CAPTASA 2009 th 9 Annual Conference Embassy Suites

CAPTASA 2009 th 9 Annual Conference Embassy Suites Lexington, KY January 23, 2009

Detox – Then What?

“Dare to be naïve. ” R. Buckminster Fuller

Medical Detox A Way That Works

Why bother? A Safe Withdrawal from Alcohol and other Drugs A Withdrawal that is Humane and Protects Dignity Prepare the Patient for Ongoing Treatment Principles of Addiction Medicine 3 rd Ed. Page 612

The patient is the one With the problem

Which drugs need medical detox ? Alcohol Sedative/hypnotics Opiates

Dopamine Pathways – Pleasure pathways striatum frontal cortex hippocampus alcohol substantia nigra/VTA cocaine nucleus heroin accumbens nicotine amphetamines opiates THC PCP ketamine heroin alcohol benzodiazepines barbiturates

We should write that spot down.

Usual detox approach Benzo’s for Alcohol Benzo’s for Benzo’s Opiates for opiates

My Experience with Benzodiazepines

Opiates don’t have to be detoxed, right? Only if you want them to stay in Tx Only if you care about their dignity How many are pure Opiate users?

Alcoholics Anonymous, page 22 from ‘There is A Solution” Perhaps he goes to a doctor who gives him morphine or some sedative with which to taper off. Then he begins to appear at hospitals and sanitariums. This is by no means a comprehensive picture of the true alcoholic, as our behavior patterns vary. But this description should identify him roughly.

ASAM Textbook, 3 rd Ed. Page 643 Clinical experience shows that phenobarbital is most useful and effective with polysubstance dependence, high-dose dependence, and in patients with unknown dose or erratic “polyphramacy”

“Well, I woke up this morning And I got myself a beer. The future’s uncertain And the end (enemy) is always near. ” Roadhouse Blues-Jim Morrison

GABA- the down button

NMDA- the up button

Here’s what I do Hx of Use (What, How much, How long, other medical conditions…) Load with Phenobarb- (stop the train from leaving the station) Add on’s depending on drugs used Mg++ for Alcohol Clonidine for Opiates

Phenobarb dosage Load Regular dose taper PRN’s based on CIWA score

DAYS 1&2 Phenobarbital 180 mg PO now, then Phenobarbital 60 mg PO every 6 hours X 8 doses Obtain CIWA score every 4 hours If CIWA score greater than 15, give Phenobarbital 260 mg IM If CIWA score 8 -15, give Phenobarbital 120 mg PO

DAYS 3&4 Phenobarbital 60 mg PO every 12 hours X 4 doses Obtain CIWA score every 6 hours If CIWA score greater than 15, give Phenobarbital 120 mg PO If CIWA score 8 -15, give Phenobarbital 60 mg PO

Magnesium Sulfate Based on Alcohol use and age of Patient 1 Gm IM every 8 hours At least 2 doses Up to 4 for high volume drinkers and those with seizure Hx* PO Magnesium oxide is poor alternative, limit is 400 mg BID *Magnesium is not for seizures

Magnesium in Alcohol withdrawal Mg-NMDA connection

Clonidine dosage Clonidine 0. 1 mg PO now, then Clonidine 0. 1 mg PO every 6 hours X 8 doses, then Clonidine 0. 1 mg PO every 8 hours X 3 doses, then Clonidine 0. 1 mg PO every 12 hours X 2 doses Hold Clonidine if BP less than 90/55

Thiamine is critical for Tx of Alcoholism Thiamine 100 mg IM now, then 100 mg a day x 5 days. Folic acid 1 mg a day for 5 days.

Detox protocol at Schwartz Center Phenobarb 180 mg now Then Phenobarb 60 mg every 6 hr x 8 doses Then Phenobarb 60 mg every 12 hr x 4 doses Magnesium oxide 400 mg BID x 3 days Thiamine 100 mg daily x 5 days Folic acid 1 mg daily x 5 days Clonidine 0. 1 mg TID x 2 days and BID x 2 days

Phenobarb equivalents 30 cc 100 proof alcohol = 30 mg Xanax 1 mg = 30 mg Ativan 2 mg = 30 mg Klonopin 2 mg = 30 mg Valium 10 mg = 30 mg Librium 25 mg = 30 mg

What about Delirium? This is where dehydration is important First load with Phenobarb and push dose Avoid anticholenergic drugs Risperdal 2 mg + Ativan 2 mg PO Haldol 5 mg +Ativan 2 mg+ Benadryl 50 mg all IM

Then What?

“The important thing is not to stop questioning. ” Albert Einstein

Abstinence and Spiritual based Recovery isn’t sexy nor profitable It can be a lonely and unpopular message, but it is the Truth…

Don’t listen to friends when the Friend inside you says “Do this!” Mahatma Gandhi

Addiction is a brain disease a primary illness, not a symptom secondary to a psychiatric disorder Brain Reward Center: Median Forebrain Nucleus Accumbens Ventral Tegmental Area Dopamine

Can Amphetamines Help Cure Cocaine Addition? “It’s an idea that really does need to be rigorously evaluated” Frank Vocci, director of pharm. Tx NIDA Time magazine 12/8/2008

“One of the first duties of the physician is to educate the masses not to take medicine. ” Sir William Osler, Aphorisms from his Bedside Teachings

Everybody is on drugs except when they really need them… Rita Rudner

“…has not been systematically studied in humans for its potential for abuse …” From PDR under Effexor, Cymbalta, Paxil, Seroquel, Neurontin, Zyprexa, Celexa…

Clinical Antipsychotic Trials of Intervention Effectiveness Although they were first developed for schizophrenia, antipsychotic drugs are now broadly used for other disorders, including behavioral signs and symptoms… Despite their widespread use in these conditions, the overall effectiveness and safety of these drugs remain unclear.

Clinical Antipsychotic Trials of Intervention Effectiveness While industry-sponsored research is critical to new product development, its emphasis is on meeting regulatory and marketing requirements and on obtaining expanded marketing claims for the drug, not on evaluating the effectiveness of the product at the general population level.

Clinical Antipsychotic Trials of Intervention Effectiveness …although a variety of claims of efficacy and safety have been made, they are often based on insufficient evidence. Among the reasons for this is the fact that traditional clinical trials have excluded many patients with schizophrenia, including those who are substance abusers, violent or uncooperative, thus making it difficult to generalize the results…

Clinical Antipsychotic Trials of Intervention Effectiveness …the exact nature and extent of the clinical advantages of the atypical drugs are not known. Moreover, they cost more than ten times as much as most older drugs.

Morbidity and Mortality in People with Serious Mental Illness National Association of State Mental Health Program Directors Medical Directors Council

M & M in People with SMI report …with time and experience the second generation antipsychotic medications have become more highly associated with weight gain, diabetes, dyslipidemia, insulin resistance and the metabolic syndrome and the superiority of clinical response (except for clozapine) has been questioned.

Additional Evidence of the Abuse Potential of Quetiapine Reeves and Brister VA Med Center Jackson, MS April 2007 SMA Journal

Alcoholics Anonymous, page 64 from “How It Works” …for we have been not only mentally and physically ill, we have been spiritually sick. When the spiritual malady is overcome, we straighten out mentally and physically.

“The 12 -step model of recovery is the core technology in the short and long term treatment of alcoholism and addiction… the standard of care” Garrett O’Connor, MD CAPTASA 2005

Willingway Four Truths The total Cause of Alcoholism and Drug Addiction is Unknown. Alcoholism is at least in part a Chemical illness. There is a relationship between Alcoholism and Addiction to other drugs. Alcoholism is an illness of the total person (body, emotions, mind and spirit). www. willingway. com

$634. 5 M settlement for Oxy. Contin maker The firm and the current and former executives, including the CEO, pleaded guilty in U. S. District Court in Abingdon, Va. , to a felony charge of misleading doctors and consumers about the drug's risks of abuse and addiction, CNN said Wednesday.

CDC: Antidepressants most prescribed drugs in U. S. " Doctors are now medicating unhappiness” said Dworkin. "Too many people take drugs when they really need to be making changes in their lives. " CNN 7 -9 -07

Alcoholics Anonymous, page 58 from “How It Works” There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.

Drugs that are problems for Addicts Antidepressants Stimulants Antihistamines Cough suppressants Antipsychotics Mood Stabilizers Muscle relaxants

Neurophysiology of Recovery Extended withdrawal for years Structural and functional brain abnormalities Gradual normalization over first recovery decade Addiction may sensitize for mental dysfunction

• If you understand, everything is just as it is • If you don’t understand, everything is just as it is Zen proverb

Detox Protocol CIWA e-mail to physicians interested gljones@bluegrass. org