Alcohol, Benzodiazepine and Opiate Detoxification: A Key Point Review

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Alcohol, Benzodiazepine and Opiate
Detoxification A Key Point Review

• Alicia M. Baros, PhD, RN
• Trina Ayeroff, DNPc, BSN
• Gulf Oaks
• Biloxi Regional Medical Center

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MOST ADULTS WITH ALCOHOL PROBLEMS DO NOT
RECOGNIZE THEIR NEED FOR TREATMENT

• According to the national survey on drug use and
  health
• When adults aged 21 to 64 were asked
• During the past 12 months, did you need
  treatment or counseling for your use of alcohol?
• Less than 2 of those with alcohol abuse realize
  their problem 
• Less than 8 of those with alcohol dependence
  realize their problem. 

Retrieved from http//oas.samhsa.gov
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Adults Aged 21 to 64Who Meet Criteria for
Alcohol Abuse
Retrieved from http//oas.samhsa.gov
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Adults Aged 21 to 64Who Meet Criteria for
Alcohol Dependence
Retrieved from http//oas.samhsa.gov
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Identifying Alcohol Disorders and Risk Factors
through Primary Care

• Primary Care is a great opportunity for early
  intervention
• Adoption of integrated healthcare models which
  include brief behavioral risk assessments and
  interventions help treat the whole person and
  eliminate barriers in traditional medical
  settings.
• When integrated models are used in primary care,
  researchers have found higher level of referrals
  made to and treatment received in mental health
  services for at risk or high risk individuals

Funderburk, J. S., et. al, doi10.1300/J465v28n04_
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Risk Factors or Co-morbidities frequently seen
with Alcohol Disorders

• Body Mass Index (BMI)
• High Blood Pressure/Hypertension
• High-Density Lipoprotein/High Cholesterol
• Cardiovascular Disease
• Smoking
• Decreased Physical Activity/Sedentary Lifestyle
• Depression
• Diabetes
• Arthritis

Funderburk, J. S., et. al, doi10.1300/J465v28n04_
02
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Alcohol Abuse Alcohol Dependence Alcohol Use
Disorder

• The American Psychiatric Association (APA) and
  the International Classification of Diseases
  (ICD) of the World Health Organization has
  proposed a revision to the upcoming Diagnostic
  and Statistical Manual of Mental Disorders
  (DSM-V)
• Many problems were identified in DSM-IV with
  determining the division between abuse and
  dependence
• Numerous studies later it has been determined the
  criteria for alcohol abuse and dependence are
  interrelated on an underlying spectrum of
  severity

Retrieved from http//www.dsm5.org
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Alcohol Use Disorder

• The new diagnosis will be defined with 11
  possible maladaptive patterns or criteria seen in
  individuals with the disorder
• Diagnosis can be made when 2 or more patterns or
  criteria are present and causes significant
  impairment or distress in 12 month period
• Severity assessment of the disorder
• Moderate- 2-3 positive criteria
• Severe- 4 or more positive criteria

Retrieved from http//www.dsm5.org
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Alcohol Use Disorder

• The diagnosis will clarify
• With Physiological Dependence evidence of
  tolerance or withdrawal
• Without Physiological Dependence no evidence of
  tolerance of withdrawal
• Tolerance and Withdrawal are defined in numbers 4
  and 5 in the criteria list of the 11 possible
  patterns seen in the disorder

Retrieved from http//www.dsm5.org
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Detoxification from Substance Dependency

• Alcohol
• CNS depressant
• Benzodiazepines
• CNS depressant, anticonvulsant, anxiolytics, and
  hypnotics
• Opiates
• Analgesics

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Alcohol

• Alcohol Intoxication
• Symptoms of Withdrawal
• Assessment
• Physiology
• Treatment

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Alcohol
BAC as it correlates with symptoms of ACUTE ALCOHOL INTOXICATION BAC as it correlates with symptoms of ACUTE ALCOHOL INTOXICATION
10-50 mg/dl Sub-clinical
30-120 mg/dl Euphoria
90-250 mg/dl Excitement
180-300 mg/dl Confusion
250-400 mg/dl Stupor
350-500 mg/dl Coma
gt450 mg/dl Death
Metabolizes at 120mg/kg/hr or 15mg/dl per hr Metabolizes at 120mg/kg/hr or 15mg/dl per hr
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Alcohol
Alcohol Withdrawal occurs within 5-10hrs of last drink - lasts 7-14 days
Psychological symptoms Anxiety, depression, indecisiveness, fatigue, irritability, nightmares, labile mood
Physical symptoms clammy skin, dilated pupils, headache, insomnia, decreased appetite, nausea, vomiting, pallor, tachycardia, sweating, tremor
Severe symptoms agitation, delirium tremens, fever, seizures
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Alcohol Withdrawal

• Consistent objective assessment
• Clinical Institute Withdrawal Assessment Alcohol
  Revised
• CIWA-Ar

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Alcohol Withdrawal Assessment Scoring Guidelines
Nausea/Vomiting - Rate on scale 0 - 7 Tremors - have patient extend arms spread fingers. Rate on scale 0 - 7.
0 - None 0 - No tremor
1 - Mild nausea with no vomiting 2 3 1 - Not visible, but can be felt fingertip to fingertip 2 3
4 - Intermittent nausea 5 6 4 - Moderate, with patients arms extended 5 6
7 - Constant nausea and frequent dry heaves and vomiting 7 - severe, even w/ arms not extended
Anxiety - Rate on scale 0 - 7 Agitation - Rate on scale 0 - 7
0 - no anxiety, patient at ease 0 - normal activity
1 - mildly anxious 2 3 1 - somewhat normal activity 2 3
4 - moderately anxious or guarded, so anxiety is inferred 5 6 4 - moderately fidgety and restless 5 6
7 - equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions. 7 - paces back and forth, or constantly thrashes about
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Paroxysmal Sweats - Rate on Scale 0 - 7. 0 - no sweats Orientation and clouding of sensorium - Ask, What day is this? Where are you? Who am I? Rate scale 0 - 4
1- barely perceptible sweating, palms moist 0 - Oriented
2 3 1 cannot do serial additions or is uncertain about date
4 - beads of sweat obvious on forehead 5 2 - disoriented to date by no more than 2 calendar days
6 3 - disoriented to date by more than 2 calendar days
7 - drenching sweats 4 - Disoriented to place and / or person
Tactile disturbances - Ask, Have you experienced any itching, pins needles sensation, burning or numbness, or a feeling of bugs crawling on or under your skin? Auditory Disturbances - Ask, Are you more aware of sounds around you? Are they harsh? Do they startle you? Do you hear anything that disturbs you or that you know isnt there?
0 - none 0 - not present
1 - very mild itching, pins needles, burning, or numbness 1 - Very mild harshness or ability to startle
2 - mild itching, pins needles, burning, or numbness 2 - mild harshness or ability to startle
3 - moderate itching, pins needles, burning, or numbness 3 - moderate harshness or ability to startle
4 - moderate hallucinations 4 - moderate hallucinations
5 - severe hallucinations 5 - severe hallucinations
6 - extremely severe hallucinations 6 - extremely severe hallucinations
7 - continuous hallucinations 7 - continuous hallucinations
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Visual disturbances - Ask, Does the light appear to be too bright? Is its color different than normal? Does it hurt your eyes? Are you seeing anything that disturbs you or that you know isnt there? Headache - Ask, Does your head feel different than usual? Does it feel like there is a band around your head? Do not rate dizziness or lightheadedness.
0 - not present 0 - not present
1 - very mild sensitivity 1 - very mild
2 - mild sensitivity 2 - mild
3 - moderate sensitivity 3 - moderate
4 - moderate hallucinations 4 - moderately severe
5 - severe hallucinations 5 - severe
6 - extremely severe hallucinations 6 - very severe
7 - continuous hallucinations 7 - extremely severe
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Alcohol Withdrawal

• Consistent objective nursing assessment
• Anticipation of severity of withdrawal
• Based on history of alcohol consumption (pattern,
  quantity, and frequency) and detox frequency
  (medicated or not)
• Kindling Effect of Alcohol Detoxification
• Severity of withdrawal symptoms increase after
  repeated withdrawal episodes
• CNS hyperexcitability increased seizure risk
  increased risk of death

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Becker, HC (1998) Kindling in alcohol withdrawal.
Alcohol Health Research World, Vol 22.
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Becker, HC (1998) Kindling in alcohol withdrawal.
Alcohol Health Research World, Vol 22.
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Alcohol Withdrawal Seizure

• Generalized Tonic-Clonic Seizures
• Loss of consciousness or fainting, usually
  lasting between 30 seconds and 5 minutes
• General muscle contraction and rigidity (tonic
  posture), usually lasting 15 - 20 seconds
• Violent rhythmic muscle contraction and
  relaxation (clonic movement), usually lasting for
  1 -2 minutes
• Biting the cheek or tongue, clenched teeth or jaw
  
• Incontinence (loss of urine or stool control)
• Stopped breathing or difficulty breathing during
  seizure
• Blue skin color
• Aura changes in vision, taste, smell,
  dizziness, hallucinations and/or sensory changes.

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Delirium Tremens

• Mental Status Delirium
• Quick deterioration in
• Alertness
• Level of consciousness/cognitive function
• Memory/recall
• Disorganized thinking
• Severe emotional unrest
• Physical Status
• Heavy sweating
• Increased startle reflex
• Irregular rapid heartbeat
• Eye muscle in-coordination
• Rapid muscle tremors
• Hyper-adrenergic syndrome
• characterized by a temperature greater than 101F
• blood pressure greater than 140/90 mm Hg
• pulse greater than 100 bpm
• Medical Emergency

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Alcohol Withdrawal

• Consistent objective nursing assessment
• Anticipation of severity of withdrawal
• Physiology of Withdrawal at the CNS level
• Thiamine
• Important energy source, involved in metabolism
• Thiamine Deficiency
• Wernicke Syndrome severe confusion abnormal
  gait paralysis of eye muscles.
• Progressive to irreversible dementia
• DM pts Thiamine should always be administered
  before giving an alcoholic patient glucose as an
  energy source to prevent precipitation of WS by
  depletion of thiamine reserves.

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Alcohol Withdrawal

• Consistent objective nursing assessment
• Anticipation of severity of withdrawal
• Physiology of Alcohol Withdrawal
• Biological Markers (Lab tests)
• CDT acute marker (1-2 wks heavy consumption)
• GGT chronic marker (4-8 wks prolonged heavy
  consumption)
• PT/INR prolonged PT/INR indicates diminished
  hepatic function (possibly cirrhosis)
• Ammonia- elevated level requires treatment but
  does not reliably correlate with hepatic disease.
• Liver Function Tests (AST, ALT, ALP)

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Alcohol Withdrawal Treatment

• Classic Approach
• Benzodiazepines Tranzene (Clorazepate)
• Rapid onset of action (peak plasma levels reached
  in 1-2 hrs), long half life (30-200 hrs)
• Newer approach trending towards the standard of
  care.
• Gabapentin 1200 mg (400 mg TID) 900 mg (300
  mg TID)
• Evidenced based practice indicates maximal
  benefit received by continuing medication for 3
  months.
• Assists with protracted alcohol withdrawal and
  craving.
• Reduces relapse rate and severity of relapse in
  comparison to classic benzodiazepine approach.
• Not appropriate for all cases, clinical judgment
  dictates protocol -

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Alcohol Withdrawal Treatment

• Monitoring Parameters regardless of approach
• Respiratory depression
• Blood pressure (hypotension)
• Sedation
• When using benzodiazepine detox remember that the
  last does of the benzo doesnt mean withdrawal
  is over, withdrawal from the benzo begins.
• Using Gabapentin removes the protracted
  benzodiazepine withdrawal and resets the
  neurochemistry.

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Alcohol Withdrawal Treatment

• Post Benzo detox
• craving still present
• Pharmacological approach Naltrexone (Revia),
  Nalmafen (Revex), acamprosate (campral),
  aripiprazole ( abilify) , topimax (topiramate),
  antabuse physiological deterrent
• Therapeutic approach CBT/CBI
• address craving and cues
• encourage communication
• -- highlight drug seeking behaviors
• -- education!!

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Cognitive Behavioral Therapy

• Two critical components
• Functional analysis
• Assist pt in determining high risk situations
• Provide insight into reasons for substance use
• Identify positive and negative coping strategies
• Skills training
• Assist pt in unlearning old habits
• Teach healthy skills, coping strategies
• Utilize a cognitive behavioral intervention for
  short office visits and for techs/RNs working
  the unit.

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Cognitive Behavioral Intervention

• 5 Critical Tasks associated with CBI
• Foster the motivation for abstinence
• Teach coping skills
• Change reinforcement contingencies
• Foster management of painful emotions
• Improve interpersonal functioning and enhance
  social supports

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Benzodiazepines

• - Mechanism of action enhancement of the
  GABA-benzodiazepine receptor complex.

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Benzodiazepines Withdrawal

• - Symptoms are similar to alcohol

• Onset of withdrawal depends predominately on
  half-life of abused drug.

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Benzodiazepine Onset of Action (PO) Peak Onset (hrs) Half-life (hrs)
Long Acting Long Acting Long Acting Long Acting
Clorazepate (Tranzene) Rapid 1-2 (30-200) metabolite
Chlordiazepoxide (Librium) Intermediate 2-4 5-30 (36-200)
Diazepam (Valium) Rapid 1 20-100
Flurazepam (Dalmane) Rapid 0.5-2 (47-100) metabolite
Intermediate Acting Intermediate Acting Intermediate Acting Intermediate Acting
Alprazolam (Xanax) Intermediate 0.7-1.6 6-20
Clonazepam (Klonopin) Intermediate 1-4 18-39
Lorazepam (Ativan) Intermediate 1-1.5 10-20
Oxazepam (Serax) Slow 2-3 3-21
Temazepam (Restoril) Slow 0.75-1.5 10-20
Short Acting Short Acting Short Acting Short Acting
Midazolam (Versed) Rapid IV 0.55-1 1-4
Triazolam (Halcion) Intermediate 0.75-2 1.6-5.5
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Benzodiazepines Withdrawal

• Similar for alcohol
• Onset of withdrawal depends predominately on
  half-life of abused drug.
• Withdrawal symptoms can last from days to months.
• Varies with type of drug and individualized
  physiology.
• Severity of symptoms depend on type of drug,
  amount of drug, duration and pattern of use.

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Benzodiazepine Withdrawal Treatment

• Classic approach utilize a benzo taper
• Treatment with antiseizure medications such as
  gabapentin should be considered post initial
  taper and continued for 3 months.
• Assists in craving and protracted benzo
  withdrawal which can precipitate relapse.

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Benzodiazepine Withdrawal Treatment

• Remember to focus on the psychological addiction
  as well as the physiological component.
• Utilize CBT/CBI
• Utilize AA and NA
• Manage underlying psychiatric issues with
  non-narcotic anxiolytics.

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Opiates

• Class
• Withdrawal symptoms
• Treatment
• Management of Craving
• Relapse Prevention

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Pure Opiates Half-life (hrs)
Morphium (Morphine) 3
Methyl morphine (Codeine) 3 - 4
Semi-Synthetic
Diacetylmorphine (Heroin) 0.5
Hydromorphone (Dilaudid) 2.5
Hydrocodone (Vicodin, Lorocet, Lortab, Norco Acetaminophen) (Vicprofen Ibuprofen) 4
Oxycodone (Oxycontin, Roxicodone) (Percocet, Roxicet Acetaminophen) (Percodan Aspirin) 3 - 5
Propoxyphene (Darvon) 6 - 12
Meperidine (Demerol) 3 - 5
Full-Synthetic
Tramadol (Ultram) 6 - 7
Fentanyl (Duragesic) 20 - 27
Methadone 8 - 59
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Opiate Withdrawal
Early Symptoms Late Symptoms
Agitation Abdominal cramping
Anxiety Diarrhea
Muscle aches Dilated pupils
Tearing/runny nose/sweating Piloerection
Insomnia Nausea
Yawning Vomiting


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Opiate Withdrawal Treatment

• Opiate Detox Protocol
• Phenergan ? Nausea
• Lomotil ? Diarrhea
• Motrin ? Pain
• Clonidine ?Chills, Leaky Fluids,GI motility
• Bentyl ? Stomach Cramps
• Flexeril ? Muscle Spasm
• Vistaril ? Anxiety

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Opiates Management of Craving and Relapse
Prevention

• Pharmacological
• Bupropion
• Methadone
• Suboxone (buprenorphine/naloxone)
• Naltrexone

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Opiates Management of Craving and Relapse
Prevention

• Pharmacological
• Behavioral/Cognitive Therapy Focus
• Personal experience
• Time management
• Development of drug refusal skills
• Motivation enhancement
• Recognize cues that induce craving
• Correct drug seeking behavior
• Development of coping skills

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Opiates Management of Craving and Relapse
Prevention

• Pharmacological
• Behavioral/Cognitive Therapy Focus
• Group Therapy
• Narcotics Anonymous

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Opiates Management of Craving and Relapse
Prevention

• Pharmacological
• Behavioral/Cognitive Therapy Focus
• Group Therapy
• Novel Approaches
• Targeted gene therapy

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Opiates Management of Craving and Relapse
Prevention

• Pharmacological
• Behavioral/Cognitive Therapy Focus
• Group Therapy
• Novel Approaches
• Rehabilitation Programs

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Summary

• Physiology (neuro, physical, psychological)
• Pharmacology
• Prevention
• Intervention (pharmacological and psychological)

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Acknowledgements

• National Institute on Drug Abuse (NIDA)
• National Institute on Alcohol Abuse and
  Alcoholism (NIAAA)
• National Institute of Health (NIH)
• National Institute of Mental Health (NIMH)
• DSM IV DSM V
• SAMHSA
• Google Images

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Questions ??????