Detox Day. RCGP June 13 th Daphne Rumball Addictions Psychiatrist. Norfolk. Daphne Rumball RCGP Detox Day June

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1 Detox Day RCGP June 13 th 2006 Daphne Rumball Addictions Psychiatrist Norfolk Daphne Rumball RCGP Detox Day June

2 Scope of presentation Undertaking detox in the community A review of evidence and best practice How is detox affected by poly-drug use and alcohol dependence? Daphne Rumball RCGP Detox Day June

3 Learning outcomes To be confident in advising patients about detox options To have improved knowledge for specialist collaboration To be able to make/ contribute to detox plans with patients To initiate and conduct detox in the community with appropriate skill Daphne Rumball RCGP Detox Day June

4 Which substances? Opiates Benzodiazepines Alcohol in context of drug withdrawal Daphne Rumball RCGP Detox Day June

5 To Detox or not? choice timing self detox enforced detox failures + adverse memories successes repeats + learning experience Daphne Rumball RCGP Detox Day June

6 Risks Demoralisation and relapse Accidental overdose More likely in completed detox than in uncompleted detox (Strang et al) More likely after enforced detox Prison Hospital Commonest cause of mortality in drug users Daphne Rumball RCGP Detox Day June

7 Loss of tolerance and overdose mortality after inpatient opiate detox: follow up study. Patients who "successfully" completed inpatient detoxification were more likely than other patients to have died within a year. No patients who failed to complete detoxification died. 43 "still tolerant" : 3 OD deaths + 1 DRD 57 "reduced tolerance" : 1 DRD 37 "lost tolerance" : nil deaths Deaths occurred in those with larger doses on admission and longer I/P stays Strang J, McCambridge J, et al BMJ Daphne Rumball RCGP Detox Day June

8 Self Detoxification 58% of 114 patients attending MMT had attempted to detoxify themselves from opiates without medical assistance Av 3.6 attempts per individual 23% decided "they could cope on their own and that they didn't need any help." 41% abstinent for at least 24 hours 23% reported that they "didn't know why they started using again." 27% reported they were just "tempted to use" The prevalence of both attempts and success suggests that, for some opiate users, self-detoxification may be a pathway to abstinence. How should we help patients choose???? Noble A, Best D et al. Addict Behav Daphne Rumball RCGP Detox Day June

9 Where to start assessment? Readiness to change Appropriate circumstances physical relationships Vulnerability for escalation of other dependencies; alcohol, benzo s Mental health vulnerability Personality disorders Seivewright N, Daly C 1997 Drug & Alcohol Review Daphne Rumball RCGP Detox Day June

10 Readiness to change Rollnick, Heather et al,1992 Br Journal Addiction Short questionnaire to measure readiness Applies to alcohol Measures Pre-contemplation, contemplation and Action Same issues essential in all care planning to avoid mis-match Daphne Rumball RCGP Detox Day June

11 Setting Primary care Specialist O/P Specialist / collaborative home detox Specialist I/P I/P kick-start & O/P or 1 o care General hospital Residential rehab Daphne Rumball RCGP Detox Day June

12 Benzo s: Why the focus? Not main focus for DDU service users goals Benzodiazepine use may impede progress in therapy Daphne Rumball RCGP Detox Day June

13 Often overlooked by practitioners Grey areas of prescribing responsibility between primary and specialist care Seen as safety net by service users Easier to forget! Daphne Rumball RCGP Detox Day June

14 Therapeutic disadvantages Cognitive side effects combine with the learning difficulties, educational and social skills deficits common in this group and impair progress in therapy Daphne Rumball RCGP Detox Day June

15 Benzos and opiate withdrawal Co-dependent patients had significantly more severe opiate withdrawal symptoms Concurrent benzodiazepine withdrawal exacerbates opiate specific withdrawal symptoms de Wet C, Reed L, et al. Drug Alcohol Depend MMT patients who abuse BZDs are at an increased risk for continuing polydrug abuse Bleich A, Gelkopf M, et al. Isr J Psychiatry Relat Sci Daphne Rumball RCGP Detox Day June

16 Problem prevalence General population Illicit benzodiazepine use, particularly by opioid users, is a major problem for users in and out of drug treatment Now the largest group of users of benzodiazepines that need help with this problem Oyefeso A, Ghodse H, Williams H Addiction Research 4 (1): 57-64:1996 Prevalence and Pattern of benzodiazepine abuse and dependence among patients in a methadone maintenance detoxification programme. Daphne Rumball RCGP Detox Day June

17 Orange Guidelines No evidence to suggest that L/T substitute benzodiazepine prescribing reduces harm L/T use above 30mg may cause harm Advises reluctance to initiate bzd scripts Gradually reduce doses of those already on more than 30mg daily Hold any methadone dose stable while reducing bzd dose Daphne Rumball RCGP Detox Day June

18 Problem prevalence DDU populations Up to 90% of people attending drug treatment centres reported benzodiazepine use in a one-year period Perera KM, Tulley M, Jenner FA 1987 Brit J of Addiction, 82, Almost half had injected them Strang J, Griffiths P, et al. BMJ 1994 Survey of use of injected benzodiazepines amongst drug users in Britain Daphne Rumball RCGP Detox Day June

19 BNF guidance DEPENDENCE AND WITHDRAWAL Withdrawal of a benzodiazepine should be gradual because abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens Gives specific advice re withdrawal process Daphne Rumball RCGP Detox Day June

20 The impact on treatment services Client progress in other areas Treatment resources, time and emotion Service users behaviour Daphne Rumball RCGP Detox Day June

21 Reduction advice: O/P setting Convert to diazepam (conversion chart BNF) Start lowest dose to prevent withdrawals Divide daily dose Reduce as tolerated e.g. 2.0mg per 2weeks Larger reductions for doses > 50mg Smaller reductions at < 10mg Use non-bzd hypnotic if required Seivewright N (1995) Benzodiazepine Misuse, Report of Health Taskforce to review services for drug misusers Orange guidelines Drug Misuse & Dependence DH,1999 Ford C, Roberts K, & Barjolin J SMMGP. Guidance on Prescribing Benzodiazepines to Drug Users in Primary Care. (2005) Daphne Rumball RCGP Detox Day June

22 Withdrawal syndrome: several months duration Anxiety symptoms anxiety, insomnia, sweating, headache, tremor, nausea sudden, extreme mood swings Consider antidepressants or mood stabilisers Disordered perceptions feelings of unreality, abnormal body sensations, sensations of movement, hypersensitivity to stimuli Offer reassurance and support Major complications Psychosis, seizures Medicate / refer Daphne Rumball RCGP Detox Day June

23 Opiates Detox only when in clear Action phase of change Ensure plenty of planning Relapse prevention strategies in place Daphne Rumball RCGP Detox Day June

24 Methods of opiate detox Dose reduction from prescription Short-term substitute Px from heroin Methadone DF118 Subutex transfer detox from herion from methadone Opiate-free detox with symptomatic meds +/- lofexidine (or clonidine) Precipitated detox using naloxone Anaesthesia assisted detox Daphne Rumball RCGP Detox Day June

25 Anaesthesia assisted detox L Gowing, R Ali, J White Cochrane Database Syst Rev studies incl 5 RCTs Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. Daphne Rumball RCGP Detox Day June

26 Opiate-free detox + lofexidine Still commonly used in prisons Poor symptom control unless high dose lofexidine and other symptomatic medication Commence lofexidine and build up dose before stopping opiate; improves symptom control Daphne Rumball RCGP Detox Day June

27 Lofexidine for stepped reduction Stepped or partial reduction of methadone or buprenorphine eg to reduce methadone in 20-30mg stages from high dose (private patients, dealers, pain patients) Initiate lofexidine 2 days prior to reducing Useful for reducing previously excessive tolerance or in preparation for full detox Daphne Rumball RCGP Detox Day June

28 Detox precipitated by naltrexone Can reduce overall severity and duration of withdrawal compared to lofexidine alone Buntwal N, Bearn J, et al.2000 Drug & Alcohol Dependence and compared to methadone reduction Bearn J, Gossop M, et al Drug & Alcohol Dependence Now largely superseded by other methods Daphne Rumball RCGP Detox Day June

29 Methadone reduction Standard, well known approach Applicable in any setting Variable rate Supplement with symptomatic treatment including lofexidine, hypnotics etc Poor outcome except in residential rehab NTORS Associated with adverse mood change and relapse Bradley B, Phillips G et al Br J Psychiatry Daphne Rumball RCGP Detox Day June

30 Buprenorphine reduction Compares well with lofexidine in completion in abstinence at 1 month Raistrick D, West D, et al Addiction Compares well with methadone reduction during detox peak symptoms less severe symptoms resolved more quickly Glasper A, Reed L, et al Poster presentation Daphne Rumball RCGP Detox Day June

31 DF118 reduction Commonly used in primary care Popular with service users;? shorter duration withdrawals Little evidence base Difficult at lower dose due to short half life Daphne Rumball RCGP Detox Day June

32 Subutex Transfer + reduction Achievable at methadone doses 30-70mg Transferred to Bup 12-16mg as I/Ps Adjunctive lofexidine prn Useful precursor to buprenorphine reduction detox completion as I/P or O/P Glasper A, Reed L et al Addiction Biology Daphne Rumball RCGP Detox Day June

33 Opiate withdrawal in poly-drug users Methadone + carbamazepine cf Buprenorphine + carbamazepine Buprenorphine group had better mood and lower anxiety higher completion Carbamazepine thought to assist symptoms of withdrawal of alcohol, benzo s and other drugs Seifert J, Metzner W et al Addiction Biology Daphne Rumball RCGP Detox Day June

34 How much? Daphne Rumball RCGP Detox Day June

35 Alcohol detox in opiate dependence Valuable intervention Enables opiate re-stabilisation Standard chlordiazepoxide schedule Beware reduced methadone requirement - take a vomiting history! David Young Personal communication Otherwise likely to need opiate dose increase after alcohol withdrawal Consider Acamprosate and Disulfiram Daphne Rumball RCGP Detox Day June

36 Alcohol detox good practice Anticipate AWS s Good doses chlordiazepoxide Avoid seizure kindling Early use of Acamprosate GABA protection from seizures Lingford-Hughes A, 2005 Verbal report Daphne Rumball RCGP Detox Day June

37 BAP Guidelines Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. Lingford-Hughes AR, Welch S et al J Psychopharmacol. Daphne Rumball RCGP Detox Day June

38 Thank you Chris Ford for the invitation SMMGP website for information The team at TADS Norfolk for working with me beyond the evidence base Jenny Bearn and others, for doing the proper research Daphne Rumball RCGP Detox Day June

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