodi- effects similar to those of GHB. At the pre- azepines (e.g., sent, overdose syndromes are more likely to lorazepam) or barbi- Withdrawal be seen than withdrawal syndromes. turates (e.g., pheno- Overdose syndromes may require airway and barbital, pentobar- syndromes have not respiratory management. GHB has been stud- bital) may be ied in Europe (Addolorato et al. 1999a) in a required (Miotto been reported with randomized, single-blind study comparing it and Roth 2001; to diazepam as a treatment for alcohol with- Rosenberg et al. hallucinogens; drawal. GHB was as effective as diazepam in 2003). Patients suppressing alcohol withdrawal symptoms experiencing GHB however, consider- and was said to be quicker in reducing anxi- withdrawal are like- ety and agitation with less sedation than ly to have a high tol- able attention has diazepam. Because of its history of abuse in erance for the seda- the United States, it is unlikely to be viewed tive effects of benzo- been paid to as a therapeutic agent any time in the near diazepines and future. require large and residual effects such frequent doses to Miotto and Roth (2001) describe a GHB with- manage the with- as delayed drawal syndrome, noting that it shares fea- drawal (Miotto and tures of both alcohol and benzodiazepine Roth 2001); in cases perceptual illusions withdrawal. They have found this syndrome where high doses of most pronounced in patients who have taken lorazepam prove with anxiety, GHB around-the-clock, at 2- to 4-hour inter- ineffective, pento- vals. The GHB withdrawal syndrome has the barbital may be “flashbacks,” prolonged duration of symptoms found in effective (Sivilotti et benzodiazepine withdrawal and features al. 2001). Clonidine residual psychotic delirium tremens that appear early (often may be used to treat within an hour) with peak manifestations episodes of tachy- symptoms, and occurring within 24 hours; the delirium may cardia (rapid heart last up to 14 days. Confusion, psychosis, and rate) (Miotto and long-term cognitive delirium are the most prominent features of Roth 2001). GHB withdrawal, and the autonomic effects impairment. (i.e., tremor, diaphoresis [sweating], hyper- tension, and temperature changes) are less Ecstasy severe than found in alcohol withdrawal. MDMA (3, 4-methylenedioxy-metham- They note that brief periods of significant phetamine) commonly known as ecstasy, was tachycardia (rapid heart rate) begin early in synthesized around the turn of the century and GHB withdrawal. Garvey and Fitzmaurice patented by Merck Pharmaceuticals in 1914 (2004) also report seizure activity in a case of (Christophersen 2000; Parrot et al. 2000). GHB withdrawal in a male who had been These drugs are phenel-ethylene stimulants

Physical Detoxification Services for Withdrawal From Specific Substances 99 with various substitution groups off the ben- tured illicitly as oral drugs of abuse. PCP fre- zene ring that give the medications hallucino- quently is sold as LSD. genic properties. There are a number of relat- ed compounds that are designated by their ini- Some studies have found that ketamine and tials (MDMA, MDA, MDEA, DOM, 2-CB, and PCP act specifically at the MDMA/glutamate DOT). Clinicians are likely to have to manage receptor as noncompetitive MDMA receptor the complications of intoxication and overdose antagonists. Research in animals indicates but not withdrawal. that both drugs are reinforcing, in that ani- mals will press a bar to obtain doses of either Patients using MDMA or related compounds drug. Furthermore, in these same animal frequently are hyperactive and hyperverbal, models, abstinence syndromes have been reporting heightened tactile and visual sensa- observed. Withdrawal symptoms in humans tions. They frequently will use camphor on have included depression, drug craving, the skin in facial masks, gloves, and other increased appetite, and hypersomnolence clothing to heighten their tactile sensations. (excessive sleep). Sometimes light sticks are used to heighten visual experiences at raves. Hyperthermia, In the clinical setting, syndromes of acute dehydration, water intoxication with low sodi- intoxication with hallucinations, delusions, um, rhabdomyolysis (severe muscular injury agitation, and violence are the most pressing and breakdown of muscle fibers), renal fail- problems. A human laboratory study (Lahti ure, cardiac arrhythmia, and coma have been et al. 2001) conducted a comparison of reported. ketamine and placebo in normal volunteers never exposed to ketamine and to people with MDMA has been proven to be toxic to sero- schizophrenia with a previous history of tonergic neurons in several animal studies. ketamine use. In both groups, ketamine pro- Heavy ecstasy users can have paranoid think- duced a dose-related, but brief, increase in ing, psychotic symptoms, obsessional think- psychotic symptoms. The magnitude of ing, and anxiety (Parrott et al. 2000). ketamine-induced positive psychotic symp- Impaired cognitive performance in heavy toms was similar for both groups, although ecstasy users also has been identified the schizophrenia group had higher baseline (Gouzoulis-Mayfrank et al. 2000). Ecstasy scores. users performed more poorly than control groups in complex attention, memory, and Although originally MDMA receptor antago- learning tasks. The duration or permanence nists were felt to have neuroprotective effects of such effects has not yet been well studied. (preventing damage to brain cells) and have been explored as post-stroke medications, there is some evidence now that ketamine and Ketamine and PCP PCP may in fact have some neurotoxic (Phencyclidine) effects. Studies (e.g., Curran and Monaghan 2001) have found greater memory impairment Ketamine and PCP (phencyclidine) were both among chronic ketamine users than infre- developed in the 1950s as anesthetic agents for quent ketamine users. Acute human laborato- humans. Phencyclidine was briefly marketed ry studies by this group indicate persistent for human anesthetic use but taken off the memory impairment with ketamine exposure. market because of an unusual high incidence of This same study did not find persistent psy- psychotic symptoms. PCP remains in legitimate chotic features beyond acute use. use for veterinarian anesthesia for large ani- mals as does ketamine for small animals. In the clinical setting, ketamine and PCP use Although both drugs were originally developed require management for the agitation and for intravenous use, they are now manufac- psychotic features produced during acute use. Occasionally, patients will have such large

100 Chapter 4 overdoses, intentionally or accidentally, that In an evaluation of admissions to publicly they will require airway management and funded detoxification programs in ventilatory support for some hours. The Massachusetts between 1984 and 1996, behavioral management of the agitation and McCarty and colleagues (2000) found a steady violence that may be seen is best managed in increase in the number of patients using both a controlled environment with limited stimuli alcohol and other substances in the month and very close supervision. Occasionally, oral prior to admission. In 1988, 26 percent of or parenteral uses of sedating medications admissions reported using two or more sub- such as benzodiazepines will be required. In stances in the previous month; by 1996 that extreme cases, restraints may be required for number had nearly protection of the patient and staff. doubled to 50 per- cent (McCarty et al. Following acute management, assessment of 2000). There is no One of the most persistent mood and cognitive effects must be reason to believe that made prior to any treatment attempts. The this trend has not significant changes persistence of psychotic symptoms may repre- appeared elsewhere sent an underlying psychiatric disorder that in this country. As in detoxification may require medication treatment. There are Miller and colleagues no studies to guide the treatment of ketamine (1990a) note, “For services in recent or PCP detoxification. The need to manage the contemporary withdrawal symptoms from these drugs is drug addict, multiple unlikely, but if it should arise, benzodi- drug use and addic- years has been the azepines should be administered. tion that includes alcohol is the rule” increase in the Other (p. 597). number of Rohypnol is a benzodiazepine that is sold In the Massachusetts under trade names in Europe and Mexico as a evaluation, which patients requiring sedative-hypnotic. Rohypnol is occasionally did not include mari- used as a club drug and at dance clubs. In the juana or nonopioid last decade it began to be smuggled into the prescription medica- detoxification United States and was commonly used among tion use, the most homeless youth involved in the sex industry. commonly seen com- from more than Rohypnol has a reputation as a “date rape” bination of sub- drug because it can produce powerful amnestic stances was alcohol one substance. and hypnotic effects, as well as coma. For fur- and cocaine. Thirty ther details on benzodiazepines, see the benzo- percent of patients diazepine section regarding intoxication and admitted for detoxifi- potential withdrawal reactions. cation in 1996 reported using this combina- tion; 12 percent used alcohol, cocaine, and heroin together; 10 percent combined alcohol Management of and cocaine; and 7 percent combined heroin Polydrug Abuse: An and cocaine (McCarty et al. 2000). Other studies, evaluating patient populations at Integrated Approach inpatient treatment centers, found that One of the most significant changes in detoxi- between 70 and 90 percent of patients who fication services in recent years has been the reported cocaine abuse also abused alcohol. increase in the number of patients requiring Rates of alcohol dependence among detoxification from more than one substance. methadone patients and patients dependent on heroin were between 50 and 75 percent,

Physical Detoxification Services for Withdrawal From Specific Substances 101 An Example of Potential Problems: Detoxification for Polydrug Abuse

Mr. L is a 43-year-old male with a 25-year heroin dependence. He is well known to the detoxification center, having been through the program there (which consisted primarily of support and hydration) on many occasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time he arrived, his course usually was about the same: 2 or 3 days of serious stomach cramps, nausea, and diar- rhea, then a few days of feeling poorly, and then a return to the community. This time, however, was differ- ent. He looked “sicker” than usual. Mr. L usually was a compliant patient; now he was hostile and belliger- ent. He seemed to be talking to himself and did not seem as alert as he should have been. The staff asked him several times if he had used anything else and each time he denied it. His drug of choice was always heroin—he drank alcohol once in a while, and occasionally smoked marijuana when he could not get any- thing else. On the third day of detoxification, Mr. L seemed acutely more ill. On his way to the bathroom he was observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand mal seizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates, opioids, and trace amounts of benzodiazepines

and 80 to 90 percent who were being treated Prioritizing Substances of for cannabis abuse also reported alcohol Abuse abuse (Miller et al. 1990a). While substances of abuse may have complex Clinicians need to be constantly aware that a interactions, it is not always possible to deter- patient may be abusing multiple substances. mine how those interactions will affect with- Even if a patient admits the abuse of one sub- drawal. Therefore, it is generally best practice stance he may not admit to using others. to prioritize the substances an individual has Patients may not see that other substances been dependent on and treat them sequentially are a problem, they may be worried about the according to the severity of the withdrawal pro- legal consequences of use, or they sometimes duced by the substance. The substances with may not even be aware of what substances the most serious withdrawal syndromes, those they have been using. For these reasons, clin- where the withdrawal syndrome can be fatal, icians should not rely on patients’ self-reports are alcohol and the sedative-hypnotics. When to determine which substances are being detoxifying a patient who has been dependent used. Interviews with family, friends, or oth- upon multiple substances, the sedative-hyp- ers who know the patient may be helpful, but notics must be addressed first. these also are insufficient. The consensus panel strongly recommends that all patients Oral methadone, LAAM, or buprenorphine receive an immediate urine drug screening should be used to stabilize withdrawal from upon admission to a detoxification program to opioids while tapering the dose of the seda- determine the types of substances being tive-hypnotic or anxiolytic (anti-anxiety medi- abused. It is not necessarily true that the per- cation) by 10 percent each day. After the son is drug free simply because a drug is not patient has been tapered off of the sedative- detected on a drug screen. It is possible that hypnotic or anxiolytic, withdrawal from the the toxicology is not able to detect the class or substitute opioid can begin (Wilkins et al. type of drug. Staff should be aware of what 1998). Some patients can successfully be the program/detoxification center/hospital detoxified from both sedative-hypnotics and tests for, what is not tested for, what cannot opioids simultaneously, but this requires a be tested for or found, and the limitations of great deal of medical and nursing attention. “dip” tests. Most patients will benefit from opioid mainte-

102 Chapter 4 nance for an extended period of time follow- screening, even a hand-held screening, can be ing the completion of sedative withdrawal. an expensive item for what often is a very limit- ed budget. Besides, in this case, the patient was If the patient has been abusing multiple seda- believed to be a known quantity—someone who tive-hypnotic substances or a sedative-hypnotic only used heroin. and alcohol, withdrawal should be handled in the same way as withdrawal from one such sub- This scenario is not uncommon. It is likely that stance. The patient should be administered a the patient himself was unaware of what was in regularly decreasing dosage of sedative-hypnot- his body. One of the more frightening facts con- ic, usually a benzodiazepine that the clinician is cerning the purchase of illicit drugs is the lack comfortable with and accustomed to using. The of knowledge of what is in them. To make buy- dosage should be decreased according to the ers believe that they are buying a higher-quali- patient’s physiologic response. Providers also ty product than they are, drugs often are cut may administer an anticonvulsant such as car- with adulterants (inferior ingredients) that can bamazepine (Tegretol XR), even in the absence produce effects similar to the drug they think of epilepsy or withdrawal seizures, to help they are buying. In this case, Mr. L may have ensure patient safety (Wilkins et al. 1998). been buying barbiturates and benzodiazepines Phenobarbital also may be used for detoxifying in his heroin for some time without knowing it, patients who have been abusing both alcohol a fact that could have had deadly conse- and benzodiazepines. When the dose of alcohol quences. Both are sedating and could have and sedative-hypnotics that a patient is taking given him some of the comfortable sedation and is not known, tolerance testing as previously euphoria he was seeking from his drug of described can be helpful in determining the choice. Unfortunately, however, where opioid dose of phenobarbital. withdrawal is not life-threatening, withdrawal from barbiturates can be. Furthermore, he When treating patients detoxifying from sub- could have gotten PCP in the marijuana he stances other than sedative-hypnotics, manage- occasionally used, again without knowing it. ment of opioid detoxification should be the next priority. Generally, other substances of abuse, including stimulants, marijuana, hallucinogen- Alternative ics (LSD and similar drugs), and inhalants, will not require specific treatment in patients who Approaches are being detoxified from sedative-hypnotics Alternative methods that have been studied sci- and/or opioids. entifically do not claim to be stand-alone with- drawal methods, nor stand-alone treatment Patients may abuse a wide range of substances modalities. Alternative approaches are in various combinations, and the clinician must designed to be used in a comprehensive, inte- be vigilant in assessing and treating withdrawal grated substance abuse treatment system that from multiple substances. The case study above promotes health and well-being, provides pal- illustrates some of the serious problems the liative symptom relief, and improves treatment clinician faces in evaluating and treating retention. Therefore, because isolation of any patients withdrawing from multiple substances. of these approaches as an independent variable In the private sector, where money for toxico- in rigorous controlled studies is difficult, if not logical screening is readily available, the first impossible, there are no conclusive data on the question many would ask concerning the case effectiveness of alternative methods of Mr. L. is, “Why wasn’t the drug screen done (Trachtenberg 2000). sooner?” However, those working in public Auricular (ear) acupuncture has been used facilities will recognize that such screenings throughout the world, beginning in Hong Kong, often are unavailable or available only after an as an adjunctive treatment during opioid extended turnaround time. Toxicological

Physical Detoxification Services for Withdrawal From Specific Substances 103 detoxification for about 30 years. Its use in the choosing outpatient programs with acupunc- United States originated in California ture were less likely to relapse in the 6 (Seymour and Smith 1987) and New York months following discharge than were patients (Mitchell 1995) but has not been subjected to who had chosen residential programs rigorous controlled research. One report (Shwartz et al. 1999). (Washburn et al. 1993) noted that patients dependent on heroin with mild habits appeared Ear acupuncture detoxification, which was to benefit more than those with severe with- originally developed as an alternative treat- drawal symptoms, which acupuncture did not ment for opioid agonist pharmacotherapy, is alleviate. The 1997 National Institute of Health now augmenting pharmacotherapy treatment Consensus Statement on acupuncture stated for patients with coexisting cocaine problems that acupuncture treatment for addiction could (Avants et al. 2000). The advocates of be part of a comprehensive management pro- acupuncture have joined with the advocates gram. The National Acupuncture of opioid agonist pharmacotherapy to create a Detoxification Association has developed holistic synthesis. Each has contributed to the acupuncture protocols involving ear acupunc- success of the other, both clinically and in ture in group settings that originated at Lincoln public perception. Hospital in the Bronx and are used by over 400 Care must be taken to ensure sterile acupunc- drug treatment programs and 40 percent of ture needles in the heroin-dependent popula- drug courts. SAMHSA’s National Survey of tion, given the high incidence of HIV infec- Substance Abuse Treatment Services (NSSATS) tion, viral hepatitis, and other infections. found that 5.4 percent of the 13,720 facilities Acupuncture is not recommended as a stand- polled in 2001 offered acupuncture as a service alone treatment for opioid withdrawal. (Office of Applied Studies 2002b). Other alternative management approaches Acupuncture is one of the more widely used that are not supported by controlled studies alternative therapies within the context of include neuroelectric therapy (the adminis- addictions treatment. It has been used as an tration of electric current through the skin) adjunct to conventional treatment because it and herbal therapy. In fact, the former has seems to reduce the craving for a variety of been shown to be no better than placebo in a substances of abuse and appears to con- controlled study (Gariti et al. 1992). The use tribute to improved treatment retention rates. of herbs for healing purposes dates back to In particular, acupuncture has been viewed the dawn of civilization, while the use of as an effective adjunct to treatment for alco- herbs in the treatment of substance abuse has hol and cocaine disorders, and it also has been documented since 1981 in methadone played an important role in opioid treatment programs, free clinics, therapeutic communi- (i.e., methadone maintenance). It is used as ties, outpatient programs, and hospitals an adjunct during maintenance, such as when (Nebelkopf 1981). Herbal remedies are used tapering methadone doses. The ritualistic in substance abuse detoxification and treat- aspect of the practice of acupuncture as part ment in a number of cultures around the of a comprehensive treatment program pro- world. However, in no scientific studies have vides a stable, comfortable, and consistent herbs been isolated as a discrete variable to environment in which the client can actively test their efficacy. Much research is currently participate. As a result, acupuncture being conducted on the effectiveness of herbal enhances the client’s sense of engagement in medicine on a wide variety of physical the treatment process. This may, in part, conditions. account for reported improvements in treat- ment retention (Boucher et al. 2003). A 1999 CSAT-funded study showed that patients

104 Chapter 4 Considerations for strong linkages to agencies that provide the above-mentioned services and should set up Specific Populations systems to ensure that pregnant women can All individuals undergoing detoxification are access the additional services they need. especially vulnerable. Patients who experience Pregnant women who present for detoxification negative attitudes from staff may experience will benefit from a comprehensive medical further loss of self-esteem, may leave detoxifi- examination that includes a careful obstetrical cation prematurely, or may experience other component. Since it is estimated that approxi- psychologically damaging feelings. Negative mately 44 to 70 percent of women who abuse experiences can undermine the recovery pro- substances have a his- cess. It is important to recognize that individu- tory of physical, emo- als do not fit into just one population category. tional, and sexual Pregnant women A person will be a member of several popula- abuse (Moylan et al. tions (e.g., a Latina woman who is pregnant, 2001; Stevens et al. who present for bisexual, and has psychiatric diagnoses of post- 1997), care should be traumatic stress disorder and major depres- given to the comfort sion) and may benefit from a number of the of the patients during detoxification will considerations discussed below. It also should the examination. One be noted that the information in the specific of the major internal benefit from a populations sections should not be used to cate- barriers that prevents gorize individuals or leave the reader with the pregnant women from comprehensive impression that the information below will fit seeking treatment is all individuals who are members of a group. the shame and stigma medical examina- attached to substance Pregnant Women use, especially during tion that includes pregnancy. Any nega- While in detoxification, pregnant women tive experience a careful should receive comprehensive medical care, encountered during especially since this may be the first time they detoxification can have sought any type of care or treatment. lead these women to obstetrical Ideally, programs detoxifying pregnant women leave treatment and from alcohol and illicit drugs should include not return. component. the following services: •Detoxification on demand Detoxification during pregnancy poses a •Woman-centered medical services special risk in that •Transportation services to and from detoxifi- care should be taken cation (as well as to substance abuse treat- to ensure the health and safety of both the ment afterward) mother and fetus. From a clinical standpoint, •Childcare services before giving any medications to pregnant •Counseling and case management services women it is of vital importance that they understand the risks and benefits of taking •Access to drug-free, safe, affordable housing these medications and sign informed consent •Help with legal, nutritional, and other social forms verifying that they have received and service needs understand the information provided to them. Since pregnant women often present to treat- While it is recognized that provision of all of ment in mid- to late-second trimester and poly- these services is an ideal to be striven for, at a drug use is the norm rather than the exception minimum detoxification programs must have (Jones et al. 1999), it is important first to

Physical Detoxification Services for Withdrawal From Specific Substances 105 screen these women for dependence on the two naltrexone, naloxone, or nalmefene adminis- classes of substances that can produce a life- tration during pregnancy. Although propra- threatening withdrawal: alcohol and sedative- nolol (Inderal), labetalol (Trandate), and hypnotics. Pregnant women should be made metoprolol (Lopressor) are the beta blockers aware of all wraparound services that will of choice for treating hypertension (high assist them in dealing with newborn issues, blood pressure) during pregnancy including food, shelter, medical clinics for inoc- (McElhatton 2001), the impact of using them ulations, as well as programs that will help with for alcohol detoxification during pregnancy is developmental or physical issues that the unclear. The use of SSRIs, a class of antide- neonate (newborn baby) may experience as a pressant medication, is safer for the mother result of substance and fetus than are tricyclic antidepressants exposure. (Garbis and McElhatton 2001). Fluoxetine (Prozac) is the most studied SSRI in pregnan- A National cy and no increased incidence in malforma- Alcohol tions was noted, nor were there neurodevel- Institutes of When pregnant opmental effects observed in preschool-age women are detoxi- children (Garbis and McElhatton 2001). Health consensus fied from alcohol, However, possible neonatal withdrawal signs benzodiazepine have been observed. Given that the greatest panel tapers appear to be amount of data are available for fluoxetine, the current practice this is the recommended SSRI for use during recommended of choice. The cur- pregnancy (Garbis and McElhatton 2001). rent state of knowl- The use of anticonvulsants, such as valproic methadone edge suggests that benzodiazepine acid, is associated with several disfiguring therapy in general malformations. If this type of medication maintenance as does not have as must be used during pregnancy, the woman much of a terato- must be told that there is substantial risk of the standard of genic (producing a malformations (Robert et al. 2001). deformed baby) risk Barbiturate use during pregnancy has been care for pregnant as do other anticon- studied to some extent, and phenobarbital is vulsants as long as used therapeutically during pregnancy, but women with they are given over the risk of any anticonvulsive medication a short time period. should be discussed with the patient (Robert et al. 2001). There also are reports of a with- opioid It appears that short-acting benzo- drawal syndrome in the neonate following prenatal exposure to phenobarbital (Kuhnz et dependence. diazepines, like the ones described to al. 1988). treat alcohol with- drawal above, can Opioids be used in low doses for acute uses such as detoxification, even in the first trimester While it is not recommended that pregnant (Robert et al. 2001). Long-acting benzodi- women who are maintained on methadone azepines should be avoided—their use during undergo detoxification, if these women the third trimester or near delivery can result require detoxification, the safest time to in a withdrawal syndrome in the baby (Garbis detoxify them is during the second trimester. and McElhatton 2001). For further information, consult the forth- coming TIP Substance Abuse Treatment: Although no teratogenic effects have been Addressing the Specific Needs of Women observed, little is known about the effects of (CSAT in development e) and TIP 43

106 Chapter 4 Medication-Assisted Treatment for Opioid but may be associated with a withdrawal syn- Addiction in Opioid Treatment Programs drome in the neonate (Jones and Johnson (CSAT 2005d). In contrast, it is possible to 2001). detoxify women dependent on heroin who are abusing illicit opioids by using a methadone A National Institutes of Health consensus taper. panel recommended methadone maintenance as the standard of care for pregnant women Before starting a detoxification, women with opioid dependence. Methadone currently should weigh the risks and benefits of detoxi- is the only medication recommended for med- fication, since many women eventually ication-assisted treatment for pregnant relapse to drug use and thus place themselves women. Clinical trials are being conducted to and their fetuses at risk for adverse conse- determine the efficacy and safety of quences (Jones et al. 2001b). During pregnan- buprenorphine with pregnant women but it cy, the protein binding of many drugs, includ- has not yet been approved for use with this ing methadone and diazepam (a benzodi- population. Two early studies on treatment of azepine), is decreased (e.g., Adams and pregnant women with opioid dependence with Wacher 1968; Dean et al. 1980; Ganrot 1972) buprenorphine showed promising results with the greatest decrease noted during the (Fischer et al. 2000; Johnson et al. 2001). third trimester (Perucca and Crema 1982). Comer and Annitto (2004) conclude, from This decreased binding may be due to the their review of the research literature, that decreased levels of albumin reported during buprenorphine should be used more aggres- pregnancy (Yoshikawa et al. 1984). From a sively to detoxify pregnant women who want clinical standpoint, it may be that pregnant to be opioid-free at delivery. women could be at risk for developing greater toxicity and side effects, yet at the same time Because of the potential for premature labor an increase in metabolism of the drug may and delivery and risks of morbidity and mor- result (such as found with methadone). This tality to the fetus related to withdrawal from may result in reduced therapeutic effect from opioids, it is recommended that a pregnant the drug, since many women require an woman who is dependent on opioids be main- increase in their dose of methadone during tained during pregnancy (Kaltenbach et al. the last trimester (Pond et al. 1985). 1998). Other reasons to stabilize a pregnant woman on methadone rather than attempt Other medications used to treat the withdraw- withdrawal are the risks of relapse, conse- al signs and symptoms include clonidine. quences associated with HIV and use of multi- Clonidine is used as a second-line drug to ple needles, and the potential lack of prenatal treat hypertension (high blood pressure) dur- care. ing pregnancy and appears to lack teratogenic effects (McElhatton 2001). It has reportedly The Federal government mandates that pre- been abused by pregnant women. Some preg- natal care be available for pregnant women nant women take clonidine with their on methadone. It is the responsibility of treat- methadone because it is hard to detect in ment providers to arrange this care. More urine and it increases the high they get from than ever, there is need for collaboration methadone. However, little is known about its involving obstetric, pediatric, and substance effects on the baby following therapeutic abuse treatment caregivers. Comprehensive doses given in a detoxification context or care for the pregnant woman who is opioid doses taken in higher than therapeutic dependent must include a combination of amounts (Anderson et al. 1997a). methadone maintenance, prenatal care, and Buprenorphine has been examined in preg- substance abuse treatment. nancy and appears to lack teratogenic effects

Physical Detoxification Services for Withdrawal From Specific Substances 107 Pregnant women should be maintained on an Specific Needs of Women (CSAT in develop- adequate (i.e., therapeutic) methadone dose. ment e). There is a documented withdrawal An effective dose prevents the onset of with- syndrome in neonates who have been prena- drawal for 24 hours, reduces or eliminates tally exposed to benzodiazepines (Sutton and drug craving, and blocks the euphoric effects Hinderliter 1990), and this syndrome may be of other narcotics. An effective dose usually is delayed in onset more than that associated in the range of 50–150mg (Drozdick et al. with other drugs. 2002). Dosage must be individually deter- mined, and some pregnant women may be able to be successfully maintained on less Stimulants than 50mg while others may require much The principles of detoxification from stimulants higher doses than 150mg. The dose often such as cocaine are the same for pregnant and needs to be increased as a woman progresses nonpregnant women. Since there is no current through gestation, due to increases in blood pharmacotherapy to use in tapering individuals volume and metabolic changes specific to from stimulant use, the use of any medications pregnancy (Drozdick et al. 2002; Finnegan to treat medical complications that might arise and Wapner 1988). from the withdrawal should only be done after discussion with the patient of the risks and ben- Generally, dosing of methadone is for a 24- efits of each medication. hour period. However, because of metabolic changes during pregnancy it might not be pos- sible to adequately manage a pregnant woman Solvents during a 24-hour period on a single dose. The principles of detoxification from solvents Split dosing, particularly during the third are the same for pregnant and nonpregnant trimester of pregnancy, may stabilize the women. It should be noted that based on a woman’s blood methadone levels and effec- review of case reports, there is a complex tively treat withdrawal symptoms and crav- array of characteristics that appear to be sim- ing. ilar to fetal alcohol effects. Fetal Alcohol Breastfeeding is not contraindicated for Syndrome (FAS) is characterized by growth women who are on methadone. Very little deficiency (born small for gestational age; methadone comes through breast milk; the failure to grow at a normal rate), particular American Academy of Pediatrics (AAP) facial features (e.g., eyes are too close togeth- Committee on Drugs lists methadone as a er, ears are set low on the head), and CNS “maternal medication usually compatible with dysfunctions (mental retardation, microen- breastfeeding” (AAP 2001, pp. 780–781). cephaly [small brain size]) and brain malfor- mations (Costa et al. 2002). Thus fetal devel- opment in pregnant women who have a histo- Benzodiazepines ry of solvent abuse should be evaluated and The principles of detoxification from benzodi- carefully monitored (Jones and Balster 1998). azepines are the same for pregnant and non- pregnant patients. It is important to taper the Nicotine dose of benzodiazepine slowly in order not to induce fetal withdrawal or other adverse con- There is extensive documentation that smoking sequences in the fetus or mother. during pregnancy causes numerous adverse Detoxification is most likely safest during the fetal consequences (see Schaefer 2001). second trimester in order to avoid sponta- Cigarette smoking during pregnancy is the neous abortion or premature labor. For more largest modifiable risk for pregnancy-related information, see the forthcoming TIP morbidity and mortality in the United States Substance Abuse Treatment: Addressing the (Dempsey and Benowitz 2001). While women

108 Chapter 4 are undergoing detoxification, they should be Marijuana, anabolic steroids, offered education about the risk of cigarette and club drugs smoking during pregnancy and, ideally, pre- vented from smoking. This is especially impor- The principles of detoxification from these tant since cigarette smoking is strongly associat- drugs is the same for pregnant and nonpreg- ed with decreased birth weight, which is a pre- nant women. The use of anabolic steroids dur- dictor of developmental problems in newborns ing pregnancy is rare; however, these can be (Ernst et al. 2002). If women are unable to stop catastrophic to a pregnancy, and if use is smoking using behavioral interventions, nico- found, a detailed ultrasound examination is tine replacement products may be used; how- recommended to determine the morphological ever, the woman should fully understand the (physical or structural) development of the possible risks and benefits of these pharma- fetus (Scialli 2001). cotherapies (Jones and Johnson 2001). Although the class of It also is important to point out to patients club drugs is rela- While women are that there are data to suggest that women may tively new there have derive less benefit from NRT than do men been a few reports undergoing and that they may derive greater benefit from (McElhatton et al. some non-NRT medications (e.g., bupropion), 1999) suggesting that detoxification, thus producing quit rates in women compara- there is an increased ble with those in men (Perkins 2001). risk of congenital they should be However, the data regarding the use of malformation in bupropion during pregnancy are limited. neonates prenatally offered education exposed to ecstasy. Examinations of the acute effects of NRT in Other club drugs about the risk of pregnant women reveal that nicotine has min- such as fluni- imal impact on the maternal and fetal cardio- trazepam (Rohypnol) vascular systems. NRT may well be viewed as may have effects sim- cigarette smoking the lesser of two evils, inasmuch as smoking ilar to those of some cigarettes delivers, in addition to nicotine, benzodiazepines; during pregnancy thousands of chemicals. Among these are however, this is spec- many that also are viewed as developmental ulative. For compre- and, ideally, toxins (e.g., carbon monoxide and lead). It is hensive information doubtful that the reproductive toxicity of on the treatment of prevented from cigarette smoking is primarily related to nico- this specific popula- tine. Thus, if NRT is to be used during preg- tion, see the forth- smoking. nancy, the dose of nicotine in NRT should be coming TIP similar to the dose of nicotine that the preg- Substance Abuse nant woman received from her ad lib (when- Treatment: ever desired) smoking. Although intermittent- Addressing the Specific Needs of Women use formulations of NRT (e.g., chewing gum) (CSAT in development e). have been recommended over continuous-use formulations (e.g., transdermal patch) due to reductions in the total dose of nicotine deliv- Older Adults ered to the fetus (Dempsey and Benowitz It has been recommended that, when treating 2001), it is unknown what the impact of inter- older adults, there should be a policy of using mittent acute doses followed by withdrawal of age-specific group treatment that is both sup- nicotine has on the fetus. portive and nonconfrontational (Royer et al. 2000; West and Graham 1999). Older adults may be dealing with depression, loneliness,

Physical Detoxification Services for Withdrawal From Specific Substances 109 and loss of career or a loved one. Thus, as a People With Disabilities or Co- standard policy, older adults should be Occurring Conditions screened for depression and grief or loss- related issues. Similar to the situation with In any patient population, the clinician other specific populations, the detoxification should expect to encounter persons with dis- setting should ideally have in place a policy abilities including co-occurring medical or that mandates, at a minimum, well-estab- mental disorders. These patients often will lished linkage with general medical services require special assistance to overcome both and specialized services for the aging, because physical and psychological barriers in under- of their increased vulnerability to physical going detoxification and treatment, including ailments. Establishing policies that create an their own psychological barriers that must be environment that is positive and does not tol- overcome, as well as those attitudinal and erate “ageism”—a general tendency to react communication barriers that often prevent negatively toward elderly adults—is impor- complete and clear understanding between tant for the optimal treatment of older indi- patient and clinician or clinician and institu- viduals. tion. Effective communication is essential for effective services. Accommodations must take Alcohol and other drug-related disorders in into consideration the expressed preference of elderly individuals often are more severe than the individual with a disability. Substance those of younger individuals and they are at abuse treatment programs need to be in com- increased risk for co-occurring medical disor- pliance with two Federal laws regarding this ders. It is the medical complications rather matter: the 1992 Amendments to the than age itself for which detoxification in a Rehabilitation Act of 1973 and the Americans medical setting is needed. The elderly may with Disabilities Act [ADA] of 1990. have slower metabolism of medications mak- According to the ADA, programs must ing dosage adjustments necessary in some remove or compensate for physical or archi- cases. The elderly also may be at greater risk tectural barriers to existing facilities when for drug interactions, since they may be accommodation is readily achievable, mean- receiving medications to treat other problems. ing “easily accomplishable and able to be car- A complete and careful assessment with ongo- ried out without much difficulty or expense” ing monitoring should be done to examine the (P.L. 101-336 § 301). Providers should exam- existence of diseases such as, but not limited ine their programs and modify them to elimi- to, heart disease, respiratory disease, dia- nate four fundamental groups of barriers to betes, and dementia. Potential for falls also treatment for people with disabilities and/or should be evaluated in the context of pre- co-occurring disorders: (1) attitudinal barri- scribed medications. The previously present- ers; (2) discriminatory policies, practices, and ed protocols for detoxification from alcohol, procedures; (3) communications barriers; and opioids, benzodiazepines, stimulants, sol- (4) architectural barriers. Federal, State, and vents, nicotine, marijuana, anabolic steroids, other sources of assistance might be available and club drugs (anabolic steroids and club to fund ADA-related improvements. See TIP drug abuse are rare in this population) 29, Substance Use Disorder Treatment for appear to be applicable to the elderly popula- People With Physical and Cognitive tion as long as sensitivity to the withdrawal Disabilities (CSAT 1998g) for further infor- medication is considered. TIP 26, Substance mation. Abuse Among Older Adults (CSAT 1998f), provides comprehensive information on the The following passage clarifies terms and treatment of this population. addresses the basic issues presented by patients with disabilities and/or co-occurring disorders. Diseases, disorders, and injuries,

110 Chapter 4 whether congenital or acquired, can have ties (WHO 1980). This complex system has diverse effects on organs and body systems. been simplified here into four main cate- Conditions (and diseases) such as multiple gories: sclerosis, traumatic brain injury, spinal cord injury, diabetes, and cerebral palsy can lead 1. Physical impairments are caused by con- to impairments, such as impaired cognitive genital or acquired diseases and disorders ability, paralysis, blindness, or muscular dys- or by injury or trauma. For example, function. These impairments in turn cause spinal cord injury is a disorder that can disabilities, which limit an individual’s ability cause paralysis, an impairment. to function in various areas of life, such as 2. Sensory impairments include blindness learning, reading, and mobility. While dis- and deafness, which may be caused by eases, impairments, and disabilities are dis- congenital disorders, diseases such as tinct categories, they often are used inter- encephalopathy or meningitis, or trauma changeably. These essential terms are defined to the sensory organs or the brain. in Figure 4-15. 3. Cognitive impairments are disruptions of thinking skills, such as inattention, memo- The field of disability services has developed ry problems, perceptual problems, disrup- its own terminology to discuss physical, senso- tions in communication, spatial disorienta- ry, and cognitive disabilities (see definitions tion, problems with sequencing (the ability below), and many treatment providers of peo- to follow a set of steps in order to accom- ple with substance use disorders will not be plish a task), misperception of time, and familiar with these terms as the profession perseveration (constant repetition of defines them. WHO has devised a method for meaningless or inappropriate words or the classification of impairments and disabili- phrases).

Figure 4-15 Some Definitions Regarding Disabilities

Disease: An interruption, cessation, or disorder of body functions, systems, or organs. Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or func- tions. Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in the manner or within the range considered normal for a human being. A disability is always perceived in the context of certain societal expectations, and it is only within that context that the disadvantages resulting from a disability can be properly evaluated. Functional capacities: The degree of ability possessed by an individual to meet or perform the behav- iors, tasks, and roles expected in a social environment. Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation), physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deaf- ness), or affective (e.g., depression) in origin and nature. They represent substandard performance on the part of the individual in meeting life activities and reflect the interaction between the person and the environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure 4-16, p112.)

Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.

Physical Detoxification Services for Withdrawal From Specific Substances 111 Figure 4-16 Impairment and Disability Chart

Impairment Category Common Disabilities

Physical Spina bifida Spinal cord injury Amputation Diabetes Chronic fatigue syndrome Carpal tunnel Arthritis

Sensory Blindness Hearing impairment Deafness Deaf-blindness Visual impairment

Cognitive Learning disabilities Traumatic brain injury Mental retardation Attention deficit disorder

Affective Depression Bipolar disorder Schizophrenia Eating disorder Anxiety disorder Posttraumatic stress disorder

Source: CSAT 1998e.

4. Affective impairments are disruptions in abilities and co-occurring medical and/or psy- the way emotions are processed and chiatric conditions. The failure to recognize expressed. For the purposes of this discus- these problems in patients can result in poor sion, affective impairments are considered outcomes (Cook et al. 1992). Additionally, to include problems caused by both affec- intoxicated individuals with co-occurring tive and mood disorders, such as major depressive disorders are at high risk for sui- depression and mania. These impairments cide attempts. Of course, an individual include the symptoms of mental disorders, patient may present with two or more disabil- such as disorganized speech and behavior, ities and/or co-occurring disorders. Clinicians markedly depressed mood, and anhedonia treating people with co-occurring substance (joylessness). use and mental disorders should consult TIP 42, Substance Abuse Treatment for Persons One of the most important practices that With Co-Occurring Disorders (CSAT 2005b). should be in place as a standard in any detox- ification setting is routine screening for dis-

112 Chapter 4 All programs should make a good faith effort al. Physical therapy and exercise, chiroprac- to provide equal access in as comprehensive a tic care, biofeedback, hypnotism, and thera- manner as possible for all patients. Individual peutic heat or cold are some other approach- unique needs should be taken into account es to caring for persons with physical prob- when providing services. For example, lems. Most of these alternative treatments patients with physical, sensory, or cognitive have limited or no research support of their disabilities may need help with self-care (e.g., efficacy; yet some clinicians believe they eating, grooming), moving (e.g., using stairs, work. Thus, consultation with experts on walking), communication (e.g., reading, their use is necessary before starting a person speaking), learning, social skills, and execu- with chronic pain on these remedies. tive functions (e.g., planning and organiza- tion, decisionmaking). Unresponsiveness to An alternative model supports the idea that instructions, lack of participation in discus- patients should be treated simultaneously in sions and activities, forgetfulness, or confu- substance abuse treatment, mental/physical sion by an individual with cognitive disabili- health, and detoxification settings, yet treat- ties should not be viewed as a lack of motiva- ments may occur in separate facilities and be tion, resistance, or denial. Programs may conducted by separate staff. The consequent need to develop the expertise or engage an task for all is to be supportive and knowl- expert on cognitive disabilities to determine edgeable about each other’s interventions. the limitations resulting from the substance The severity of the addiction and abuse and those resulting from the disability. medical/psychiatric problems at the time of Both require patience in the response. detoxification entry should determine which Information presented to the person with a acute services the patient receives first. cognitive disability should include different Naturally, a person’s medical and psychiatric and complementary media; for example, visu- disabilities must be accounted for in the al and tactile materials can reinforce the preparation of any treatment plan. In some usual verbal interaction. cases, substance abuse treatment cannot begin until issues relating to medical and psy- Programs also may need to alter their policies chiatric disabilities are settled. regarding the use of drugs prescribed for pain control, since most medications of this class There are a number of resources for clini- are drugs with a high abuse potential. A num- cians to employ, including experts in the field ber of patients with substance use disorders of disability services. Figure 4-17 (p. 114) dis- also live with chronic pain. Living in a drug- cusses ways of locating expert help for treat- free state may not be desirable if it is associ- ing patients with disabilities and/or co-occur- ated with unrelieved pain, which can be quite ring disorders. disabling. The clinician should explore with Finally, integrated treatment combines sub- patients what pain management options have stance abuse treatment, treatment for co- been tried in the past, and which management occurring disorders, and detoxification services medications are being used currently. into one program. For more complete informa- Patients should be encouraged to discuss tion on the treatment of many of these disor- their feelings about pain and how it affects ders, see chapter 5. their daily life, and especially to what extent it curtails or prevents their participation in the activities of daily living. African Americans There are a number of alternative treatments For African Americans, entrance into detoxifi- for chronic pain. Acupuncture is already in cation has been associated with enrolling in fur- use in some treatment programs for detoxifi- ther treatment, reductions in HIV/AIDS risk cation to help relieve symptoms of withdraw- behaviors, and linkages with social and health-

Physical Detoxification Services for Withdrawal From Specific Substances 113 Figure 4-17 Locating Expert Assistance

“Experts” in disability services can be located in several ways, depending upon the nature of the patient’s disability and the local resources available. Patients who understand their disability may in fact be the best “experts” on their condition and specific needs; however, it is not uncommon that persons requiring treat- ment for substance use disorders will not understand basic aspects of their situation or condition. In such cases, immediate family members or close friends may be important sources of information and guidance. The treatment team also should consider contacting other sources: •A disability-specific service organization (e.g., United Cerebral Palsy, organizations for the blind or deaf such as the National Association of the Deaf and American Deafness and Rehabilitation Association, the Association for Retarded Citizens) •Social workers •Case managers •Rehabilitation specialists •Psychologists •Nurses or physicians associated with a social service agency providing disability services for the individual patient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard of hearing, the Department of Veterans Affairs’ physical rehabilitation unit, community case management services) •Other organizations recognized by the disability community (e.g., Centers for Independent Living, gover- nors’ committees for persons with disabilities, Paralyzed Veterans of America, local or State consumer coalitions for persons with disabilities)

Source: CSAT 1998e.

care services (Lundgren et al. 1999). African mind the standard of respecting the client as Americans are at greater risk than other popu- an equal partner in treatment. For further lations for the co-occurrence of diabetes and information on this subject (as well as infor- hypertension (high blood pressure) that can mation on working with members of other predispose them to a risk of stroke. This cultural/ethnic groups), see the forthcoming should be taken into account when placing and TIP Improving Cultural Competence in monitoring them on withdrawal medications. Substance Abuse Treatment (CSAT in devel- opment a). In treating African-American patients, treat- ment efficacy and therapist efficacy may be The previously discussed protocols for detoxi- associated with the therapist’s understanding fication from all substance of abuse appear of how race plays a role in recovery adequate for the detoxification of African (Luborsky et al. 1988; Pena et al. 2000). In Americans. However, there are a few further addition, when working with counselors from aspects to consider: other cultures, African Americans may dis- •If treating African Americans with beta play mistrust and a reluctance to show any blockers, propranolol is less effective in weakness. To overcome this mistrust and to treating African Americans than Caucasians build rapport, especially when the clinician is (Pi and Gray 1999). discussing the detoxification process, it is par- •African Americans are more likely (15 to 25 ticularly important for the clinician to keep in percent) to have less of the enzyme activity

114 Chapter 4 needed to eliminate diazepam than others, so quate for the detoxification of Asians and it may have a longer half-life in African Pacific Islanders. During the detoxification Americans than it does in other ethnic groups process, there are a number of issues to con- (Pi and Gray 1999). sider: •Since co-occurring disorders such as depres- •If possible and appropriate, incorporate tra- sion frequently are seen in people with sub- ditional healing methods (e.g., meditation stance use disorders, it is important to know and religious exercises). These can help that African Americans may require lower reduce stress and anxiety and promote recov- doses and may be at greater risk of develop- ery (Chang 2000). While there is a large ing toxic side effects when prescribed antide- immigrant population among many Asian- pressants, since they are likely to metabolize American groups, it is erroneous to assume tricyclic antidepressants and SSRIs less effi- that all are foreign born. Variation in prac- ciently than Caucasians (Pi and Gray 1999). tice of traditional healing methods is consid- •Although the clearance of nicotine is similar erable and consistent with generational dif- for African Americans and Caucasians, the ferences. When considering detoxification, clearance of cotinine, a metabolite of nico- recognize the importance of bicultural prac- tine, is slower in African Americans, which tices, values, and beliefs that might influence may cause different smoking patterns than responsiveness to treatment. found in Caucasians (Ahijevych 1998). •When discussing detoxification medications, discuss with patients their feelings about tak- Asians and Pacific Islanders ing “Western” medications for detoxification. In some Southeast Asian cultures, Western This group is the most diverse in nations of medications are believed to be too strong for origin and has widely differing languages, the Asian person. It is important to assess a beliefs, practices, dress, and values. Often person’s feelings about these since the patient the only common thread among these people may not wish to disagree with the clinician is their geographic origin (Chang 2000). yet may be noncompliant in taking the medi- Although this group appears to have lower cations. Compliance with detoxification medi- rates of alcohol and illicit drug use, these cation may be better achieved if doses are problems should not be overlooked; members reduced or regimens shortened, yet this of this group may not seek treatment until the should only be attempted if it is in the best problems are quite severe. Successful treat- interest of the patient. ment involves the family and important val- ues include balance, harmony, wisdom, and •Racial differences in alcohol sensitivity modesty. Thus, it may be important to talk to among Asians and Caucasians have long been the family about the process of detoxification recognized, with more than 80 percent of and dispel their fears and concerns as well as some Asians compared to 10 percent of the patient’s. Caucasians being sensitive to alcohol (i.e., having a flushing reaction) (Wolff 1972, Asians and Pacific Islanders tend to be con- 1973). This is the result of genetic differences cerned about the clinician’s credibility and in alcohol metabolizing enzymes. trustworthiness. Generally speaking, male- Approximately 50 percent of Asians lack the ness, mature age, the projection of self-confi- enzyme ALDH2, found in the liver, that helps dence, possession of sound cultural compe- the body get rid of alcohol (Hsu et al. 1985; tence skills, good educational background, Yoshida et al. 1985). One reason for lower and level of experience are of importance. In drinking rates among Asians may be the addition, a concrete logical approach to the flushing reaction in the face and body follow- problem at hand is valued (Brems 1998). The ing alcohol ingestion and an increase in skin previously discussed protocols for detoxifica- temperature. Other uncomfortable signs and tion from all substances of abuse appear ade- symptoms associated with the negative reac-

Physical Detoxification Services for Withdrawal From Specific Substances 115 tion to alcohol ingestion can include nausea, American Indians dizziness, headache, fast heartbeat, and anx- iety (Caetano et al. 1998). There are currently more than 500 federally recognized American-Indian tribes, and there •Five studies have shown that the metabolism is among them great variability in appear- of codeine is slower in Chinese people than ance, dress, values, religious beliefs, prac- in Caucasians. Chinese patients seem to tices, and traditions. More than 200 different require lower doses of codeine, since the languages are spoken by American-Indian slower metabolism leads to a higher concen- tribes. Alcohol use varies widely among tribes tration of codeine in the blood (Smith and (Mancall 1995). Of all ethnic and racial Lin 1996). groups, American Indians have the greatest •If treated with beta blockers, Asians require rates of alcohol and illicit drug use (Office of much lower doses than Caucasians, since Applied Studies 2002a). they are very sensitive to this medication’s blood pressure and heart rate effects (Pi An early study of treatment utilization by and Gray 1999). American Indians found that there was a sig- nificant association between involvement in •Asians as a group have a higher number of society and treatment outcomes. Those individuals than other ethnic groups who involved in either the traditional Indian soci- are poor metabolizers of diazepam. This ety or both the traditional Indian society and may result in the need for lower doses, Caucasian society had more than a 70 percent since they report greater sedative effects success rate, whereas those involved in nei- with a typical dose (Lesser et al. 1997). It ther society had a 23 percent success rate also may be that a lower body fat, which is (Ferguson 1976). At a 10-year followup, those typical of Asian-American individuals, can who had reported greater Indian culture affil- lead to differences in the pharmacokinetics iation and more severe liver dysfunction at of lipophilic drugs (Lesser et al. 1997). baseline had better alcohol treatment out- •In treatment for co-occurring depression comes (Westermeyer and Neider 1984). and a substance use disorder, Asians appear to metabolize clomipramine more When engaging an American Indian in the slowly than Caucasians (Pi and Gray 1999). process of detoxification, moving through the In contrast, Asians may metabolize process too quickly or abruptly can be per- phenelzine faster, resulting in the need for a ceived as showing a lack of caring and is con- higher dose relative to that which would be sidered contrary to trust building (Brems appropriate for Caucasians (Pi and Gray 1998). The pace of conversation is important; 1999). a slower pace is more agreeable than a rapid •Chinese Americans tend to metabolize nico- conversation. Moreover, a confrontational tine 35 percent more slowly than approach also is not advised with this popula- Hispanics/Latinos and Caucasians. Thus, tion (Abbott 1998). American Indians may they may need to smoke less frequently and want a close and involved relationship with take in less nicotine to achieve the same their therapists and often want the clinician nicotine levels as do Hispanics/Latinos and to be a friend or relative (Brems 1998). The Caucasians. This may have implications for trust often is built by idle small talk to a level the dosing of NRTs (Benowitz et al. 2002). of shared understanding. Use of fables and illustrative stories to express ideas can be •Smoking rates among male Asian extremely helpful. According to the forthcom- Americans, especially immigrant males, are ing TIP Improving Cultural Competence in exceedingly high and masked by the lower Substance Abuse Treatment (CSAT in devel- rates among Asian-American females. opment a), avoidance of eye contact also is traditional. The Talking Circle is a native tra-

116 Chapter 4 dition that can be helpful in the treatment Spanish or Portuguese does not guarantee process (Canino et al. 1987; Coyhis 2000). cultural sensitivity or competence. For The previously discussed protocols for detoxi- instance, it is important that the treatment fication from all substances of abuse appear staff understand the role of the family. The adequate for the detoxification of American functional family can be extended and should Indians. The following are some issues to con- take into account people who have day-to-day sider during detoxification. contact with and a role in the family •Fetal Alcohol Syndrome is 33 times higher in (Markarian and Franklin 1998). this population than the national average Hispanics/Latinos are likely to view drug (CSAT in development a). This may be dependency as moral failing or personal important for pregnant women coming to weakness. Traditional healing such as folk detoxification and also may be important if remedies and folk the adult has FAS. healers may provide benefit. The previ- •Indian women who drink have a six-fold Hispanics/Latinos ously discussed pro- increase in cirrhosis of the liver relative to tocols for detoxifica- Caucasian women (Heath 1989). are now the tion from alcohol, •Although some American Indians have opioids, benzodi- largest ethnic reported a flushing response to alcohol, it azepines, stimulants, appears that the flushing reaction in solvents, nicotine, minority group in American Indians is milder and less adverse marijuana, anabolic than that experienced by Asians (Gill et al. steroids, and club 1999). drugs appear ade- America. •If Alcoholics Anonymous or other 12-Step quate for the detoxi- programs are to be introduced, framing the fication of Assessment of the steps in terms of a circle rather than a ladder Hispanics/Latinos. may be better received, since the circle is patient’s level of important concept in Indian culture (CSAT in development a). Gays and acculturation can •If possible and appropriate, other traditional Lesbians methods that can help recovery are sweat Approximately 5 to be helpful in lodges, vision quests, smudging ceremonies, 33 percent of all les- sacred dances, and four circles (Abbott bian and gay individ- understanding 1998). uals are estimated to substance abuse •Overall, detoxification for this population is have a substance the same as for other populations, but abuse problem American Indians are likely to seek treatment (Cochran and Mays patterns. later and have more medical complications 2000; Hughes and and poorer nutrition (Abbott 1998). Wilsnack 1997). A contributing factor may be the stress and Hispanics/Latinos anxiety associated with the social stigma attached to homosexuality. Further, alcohol Hispanics/Latinos are now the largest ethnic and drugs may serve as an escape and ease minority group in America. Assessment of the social interactions at social settings such as patient’s level of acculturation can be helpful bars. More information on this subject will be in understanding substance abuse patterns. available in the forthcoming TIP Improving Language is one of the most difficult barriers Cultural Competence in Substance Abuse to treatment entry and success for Treatment (CSAT in development a). The Hispanics/Latinos. However, simply knowing previously discussed protocols for detoxifica-

Physical Detoxification Services for Withdrawal From Specific Substances 117 tion appear adequate for gay and lesbian there is liver toxicity or suicidal intent patients. Since numerous misconceptions and (Giannini et al. 1991). The use of club drugs stereotypes exist concerning gay and lesbian is higher in this population than in others. individuals, it is important for the clinician to assess his beliefs and take care not to impose TIP 31, Screening and Assessing Adolescents them on the patient. for Substance Use Disorders (CSAT 1999d), and TIP 32, Treatment of Adolescents With There are a number of principles of care for Substance Use Disorders (CSAT 1999f), pro- treating gay and lesbian individuals, which vide comprehensive information on the treat- are outlined in A Provider’s Introduction to ment of adolescents. Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001). These principles include: (1) Incarcerated/Detained Persons counselors’ being able to monitor their own Substance use disorders are common among feelings about working with this population of inmate populations. At the time of arrest and patients in order to provide professional, eth- detention, it has been estimated that 70 to 80 ical, and competent care; (2) helping patients percent of all inmates in local jails and State heal from the negative experiences of homo- and Federal prisons had regular drug use or phobia and heterosexism; (3) helping patients had committed a drug offense, and 34 to 52 understand their reactions to discrimination percent of these inmates were intoxicated at and prejudice; and (4) helping patients accept the time of their arresting offense (Federal personal power over their own lives by help- Bureau of Prisons 2000; Mumola 1999). ing them improve their self-images and build Although women comprise a small proportion support networks. of the incarcerated population (12.3 percent in jails and 7.4 percent in State and Federal prisons) than men (Harrison et al. 2004), Adolescents females have a greater prevalence of illicit The previously discussed protocols for detoxifi- drug use (i.e., 40 percent compared to 32 per- cation from all substances of abuse appear ade- cent were under the influence of drugs at the quate for the detoxification of adolescents; time the crime was committed) than do males however, there are several additional aspects to (Greenfeld and Snell 1999). consider: Persons who are incarcerated or detained in •Physical dependence generally is not as holding cells or other locked areas should be severe, and response to detoxification is more screened for physical dependence on alcohol, rapid than in adults. opioids, and benzodiazepines and provided •Retention is a major problem in adolescent with needed detoxification and treatment. treatment (Thurman et al. 1995). Screening should occur over time, since the •Peer relationships play a large role in treat- onset and intensity of withdrawal is depen- ment. Among adolescents who do not use dent on the type of drug taken, when the per- drugs, few of their friends reported use. In son last took the drug, and how long the drug one study, among those who reported specific lasts in the person’s body. The duration of drug use, over 90 percent of their friends detention will affect what detoxification ser- reported using the same drug (Dinges and vices can be provided, and many facilities will Oetting 1993). not be able to provide detoxification or con- •It is estimated that 75 percent of those tinuing care services. There are some special reporting steroid use are high school stu- considerations for the detoxification of this dents, and most of them are male. Detoxifica- population: tion from steroids does not typically require •Abrupt withdrawal from alcohol can be life- specific pharmacological intervention unless threatening.

118 Chapter 4 •Abrupt withdrawal from opioids or benzo- •Many correctional facilities have restric- diazepines is not life-threatening but can tions on the use of methadone or LAAM and cause severe withdrawal signs and symp- special provisions for maintaining or taper- toms and great distress. ing the individual may need to be made. •It should be determined whether depen- •If medications are provided to medically dence on either opioids or benzodiazepines detoxify inmates, the Federal Bureau of is the result of illicit use and not the result Prisons’ Clinical Practice Guidelines for of taking medications that have been pre- Detoxification of Chemically Dependent scribed to treat pain or anxiety disorders. Inmates (2000) suggest retaining strict con- •If medically supervised withdrawal is indi- trol over access to these medications to pre- cated, the substitution of a long-acting drug vent diversion or misuse (e.g., eating cloni- from the same class of substances the dine patches to obtain a state of euphoria). patient is using (e.g., giving methadone to TIP 44, Substance Abuse Treatment for treat heroin dependence) and the gradual Adults in the Criminal Justice System (CSAT tapering of that substance (no faster than 2005b), and TIP 30, Continuity of Offender 10 to 20 percent per day) should be con- Treatment for Substance Use Disorders From ducted under closely monitored settings. Institution to Community (CSAT 1998b), pro- •There are cases when individuals main- vide more detailed information about the tained on opioid agonist medications are treatment of this population. TIP 21, detained or incarcerated. If the incarcera- Combining Alcohol and Other Drug Abuse tion is 30 days or less, the individual should Treatment With Diversion for Juveniles in be maintained on her usual dosage. If the the Justice System (CSAT 1995b), also pro- incarceration is longer, the individual may vides information about incarcerated youth. be appropriate for gradual dose tapering. •Persons who transition from a state of opi- oid dependence to a drug- or medication- free state are at greater risk of overdose upon relapse to opioid use.

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