1. TREATMENT GUIDELINES

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1 Detoxification Standards and Guidelines The following Detoxification Standards and Guidelines are sanctioned for use in District Withdrawal Management Units of Addiction Services, Nova Scotia. 1. TREATMENT GUIDELINES The Registered Nurse in charge, based upon nursing assessment of the client, will utilize the following treatments for drug withdrawal. Based on the admission assessment, the Registered Nurse may deem it necessary to consult with the family physician regarding medical history, indications for previous medications and/or client conditions requiring ongoing medical procedures. The Registered Nurse in charge may request that the physician perform a medical history and physical examination on a client. Appropriate diagnostic tests (where available) will be ordered by the physician. Results will be forwarded appropriately. In areas of the province where physician availability is limited, a client may be requested to receive medical stabilization for Detoxification from their family physician or from an outpatient department physician. Detox staff will conduct close monitoring of all Detox clients. Vital signs will be taken upon admission and at least every four hours for the first twenty-four hours (or longer if appropriate) and recorded. Vital signs should be taken every four hours while the client is awake unless otherwise indicated. Any marked variations in vital signs should be managed with the medications outlined in the withdrawal protocol or be brought to the attention of a physician according to the assessment of the Registered Nurse in charge. Counsellor attendants may take and record vital signs and will report the information to the Registered Nurse. Any observed or suspected medical or psychiatric complications, which may pose a risk, will be reported immediately to the physician. The client may be transferred to hospital. In the event of a medical emergency, the client will be given immediate treatment to preserve life (see Basic Life Support Protocol). 1 of 14 pages

2 2. BASIC LIFE SUPPORT Objectives To preserve life. To prevent deterioration until more definite treatment can be given. To transfer the client to a medical setting as soon as possible. Procedures Maintain client's airway. Administer O 2 therapy if indicated. Control bleeding. Monitor vital signs. Reduce anxiety and keep the client as comfortable as possible. Call an ambulance and transport the client to hospital. Phone the physician to inform him/her of the situation. Notify family members about the client's condition and his/her transfer to hospital. The Registered Nurse in charge will supervise the above procedures. Specific procedures may vary depending on the severity of the client's condition. The client's physician, his/her family, and the Registered Nurse will be notified after transfer to hospital. In order to meet basic life support objectives, all Detox staff will be trained in CPR techniques and skill level will be maintained as outlined by the Canadian Heart Foundation. 3. EMERGENCY EQUIPMENT The following equipment will be available and maintained in up-to-date status for emergency use: Oxygen Suction apparatus This is a list of the minimal equipment requirements. Additional equipment and supplies may be made available based upon the requirements of a particular District. 2 of 14 pages

3 4. SEIZURE CONTROL PROTOCOL Grand mal seizures are one manifestation of alcohol withdrawal. Withdrawal seizures usually begin 8 to 24 hours after the last drink and may occur before the blood alcohol level has reached zero. Most are generalized major motor seizures occurring singly or in short bursts of several seizures occurring over a period of one to six hours. The peak incidence of withdrawal seizures is within 24 hours after the last drink corresponding to peak abnormalities in EEG readings. The risk of seizures appears to be genetically determined and is increased in clients with a prior history of withdrawal seizures or in individuals who are undergoing concurrent withdrawal from Benzodiazepines or other sedative-hypnotics. There is also evidence to suggest that the risk of seizures increases as s client undergoes repeated withdrawals. This association has been described as a kindling effect. 4.1 Clients Withdrawing From Alcohol and Presenting With a History of Seizures For any client presenting with a history of alcohol withdrawal seizures (with or without liver dysfunction), a loading dose of 20mg of Diazepam p.o. and 20mg of Diazepam q 1-2 hrs to a minimum of 60 mg is to be administered. If any one of the Diazepam doses over- sedates a client, the remaining dosages are to be continued when the client wakes up. For example, if a client falls asleep after receiving 40 mg of Diazepam, the remaining 20mg of Diazepam is to be administered when the client awakes. All clients will receive a loading dose of 60 mg of Diazepam for seizure prophylaxis. Further doses of Benzodiazepines, based upon nursing assessment, may be necessary to control withdrawal symptoms (see individual Drug Withdrawal Protocols). The doses of Diazepam used for seizure prophylaxis are to be included in the 24-hour Benzodiazepine limits if further doses of Benzodiazepines are required to treat withdrawal. Note: Clients who have a history of seizures during drug withdrawal and are receiving a prescription of Phenytoin (Dilantin ) will remain on this medication while on the Detoxification Unit. 4.2 When to Start the Seizure Control Protocol For clients who are intoxicated at the time of admission, the Diazepam is to be administered when withdrawal symptoms appear (typically 4-6 hours after the last drink). Blood alcohol concentration can fall as quickly as 32mg% in alcohol-dependent individuals as compared to mg% in the normal population. For example, a client admitted to the Detox Unit with a BAC of 240mg% may start to go into withdrawal in 4-5 hours. 3 of 14 pages

4 4.3 Management of the First Seizure During Withdrawal After appropriate medical stabilization after a seizure, 20 mg of Diazepam po and the client transferred by ambulance to the nearest Emergency Department. 4.4 Management of a Second Seizure After a second drug withdrawal seizure, the client will be transferred to the hospital. The appropriate DDS staff, family members and medical professionals will be notified after transfer to hospital. 5. MEDICATIONS The following medications are those sanctioned for routine use in District Withdrawal Management Units of Addiction Services. The decision to use these medications is the responsibility of the Registered Nurse in charge based on nursing assessment of the client. 5.1 Thiamine (Vitamin B 1 ) Indications: To be administered to all clients upon admission. Thiamine appears to reduce irritability and depression and is essential for many biochemical processes. Daily administration of thiamine is acceptable until peak symptoms subside (usually up to three days). Thiamine should be administered 100 mg PO or IM daily or 50 mg bid PO or IM for up to 3 days, unless contraindicated. Additional thiamine will be given in the multivitamin preparations discussed below. 5.2 Nutritional and Vitamin Supplements Indications: B-complex with C is recommended for all clients throughout their stay in Detox. In addition, the physician may recommend that clients with substantial emaciation or nutritional disturbances require a broader mix of water and fat-soluble vitamins (e.g., B 6, A, D, B 12 ), essential minerals (e.g., zinc, magnesium, copper) and other nutrients (e.g., choline, folacin). Beginning these supplements early in the appropriate clients will reduce the severity of the withdrawal. Liquid preparations may be more appropriate for some clients. Clients should be encouraged to eat well-balanced and frequent meals unless they cannot keep the food down because of gastric distress. In such clients, the use of comprehensive nutritional supplements such as Ensure and Simalac may be appropriate for a few days until solids may be retained. Nova-B or Albee with C or comparable multivitamin preparation: 1 cap or tab daily throughout Detox stay. Other preparations as needed. 4 of 14 pages

5 5.3 Antiemetics Indications: Dimenhydrinate (Gravol or Dramamine ) will be administered as required for nausea and vomiting mg orally, intramuscularly or by suppository every four hours or as needed. 5.4 Pruritus Indications: Diphenhydramine (Benadryl ) will be administered to control for itching. Benadryl 50 mg qid prn. 5.5 Anaphylaxis Shock Epinephrine: ( mg SC (1:1000 solution) Epi Pen Transfer to hospital 5.6 Gastric Antacids, Laxatives, Antidiarrheal Compounds. Antacids (e.g., Diovol, Malox ), laxatives (e.g., Magnolax ) and antidiarrheal preparations (e.g., Imodium ) will be administered as required. A stool softener such as Docusate (Colace ), 100 mg daily with water may help relieve gastrointestinal problems. 5.7 Expectorants, Decongestants, Antitussive and Sinus Medications Non-alcohol containing preparations will be administered as necessary. 5.8 Headaches Acetaminophen 325 mg po 1 or 2 tabs q4h prn to a max of 3900 mg in 24 hrs Contraindicated or use with caution in clients with liver disease. Ibuprofen mg po q4h prn to a max of 1200 mg in 24 hrs Contraindicated in clients with a peptic ulcer or history of hypersensitivity reaction to such medications. 5 of 14 pages

6 5.9 Sleep-Inducing Medications In general, no medications will be given to specifically induce sleep other than those indicated in specific withdrawal protocols. Clients should be encouraged to utilize the various non-drug resources available such as relaxation tapes and techniques and to reduce their caffeine intake. Consumption of these substances will intensify and prolong withdrawal symptoms. Clients should be informed that daytime naps might make sleep difficult and that normal sleep patterns will be slow to return. If sleep medications are required, Zopiclone (Imovane ) is recommended. Zopiclone (Imovane ) 7.5 mg po per night prn for a maximum of 5 doses Severe Agitation Some individuals may become severely agitated or irritable during the withdrawal process. If there is a need to calm an individual down, sublingual Lorazepam (Ativan ) is recommended. A single dose of 1-2 mg sublingual Lorazepam (Ativan ) Other Medications Other medications not included in Sections 5.1 to 5.10 or included in specific drug withdrawal protocols may be prescribed by the physician as needed. 6 of 14 pages

7 6. CLIENT PRESENTING WITH ALCOHOL AND/OR MEDICATIONS The following procedure is recommended to deal with those situations in which the client to be admitted to Detox presents with either alcohol and/or other drugs. 6.1 Alcohol Beverages and Unlabelled Drugs The client will turn over all unlabelled drugs and alcohol before admission and/or at any later time upon discovery during their stay in Detox. These will be discarded. 6.2 Prescribed Medication (labelled) The client will be asked to turn over labelled prescribed medicines to the Detox staff. The family or roster physician will be consulted to determine if the client should continue on such medication while in Detox or after discharge. 6.3 Non-psychoactive Medications The family or roster physician will be consulted to determine if the client should continue on such medication while in Detox or after discharge. Clients will be given their medication as required. Bronchodilators, nitroglycerin and birth control pills may be returned to the client for selfadministration while on the Detoxification Unit. 6.4 Psychoactive Medications Clients will be informed of the danger of use of psychoactive medications and will be encouraged to destroy all medications deemed unnecessary. Upon request by the client, all legally prescribed and properly labelled medications will be returned to the client upon discharge. 7. SIGNS AND SYMPTOMS OF WITHDRAWAL Table 1 summarizes the signs and symptoms of withdrawal from alcohol, stimulants, depressants and opiates. 7 of 14 pages

8 Table 1 Signs and Symptoms of Withdrawal Signs & Symptoms Abdominal Cramps Aches, muscles Anorexia Anxiety Chills Convulsions Coryza (runny nose) Delirium Depressed mood Diarrhea Fatigue Flushing Hallucinations Headaches Hyperphagia Hypertension Hypotonia Irritability Lacrimation Memory, poor Alcohol Stimulants Depressants Opiates 8 of 14 pages

9 Table 1 (cont.) Signs and Symptoms of Withdrawal Signs & Symptoms Motor seizures (grand mal) Mouth, dry Muscle spasms (rigidity) Nausea Nystagmus Orthostatic hypotension Paraesthesia Piloerection (goose flesh) Pupils, dilated Reflexes, hyper reactive Restlessness Rhinorrhea Sleep Disturbances Sleepiness Sweating Tachycardia Tremors Violence Vomiting Yawning Alcohol Stimulants Depressants Opiates Adapted from the American Society of Addiction Medicine, Topics in Addiction Medicine, Vol. 1, No. 2 9 of 14 pages

10 8. DETOXIFICATION PROTOCOLS The following protocols are sanctioned for use in regional primary care Detoxification units of Addiction Services. Alcohol Withdrawal Protocol Benzodiazepine Withdrawal Protocol Cocaine Withdrawal Protocol Methadone Stabilization Protocol Opiate Withdrawal Protocol Nicotine Withdrawal Protocol 9. ORDER OF DETOXIFICATION Many clients abuse various combinations of drugs. Because the morbidity and mortality risks are greater with Central Nervous System (CNS) Depressants (i.e. alcohol, Benzodiazepines and barbiturates) than with Opiates or CNS Stimulants, treatment should be directed towards CNS depressant withdrawal first (see Figure 1). The following table provides guidelines to manage withdrawal from multiple drugs. Table 2 Guidelines to Manage Withdrawal from Multiple Drugs Client Dependent Upon Technique Alcohol Diazepam load Alcohol and Benzodiazepine(s) Diazepam load /Benzodiazepine taper Alcohol/Cocaine/Benzodiazepine(s) Diazepam load / Benzodiazepine Taper Alcohol/Cocaine/Benzodiazepine(s)/Opiates Diazepam load / Benzodiazepine taper Methadone administration based upon the presentation of opiate withdrawal symptoms 9.1 Benzodiazepine and Opioid Dependent Clients For clients presenting with a combination of Opioid and Benzodiazepine withdrawal management issues, Lorazepam to be used to stabilize and manage the taper from the Benzodiazepine(s) of abuse. 10 of 14 pages

11 Figure 1 Order of Detoxifications CNS Depressants Before Opiates Before CNS Stimulants Alcohol Before Barbiturates Before Benzodiazepines Short Half-Life Barbiturates Short Half-Life Benzodiazepines Before Before Long Half-Life Barbiturates Long Half-Life Benzodiazepines 11 of 14 pages

12 10. DETERMINING DOSE OF MEDICATIONS There are two strategies employed in choosing the dose for the medications used to manage alcohol withdrawal: 1. Fixed Dosages at Scheduled Intervals Approach Medications are given in fixed amounts at specific times (i.e. 50 mg Librium every 4 hours for a period of 5-7 days). With this approach, it is extremely important that provisions be made for the administration of additional medication should the fixed dose be inadequate to control withdrawal symptoms. 2. Symptom-Triggered Approach Clients receive medication based upon nursing assessment or through the use of a structured assessment scale (i.e. CIWA) when withdrawal symptoms exceed a threshold of severity. Research has shown this approach to be as effective as the fixed dose approach but results in the administration of significantly less medication and shorter duration of treatment. This approach facilitates the delivery of large amounts of medications when withdrawal symptoms are most severe. Additionally, this approach reduces the risk of under treatment that may result from the fixed dose approach. For these reasons, the symptom-triggered approach is recommended. 11. MEDICATIONS TO MANAGE WITHDRAWAL FROM OTHER DRUGS 11.1 Barbiturates A clear withdrawal syndrome has been described for barbiturate withdrawal. Withdrawal typically begins hours after the final dose of the drug. Withdrawal symptoms are similar to alcohol withdrawal and include tremors, anxiety, insomnia, nausea, delirium and seizures. Due to the risk of seizure, a physician must be contacted for drug withdrawal orders Amphetamines Amphetamine withdrawal is similar to the symptoms of cocaine withdrawal with the exception of amphetamine psychosis. Clients using high doses of amphetamines intravenously may develop a toxic reaction similar to paranoid schizophrenia. Diazepam may help individuals who develop agitation or sleep disturbances mg Diazepam q 1-2 hr po prn to a maximum of 120 mg in a 24 hour period to manage withdrawal symptoms. 12 of 14 pages

13 11.3 Cannabis No clinically significant cannabis withdrawal syndrome has been described in the literature. However, some individuals may experience anxiety, depression, irritability, insomnia and tremors after abrupt cessation of cannabis use. These individuals may benefit from the use of Diazepam and a supportive environment mg Diazepam po prn q1-4h to a maximum of 40mg in 24 hours times three days to manage withdrawal symptoms Solvents and Inhalants Individuals may become physically dependent to hydrocarbons which include gasoline, glue and aerosol sprays. There is clinical evidence of a withdrawal syndrome from inhalants, which mimics withdrawal from alcohol. These individuals may benefit from the use of a Diazepam mg Diazepam po prn q1-4h to a maximum of 40mg in 24 hours times three days to manage withdrawal symptoms Hallucinogens There is no evidence of a clinically significant withdrawal syndrome from hallucinogens such as lysergic acid diethylamide (LSD), mescaline or psilocybin. Thus, there is no role for medications in the management of withdrawal from hallucinogens. A flashback is the spontaneous reoccurrence of specific experiences originally occurred during an LSD episode. Flashbacks may occur shortly after an LSD episode or up to four to five years later. Visual images are by far the most frequently reported form of flashbacks. The anxiety that may accompany the flashback can be managed by putting the person in a darken room to relax. 12. PREGNANT AND NURSING WOMEN Women who enter the Detoxification unit may benefit from a comprehensive physical examination including a gynaecological and obstetrical examination. Staff sensitivity to the needs of female clients is critical. Leaving an environment where drug and alcohol abuse is occurring may be more important for women than men. The physician must be contacted before implementing any protocol to pregnant, substance-abusing women. 13. PERSONS WITH A BLOOD BORNE PATHOGEN A diagnosis of HIV does not change the indications for Detoxification medications. Staff may have questions about the safety about dispensing medications, collecting samples for urinalysis or being in close proximity to individuals with HIV. Program staff and management should clarify these issues by referring to the HIV and Other Blood Borne Pathogens Resource Manual. In individuals with hepatitis and a compromised liver function, a short acting Benzodiazepine like Lorazepam should be used. 13 of 14 pages

14 SUGGESTED READINGS BY SUBJECT DETOXIFICATION Center for Substance Abuse Treatment (1995). Detoxification from Alcohol and Other Drugs. Treatment Improvement Protocol (TIP) Series, Number 19. Rockville, MD: U. S. Department of Health and Human Services. Public Health Service. DHHS Publication Number (SMA) Kasser, Christine, Anne Geller, Elizabeth Howell and Alan Wartenberg (1998). Principles of Detoxification. In Principles of Addiction Medicine, 2 nd Edition (Allan Graham and Terry Schultz, Eds.). ASAM, Chevy Chase, MD, p423 O Brien, Charles P. (1997). A Range of Research Based Pharmacotherapies for Addiction. Science. Vol. 278, Issue 5335, p66 MARIJUANA Ashton, Heather (2001). Pharmacology and Effects of Cannabis: A Brief Review. The British Journal of Psychiatry, Vol. 178, p101 Wesson, Donald R. (1995). Detoxification from Alcohol and Other Drugs. Contract Number ADM U.S. Department of Health and Human Services. Public Health Service. Substance Abuse and Mental Health Services. Centre for Substance Abuse Treatment. Rockville, MD Wilkins, Jeffrey, Bradley Conner and David Gorelick (1998). Management of Stimulant, Hallucinogen, Marijuana and Phencyclidine Intoxication and Withdrawal. In Principles of Addiction Medicine, 2 nd Edition (Allan Graham and Terry Schultz, Eds.). ASAM, Chevy Chase, MD, p465 PREGNANCY Center for Substance Abuse Treatment (1995). Pregnant, Substance Using Women. Treatment Improvement Protocol (TIP) Series, Number 2. Rockville, MD: U. S. Department of Health and Human Services. Public Health Service. DHHS Publication Number (SMA) Chasnoff, Ira (1991(. Drugs and Alcohol Effects in Pregnancy and the Newborn. In Comprehensive Handbook of Drug and Alcohol Addiction (Norman S. Miller, ed.). Marcel Dekker Inc. New York: p131 Miller, Laura J. and Valerie D. Raskin (1995). Pharmacological Therapies in Pregnant Women with Drug and Alcohol Addictions. In Pharmacological Therapies for Drug and Alcohol Addictions (Norman S. Miller and Mark S. Gold eds.) Marcel Dekker Inc. New York: p265 WITHDRAWAL SEIZURES Devenyi, Paul and Marion Harrison (1985). Prevention of Alcohol Withdrawal Seizures with Oral Diazepam Loading. Canadian Medical Association Journal, Vol. 132, April: p of 14 pages

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