Basic Principles of Detoxification

Basic Principles of Detoxification Mark Menestrina, MD, FASAM Medical Director, SEMCA National Field Medical Advisor, Reckitt Benckiser Pharmaceuticals April 30, 2012

Credit where credit due Detoxification and Substance Abuse Treatment Training Manual: Based on a Treatment Improvement Protocol (TIP#45) SAMHSA, 2008 Priniciples of Addiction Medicine, R Ries et. al., 4e, Lippincott Williams and Wilkins, 2009 Addiction Medicine: An Evidence-Based Handbook, Rastegar and Fingerhood, Lippincott Williams and Wilkins, 2005 Principles of Addiction Medicine: The Essentials, C Cavacuiti, Lippincott Williams and Wilkins, 2011

Integration of Detoxification and Substance Abuse Treatment Detox patients are in a crisis, providing a window of opportunity to acknowledge substance abuse problem and seek treatment Research shows that detox is often followed by a reduction in drug use and a desire to seek treatment Detox staff can facilitate patient s entry into treatment

Addiction is a Brain Chemistry Disease Involves the Meso-Limbic System (Primitive and not conscious) Neurotransmitter Mediated Denial is a Hallmark Feature Emotional, Physical, Psychological Chronic, Progressive, potentially Fatal Affects Family, Community, Society Different than Abuse, anyone can Abuse Drugs or Alcohol. A Preventable Behavior

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8 Chemical Dependence

9 Behavioral Dependence

Detox DOES NOT equal Treatment But it is often the first step in the Recovery Process

Withdrawal Syndrome and Detoxification WITHDRAWAL SYNDROME is the predictable constellation of signs and symptoms following abrupt discontinuation of, or rapid decrease in, intake of a substance that has been used consistently for a period of time. DETOXIFICATION is the management of the Withdrawal Syndrome

First, do no harm Hippocrates

Loeb s Laws of Medicine 1) If what you are doing for the patient is helping the patient, keep doing it. 2) If what you are doing for the patient is not helping the patient, stop doing it. 3) Never ever let your patient see a surgeon.

Goals of Detoxification CSAT 1995a Provide a safe withdrawal and enable the patient to become free of nonprescribed medications Provide a withdrawal that is humane and protects the patient s dignity Prepare the patient for ongoing treatment of his or her dependence

Module 1 Objectives Define detox as distinct from substance abuse treatment Describe the three essential components of detox: evaluation, stabilization, and fostering entry to treatment Distinguish the six different DSM-IV-TR definition of terms relating to detox and treatment Identify at least two challenges to providing effective detox

History of Detoxification Services AMA declares alcoholism a disease in 1958 The Uniform Alcoholism and Intoxication Treatment Act (1971) Emergence of humanitarian views of those who are substance use dependent Emergence of new treatment models

Three Components of Detoxification Process Evaluation: screening and assessment Stabilization: assisting the patient through detox and withdrawal Fostering readiness and entry into treatment

Review of Terms Substance Substance-related disorders Substance dependence Substance abuse Substance intoxication Substance withdrawal

Fostering and Maintaining Abstinence Fostering abstinence includes: - Ongoing assessment of physical, psychological and social status - Identification of relapse triggers - Primary medical and psychological care as needed Maintaining abstinence includes: - Continuation of counseling and support - Refinement and strengthening of strategies for relapse prevention

7 Key Assumptions and Guiding Principles for Detox and Substance Abuse Treatment 1) Detox is not complete treatment 2) Detox process includes evaluation, stabilization and fostering treatment readiness 3) Detox takes place in a wide variety of setting 4) All treatment must be of the same quality and thoroughness

7 Key Assumptions and Guiding Principles for Detox and Substance Abuse Treatment 5) Insurance coverage for complete detox is cost-effective 6) Detox programs must be culturally competent in order to address the unique needs of all patients 7) Success depends on continuation of treatment after detox

Linkages to Treatment Services Linkages from detox to treatment leads to an increase in recovery and a decrease in repeated detox and treatment services Recovery leads to reductions in crime and reductions in expensive medical and surgical treatments Effective linkage to treatment services remains a signficant challenge to detox providers

Module 2 Objectives Define the types of settings for detox and treatment services Describe the role of the settings in the delivery of services Identify at least five issues to consider in determining whether inpatient or outpatient detox is preferred setting

Five Settings for Detoxification 1) Physician s office Services 2) Freestanding urgent care center or emergency department 3) Freestanding substance abuse treatment or mental health facility 4) Intensive outpatient and partial hospitalization programs 5) Acute care inpatient services

Six ASAM Assessment Criteria for Patient Placement 1) Acute intoxication and/or withdrawal potential 2) Biomedical conditions and complications 3) Emotional, behavioral or cogntive conditions and complications 4) Readiness to change 5) Relapse, continued use or continued problem potential 6) Recovery/living environment

Setting #1: Physician s Office Ambulatory Detox Without Extended Onsite Monitoring - Trained clinicians - Medically supervised evaluation, detox and referrals - Patients regularly monitored - Patients must have positive social support - Services delivered in office, treatment facility or patient s home

Setting #1: Physician s Office Ambulatory Detox With Extended Onsite Monitoring - Services provided by RNs or LPNs - Include medically supervised evaluation, detox and referrals - Patients monitored for several hours each day - Patients must have positive social support network - Services provided in treatment setting such as a day hospital

Setting #2: Freestanding Urgent Care Center or Emergency Dept Patients who require primary medical and/or nursing care services Include physician managed procedures and protocols Medically directed assessments and acute care include initiation of detox Not likely to include biomedical stabilization or 24 hour observation Triage to inpatient can be facilitated Staffing is typically physicians and nurses

Setting #3: Freestanding Substance Abuse Treatment or Mental Health Facility Inpatient Medically managed intensive patient detoxification 24 hour supervision, observation and support for intoxicated or withdrawing patients Stabilization and facilitation of linkages to other services Multidisciplinary staff: physicians, nurses, counselors, social workers, psychologists

Setting #3: Freestanding Substance Abuse Treatment or Mental Health Facility..Residential Medically managed or social detox 24 hour supervision and support Emphasize peer and social support Staffing: credentialed personnel using physician-approved protocols for observation, monitoring and supervision Medical consultation available 24/7 Some provide supervision of selfadministered medication

Setting #4: IOP and Partial Hospitalization Programs Regularly scheduled detox sessions Follows established protocols Onsite patient monitoring Linkages to treatment services Staffing includes interdisciplinary team of physicians, RNs, LPNs, counselors, social workers and psychologists

Setting #5: Acute Care Inpatient Settings Medically monitored inpatient detox 24 hour medically supervised eval and monitoring Follows established protocols Staffing includes interdisciplinary team of physicians, RNs, LPNs, counselors, social workers, psychologists Counselors available 8 hours a day for planned interventions

Module 3 Objectives Identify overarching principles for patient care during detox Describe strategies for evaluating/addressing psychosocial/medical issues for detoxing patients Address issues with special populations Describe strategies for engaging/retaining detox patients Identify effective referral techniques promoting initiation of substance abuse treatment

Biomedical Evaluation Domains General health history Mental status Physical assessment Use and patterns of substance abuse Past treatments for substance abuse

Psychosocial Evaluation Domains Demographics Living conditions Violence/suicide risk Transportation availability Financial situation Dependent children Legal status Physical, sensory or cognitive abilities

Conditions Requiring Immediate Medical Attention Change in mental status Increase in anxiety or panic Hallucinations High body temperature Increase/decrease in blood pressure Insomnia Abdominal pain Gastrointestinal bleeding Changes in responsiveness of pupils

Conditions Requiring Immediate Psychiatric Attention Suicide risk Anger De-escalating aggressive behaviors Co-occurring mental disorders

Nutritional Considerations During Detoxification Malnutrition can interfere with detox process Stress of detox requires additional nutrients Nutritional evaluation is necessary for detox New routines for mealtime and diet are crucial Important to manage gastrointestinal symptoms during detox Nutritional therapy may be required

Detoxification Considerations for Adolescents Binge drinking is common and can cause escalating alcohol levels Some drugs taken are not identifiable, routinely screen for illicit drugs Nondisclosure of drug use: (multiple substances with alcohol) establish rapport and obtain thorough history Screen for suicide potential

Detox Consideration for Parents with Dependent Children Barriers to Treatment: Parents, especially mothers, fear for the safety of their children Some children experience distress while parent is in treatment Ensure children have a safe place to stay Social services may need to be involved

Detox Considerations for Domestic Violence Victims Both men and women may be vicitims Increased risk for female drug abusers to be victims Develop safety plan when violence is disclosed Avoid communications between abused and abuser during detox Vicitms may need help with parenting skills Know local childcare resources

Detox Consideration for Culturally Diverse Patients Patient s detox expectations may vary Patient s experience in health care system may vary Patient s cannot be defined by their culture/ethnicity Use open-ended questions to gain understanding Important to have bilinual staff if possible to avoid language barriers

Detox Consideration for Chronic Relapsers Relapser may feel hopeless and vulnerable Acknowledge progress made before relapse Reassure that gains from prior progress have not been lost Reinforce the importance of recovery

Strategies to Engage and Retain Patients in Detoxification Offer hope Provide atmosphere with comfort, relaxation, cleanliness and security Educate patients on withdrawal process Utilize support systems Maintain a drug-free enviornment Consider alternative approaches Enhance patient motivation Foster a therapeutic alliance

Enhancing Patient Motivation Focus on strengths Show respect for autonomy Avoid confrontation Provide individualized treatment Avoid using labels Use empathy Recognize small steps toward achieving goals Raise awareness of discrepancies Use reflective listening

Stages of Change Precontemplation: no consideration for change, unaware of problem Contemplation: some awareness of problem, willing to consider change but ambivalent Preparation: aware of problem, decision made to change, goal setting Action: takes steps to achieve goals to change Maintenance: works to maintain changes made

Fostering a Therapeutic Alliance Be supportive and empathetic Refer when patient cannot be engaged Establish rapport, discuss confidentiality issues, be cognizant of challenges for patient Be consistent, trustworthy, reliable, calm and cool, confident and humble Be able to set limits without power struggle Be cognizant of patient s progress Encourage patient s self-expression

Common Barriers to Referral After Detox Patient s may believe they are cured once eliminating substance Patient s may feel they no longer need help after detox Insurance may only provided partial or limited coverage Paperwork for insurance may be overwhelming Patients may struggle with insurance system

Evaluating Rehab Needs Psychosocial needs Special needs may limit access to rehab Limitations or conditions may limit suitable treatment settings Support system may influence referral Dependent children may impact needs May be need for gender-specific treatment

Areas for Assessment Medical Motivation Physical, sensory or mobile limitations Relapse history and potential Substance abuse/ dependence Developmental or cognitive issues Family/social support Co-occurring issues Dependent children Trauma/violence Treatment history Cultural background Strengths and resources Language

Treatment Settings Inpatient programs Residential treatment programs Therapeutic communities Transitional/halfway houses PHP and day programs Intensive outpatient programs Traditional outpatient services Recovery maintenance activities

Following Through with Treatment Referral Patients are more likely to initiate treatment if they: - Believe they will be helped - Are employed - Motivated beyond precontemplation - Have family and social support - Have co-occurring psychiatric conditions

Strategies to Promote Initiation of Treatment After Detox Assess degree of urgency Reduce appointment wait times Call to reschedule missed appointments Provide information to show expectations Offer tangible incentives Engage support of family members Introduce patient to counselor Offer referral/services to address other needs Minimize accesss to treatment barriers Maintain motivation during waitng list period Facilitate coordination of co-occurring treatment Ensure medical appointments are being made Some patients may require non-traditional treatment

Module 4 Objectives Identify biochemical markers and their use for screening and assessment Describe key concepts for treatment regimens for detox from specific substances Explain why management of polydrug abuse and use of alternative approaches to detox are important Identify special considerations for special populations in the detox process

Biochemical Markers Lab tests that detect the presence of alcohol or other drugs Used to support a diagnosis Used for forensic purposes Used to detect the use of alcohol or other drugs during treatment Can serve as motivational enhancement Can help in moving patient from contemplation to action

Most Common Types of Biochemical Markers Blood alcohol levels Breath alcohol levels Urine drug screens Gamma-glutamyltransferase GGT Carbohydrate-deficient transferrin CDT Mean corpuscular volume MCV Ethylglucoronide EtG

Alcohol Intoxication 20-100mg%: Mood, behavior changes, reduced coordination, impaired driving 101-200mg%: Reduced coordination, speech, gait, judgment impaired 201-300mg%: Marked impairment of thing, memory, alertness. Blackouts 301-400mg%: Reduction of BP and temp. Sleepiness, amnesia, N&V 401-800mg%: Coma, incontinence, death

Alcohol Withdrawal Restless, irritable, anxiety, agitation Anorexia, N&V Tremors, increased HR and BP Insomnia, intense dreams/nightmares Poor concentration, impaired memory and judgment Increased sensitivity to sound, light, tactile sensations Hallucinations auditory, visual or tactile Delusions Seizures Hyperthermia Delirium

Alcohol and other Sedatives Alcohol and other Sedatives exert their effects by directly or indirectly enhancing GABA (inhibitory) With abstinence there is a relative deficiency of GABA Alcohol also inhibits the sensitivity of autonomic adrenergic systems with resulting upregulation with chronic alcohol intake Discontinuation leads to rebound overactivity of brain and peripheral noradrenergic systems

Alcohol/Sedative Withdrawal Signs and Sx Begin 6-24 hours after alcohol cessation, variable for other sedatives, depending on half-life Early s/s include anxiety, sleep disturbances, vivid dreams, anorexia, nausea and headache Tachycardia, hypertension, hyperactive reflexes, diaphoresis, hyperthermia Seizures most often occur within 48 hours Delirium Tremens (DTs) typically begins 48-72 hours after last drink, preceded by typical signs and symptoms of early withdrawal

CIWA-Ar Nausea and Vomiting Tremor Paroxysmal Sweats Anxiety Agitation Tactile Disturbances Auditory Disturbances Visual Disturbances Headache Orientation/Sensorium Scored from 0-7 (0-4 for Orientation Maximum Score 67 <10 generally don t require meds, >20 do Between 10-20, follow closely for worsening withdrawal

Pharmacological Management Suppression of Withdrawal through use of a cross-tolerant medication, usually with a longer duration of action Reduction of signs and symptoms of withdrawal through alteration of another neuropharmacological process May use one or the other or both

Benzodiazepines for Detox Safer Therapeutic Index Anxiolytic Better with hepatic dysfunction (lorazepam and oxazepam) Euphorogenic Abuse Potential and Cross Addiction Many Alcoholics are also using/ dependant on Benzos

Phenobarbital for Detox Not very euphorogenic Long half-life Lower abuse potential Therapeutic Index not as favorable as benzos Not as anxiolytic Caution with hepatic disease, porphyria

Benzodiazepines and Other Sedative Hypnotics Important Factors for Success: Start detox during period of low external stressors Patient must be committed to taper off substance Develop plan for managing underlying anxiety disorders Frequent patient contact

A Protocol for Benzodiazepine Withdrawal (+/- Alcohol) Phenobarb Protocol, with phenobarb taper after detox (3-6 days?) Begin valproic acid 1000 mg +/- daily unless contraindication, in which case consider gabapentin or other anticonvulsant mood stabilizer continue 6 weeks or more, taper? Significant withdrawal symptoms may be treated with propanolol, quetiapine, etc Insomnia usually treated with trazodone, occasionally atypical antipsychotics

Seizures and Alcohol / Benzodiazepine Withdrawal The number one predictor of w/d seizures is a previous history of w/d seizures get a good history! For alcohol w/d only (no hx of benzos) consider adding valproic acid to phenobarb Brighton Hospital: ~2-3 seizures per year (~2500 admissions), usually non-disclosed significant benzo dependence and occur after detox and transfer to rehab

Opioid Intoxication Lowered HR, BP, body temperature Sedation Pinpoint pupils (miosis) Slowed movement Slurred speech Head nodding Euphoria, calmness, imperviousness to pain

Opioid Withdrawal Syndrome Usually begin within 12 hours after cessation of short acting opiates (heroin, hydrocodone, immediate release or crushed oxycodone), later with longer acting drugs (methadone, oxycodone) Rarely life-threatening the Safest Withdrawal, or is it?

Opioid Withdrawal Increase HR, BP, body temperature Insomnia, increased reflexes Enlarged pupils Sweating, increased respirations Tearing, runny nose, muscle spasms Abdominal cramps, N&V, diarrhea Bone and muscle pain Anxiety

Clinical Opioid Withdrawal Scale (COWS) Wesson & Ling 2003 Resting Pulse Sweating Restlessness Pupil Size Bone/Joint Aches GI symptoms Tearing/Rhinorrhea Tremor Yawning Anxiety Gooseflesh Like CIWA, numerical values given and score totaled Various Scales exist, all serve to measure withdrawal and guide need for treatment

Common Medications Used to Manage Opioid Withdrawal Methadone Clonidine (Catapress ) Buprenorphine (Suboxone ) Rapid and Ultra-rapid opioid detoxification

Stimulant Withdrawal (Cocaine, Crack, Amphetamines) Depression, fatigue, anxiety, irritability Hypersomnia or insomnia Poor concentration Psychomotor retardation Increased appetite Paranoia Drug craving

Cocaine and other Stimulants Regular users seem to experience withdrawal, but not as clear cut as sedatives or opioids Symptoms include dysphoria, fatigue, insomnia or hypersomnia and psychomotor agitation or retardation, cravings, increased appetite and vivid unpleasant dreams ( using dreams ) Peak at 2-4 days, longer for amphetamines Treatment generally supportive (amantadine?)

Symptoms of Inhalants and Solvents Delirium, tremors, weakness, weight loss, inattentive behavior, depression Impaired cognitive, motor and sensory functioning Internal organ damage, including heart, lungs, kidneys and liver

Medical Management of Inhalant Abuse and Dependence Provide safe environment that is free of inhalants Supportive care, including ample sleep and well-balanced diet Determine if patient is abusing other substances Access mental status Provide appropriate therapy and interventions

Nicotine Withdrawal Symptoms Depressed mood, anxiety Insomnia, irritability, frustration, anger Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

Medical Management of Nicotine Withdrawal Self-help interventions Behavioral interventions Nicotine replacement therapy Bupropion (Wellburtin ) Combination therapy Varenicline (Chantix )

USPHS Nicotine Intervention: The 5 A s ASK about tobacco use ADVISE to quit ASSESS willingness to make a quit attempt ASSIST in the quit attempt ARRANGE a follow up

Marijuana THC abstinence syndrome Symptoms include: - Anxiety - Restlessness, irritability - Sleep disturbance - Change in appetite No medical complications of withdrawal

Anabolic Steroids Subject to abuse Aggressive, manic-like behavior W/D includes fatigue, depression, restlessness, insomnia, anorexia, reduced sex drive, headache, nausea Side Effects can be reversed and may include: UTIs, skin redness and blistering, edema, behavior changes No detox protocol for steroids

Club Drugs A diverse class including GHB, Ecstasy, Rohypnol Used in nightclubs and raves Withdrawal symptoms may include intoxication and overdose Destructive effects on nervous system and mental health

Best Practices for Management of Polydrug Abuse Prioritize substances according to withdrawal severity Alcohol and sedative hypnotics (benzos) have the most severe w/d Opioid detox is the next priority Some substances will not require treatment during detox, including stimulants, marijuana, hallucinogens and inhalants

Considerations for Pregnancy Detox on demand, women-centered Transportation, child care issues Counseling and case management Access to safe housing Legal, nutritional, social needs Ensure health and safety of both infant and mother Clarify risk/benefit of any medications Protocol for w/d may vary with each pregnancy

Considerations for Elderly Supportive, nonconfrontational agespecific group Screen for depression, grief, loss Linkages to specialized services Alcohol and drug issues more severe with elderly At risk for co-occurring disorders Ongoing assessments and monitoring for medical problems common in aged

Considerations for Disabled Eliminate barriers: attitudinal, discriminatory, communication and architectural Impairment categories include physical, sensory, cognitive, affective Detox programs must screen for disabilities, be compliant with federal laws, provide access to services, coordinate treatment and know local and national disability resources

Considerations for Minorities African Americans are at greater risk for DM and HTN, may display distrust with counselors of different culture and may be at greater risk of toxic side effects with antidepressants Hispanic/Latinos are largest minority in US. Access level of acculturation, language competency helpful, family is important, substance use often viewed as moral weakness

Considerations for Minorities Native Americans, great diversity, highest rate of alcohol and drug use. Fables and Healing Circles may be helpful. Frame 12 steps in terms of circle, not a ladder Avoiding eye contact is traditional Tend to seek treatment later with more medical complications Fetal Alcohol Syndrome 33x US average

Considerations for Minorities Asians and Pacific Islanders, also a very diverse group May show concern for counselor credibility, trustworthiness Higher sensitivity to alcohol Smoking rates tend to be high Some detox meds may be metabolized more slowly Important to use traditional healing methods and ask attitude toward Western medicine

Considerations for Other Populations Gay, Lesbian, Bisexual and Transgender - Monitor staff attitude - Help patients with previous negative experiences and accept personal power Adolescents - Physical dependence not as severe, more rapid response to detox - Retention is a problem - Higher club drugs and steroids - Peer relationships play a large role in treatment

Considerations for Incarcerated or Detained Individuals Substance use common, 70-80% of inmates have used or committed drug offenses Abrupt w/d from alcohol or sedatives can be life-threatening W/D from opioids can cause great stress Substance abuse can continue during incarceration Access to detox can be major problem

Summary Detoxification is not treatment, but it often may be the first phase of engaging a person, and can serve as an entry point to facilitate ongoing change and entry into the recovery process A teachable moment

Selected Cases Male alcoholic, with severe cirrhosis, who states his doctor told him to stay away from liquor, just drink beer or wine Alcoholic, relapsed after chemo nurse told him to have a glass of wine after txs Alcoholic, on alprazolam for 3 months after doctor told him to take a pill each time he wanted to drink Gentleman who said his doctor of 17 years didn t know he drank

Warren L. 51 yo wm, presents intoxicated but walking and talking, BAT of 0.43 Except for hx of HTN, no other problems What would you be concerned about in addressing and treating his withdrawal?

Shirley B. 63 yo wf, hx of multiple admissions for alcoholism w/o sustained recovery Denies any other drug use, but UDS on admission is positive for benzos which, when questioned, she says she got something in the ER 2 days previously

Lawrence T. 44 yo AA male, presents with hx of heroin, hydrocodone and oxycodone 20 hours after admission, he c/o of being dope sick, and buprenorphine is started He becomes violently ill, with sweats, vomiting, diarrhea, refuses to take any further Rx and leaves AMA

ADDICTION TREATMENT MADE EASY. A to B M Menestrina NEGATIVE Consequences: The job, liver, judge, wife, boss, friend get the individual s attention! POSITIVE Reinforcement: The individual actually begins to like and enjoy recovery While this process is achievable, it is not likely to all make sense to the patient. It may involve 12 step, counseling, treatment of co-morbid conditions, Medication Assisted Treatments and other modalities.

NEVER DOUBT THAT A SMALL GROUP OF DEDICATED CITIZENS CAN CHANGE THE WORLD INDEED IT IS THE ONLY THING THAT EVER HAS Margaret Meade