Q2: What interventions are safe and effective for drug withdrawal (cannabis, amphetamines, cocaine, benzodiazepines, and inhalants)?

Transcription

1 updated 2012 Management f drug withdrawal Q2: What interventins are safe and effective fr drug withdrawal (cannabis, amphetamines, ccaine, benzdiazepines, and inhalants)? Backgrund Cessatin f dependent substance use can result in a withdrawal syndrme, which may range in severity frm mildly uncmfrtable t severely distressing and can result in cmplicatins such as seizures, delirium and relapse t drug use. Many medicatins have been used t treat specific withdrawal symptms, such as benzdiazepines fr insmnia, NSAIDS fr muscle aches and s n. Sme medicatins have been used t amelirate withdrawal symptms mre generally, and these are the subject f this review. Ppulatin/Interventin(s)/ Cmparisn/Outcme(s) (PICO) Ppulatin: Interventins: medicatin fr the treatment f withdrawal Cmparisn: Outcmes: persns dependent n cannabis, stimulants, benzdiazepines f inhalants placeb r n treatment r treatment as usual withdrawal severity cmpletin f withdrawal cmplicatins f withdrawal drug use 1

2 List f the systematic reviews identified by the search prcess A number f reviews have examined pharmactherapy appraches fr cannabis (Benyamina et al 2008; Cpeland & Swift, 2009; Budney et al, 2007; Elkashef et al, 2008; Shptaw et al, 2009; ccaine (x 3 Cchrane reviews). These reviews have identified small numbers f studies using varieties f medicatins fr different drug classes. Reviews were nt GRADEd. Narrative descriptin f the studies that went int the analysis Studies fr cannabis withdrawal have examined a range f medicatins, withut any licensed medicatins being identified as cnsistently imprving utcmes in cntrlled trials. Studies f ccaine and amphetamine withdrawal have examined a range f medicatin appraches, including tricyclic antidepressants, SSRIs, dpamine agnists, anticnvulsants and mdafinil. T date, there have been n medicatins shwn t cnsistently imprve utcmes fr stimulant withdrawal. Benzdiazepines: a review f cntrlled studies examining pharmaclgical appraches t benzdiazepine withdrawal identified 8 RCTs with 458 subjects, all examining different benzdiazepine tapers in utpatient settings, and the ptential rle f adjunctive medicatin. Studies supprted gradual taper ff BZDs (e.g. ver a 10-week perid) rather than an abrupt cessatin f medicatin (Murphy & Tyrer, 1991; Lemine et al, 1997), and the use f lng-acting ver shrt acting BZDs Carbamazepine was identified in ne small RCT (Schweizer et al, 1991) as a ptential adjunct t BZD in alleviating withdrawal discmfrt, but did nt cnsiderably imprve ther utcmes (e.g. withdrawal cmpletin). Evidence suggests that psychscial supprt assist withdrawal frm benzdiazepines. References Benyamina A et al (2008). Pharmactherapy and psychtherapy in cannabis withdrawal and dependence. Expert Review f Neurtherapeutics, 8: Budney AJ et al ( 2007). Marijuana Dependence and Its Treatment. Addictin Science and Clinical Practice. Available nline at Cpeland J, Swift W (2009). Cannabis use disrder: epidemilgy and management. Internatinal Review f Psychiatry, 21: Elkashef A et al (2008). Marijuana neurbilgy and treatment. Substance Abuse, 29:

3 Lemine P, Tuchn J, Billardn M (1997). [Cmparisn f 6 different methds fr lrazepam withdrawal. A cntrlled study, hydrxyzine versus placeb] (in French). Encéphale, 23: Murphy SM, Tyrer P (1991). A duble-blind cmparisn f the effects f gradual withdrawal f lrazepam, diazepam and brmazepam in benzdiazepine dependence. The British Jurnal f Psychiatry, 158: Shptaw SJ et al (2009). Treatment fr amphetamine withdrawal. Cchrane Database f Systematic Reviews, (2):CD Schweizer E et al (1991). Carbamazepine treatment in patients discntinuing lng-term benzdiazepine therapy. Effects n withdrawal severity and utcme. Archives f General Psychiatry, 48: Frm evidence t recmmendatins Factr Explanatin Narrative summary f the evidence base Studies fr cannabis withdrawal have examined a range f medicatins, withut any licensed medicatins being identified as cnsistently imprving utcmes in cntrlled trials. Studies f ccaine and amphetamines withdrawal have examined a range f medicatin appraches, including tricyclic antidepressants, SSRIs, dpamine agnists, anticnvulsants and mdafinil. T date, there have been n medicatins shwn t cnsistently imprve utcmes fr stimulant withdrawal. Benzdiazepines: a review f cntrlled studies examining pharmaclgical appraches t benzdiazepine withdrawal identified 8 RCTs with 458 subjects, all examining different benzdiazepine tapers in utpatient settings, and the ptential rle f adjunctive medicatin. Studies supprted gradual taper ff BZDs (e.g. ver a 10-week perid) rather than an abrupt cessatin f medicatin (Murphy & Tyrer, 1991; Lemine et al, 1997, and the use f lng-acting ver shrt acting BZDs. Carbamazepine was identified in ne small RCT (Schweizer et al, 1991) as a ptential adjunct t BZD in alleviating withdrawal discmfrt, but did nt cnsiderably imprve ther utcmes (e.g. withdrawal cmpletin). Summary f the quality f evidence Quality f evidence nt GRADEd, but in general pr quality evidence with few studies, and small sample sizes. 3

4 Balance f benefits versus harms Define the values and preferences including any variability and human rights issues Define the csts and resurce use and any ther relevant feasibility issues There is a belief that the best interventin fr substance withdrawal is "cld turkey". The perspective taken here is that if a persn experiencing substance withdrawal symptms requesting assistance t manage substance withdrawal shuld receive what supprt is reasnably available. The supprtive medicatins used fr the treatment f substance withdrawal are nt expensive (benzdiazepines, antiemetics, analgaesics, antidiarrheals, and s n). Recmmendatin(s) Withdrawal frm cannabis, ccaine r amphetamines is best undertaken in a supprtive envirnment. N specific medicatin is recmmended fr the treatment f withdrawal frm these drugs. Strength f recmmendatin: STANDARD Relief f symptms (e.g. agitatin, sleep disturbance) may be achieved with symptmatic medicatin fr the perid f the withdrawal syndrme. Less cmmnly, depressin r psychsis can ccur during withdrawal, in these cases the individual needs t be mnitred clsely and advice sught frm relevant specialists, if available. Strength f recmmendatin: STANDARD Withdrawal frm benzdiazepines is best undertaken in a planned (elective) manner, using a gradually tapering dse ver 8-12 weeks and with cnversin t lng-acting benzdiazepines, rather than using shrt-acting nes. Psychscial supprt is helpful fr individuals underging a tapering regime. Benzdiazepine withdrawal syndrme, if uncntrlled, can be severe; if a severe withdrawal develps (r ccurs in an unplanned way n sudden stppage f these drugs), specialist advice shuld be btained regarding starting a high-dse benzdiazepine sedatin regime and hspitalizatin. Strength f recmmendatin: STRONG In individuals withdrawing frm benzdiazepines, the presence f physical cmrbidity (such as seizures r chrnic pain) r psychiatric cmrbidity may be an additinal indicatin fr hspitalizatin. Strength f recmmendatin: STANDARD 4

5 Update f the literature search June 2012 In June 2012 the literature search fr this scping questin was updated. N new systematic reviews were fund t be relevant. 5