Detox Basics

Definition of Addiction
Compulsion: loss of control
The user cant not do it s/he is compelled to use.
Compulsion is not rational and is not planned.

Continued use despite adverse consequences

An addict is a person who uses even though s/he knows it is causing problems.
Addiction is staged based on adverse consequences.

Craving: daily symptom of the disease

The user experiences intense psychological preoccupation with getting and
using the drug.
Craving is dysphoric, agitating and it feels very bad.

Denial/hypofrontality: distortion of cognition caused by craving

Under the pressure of intense craving, the user is temporarily blinded to the
risks and consequences of using.
 Neuroadaptation, Tolerance,
and Withdrawal
Neuroadaptation is the brains response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and
stimulation or intoxication.

Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure
neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive
(deaf) to normal levels of stimulation.

In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also
neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy.

Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug
effects. Cessation of drug use leads to inversion of the high; sobriety becomes pleasureless, anxious, sleepless, and lacking
energy

Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure.
When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months
to years, interfering with sobriety, learning, and impulse inhibition.
Drug-Specific Neural Dysregulation
Withdrawal
Withdrawal: Negative symptoms that mirror positive
drug effects AND reflect neuroadaptation (tolerance).

Cessation of drug use leads to inversion of the high; sobriety

becomes pleasureless, anxious, sleepless, and lacking energy.

Under unstimulated conditions (without drugs) interference with

the ability to experience normal pleasure is profound . When sober,
the user feels anhedonia, anxiety, anger, frustration and craving.

The pleasure system remains impaired for months to years,

interfering with learning, impulse inhibition, and sobriety.
 Kindling
In tolerant users:

Progressive nervous system arousal

causing withdrawal symptoms to
worsen each time drug use is
discontinued.

Also called withdrawal sensitization.

 C I M Model Treatment
Tolerance/Withdrawal
Over-stimulation of brain pathways induces
neuroadaptation, requiring the user to escalate
the dose to achieve the effects formerly seen at
lower doses.

Whenever there is tolerance to drugs/alcohol,

there will always be the appearance of negative
symptoms (withdrawal) when the user is sober;
these negative symptoms are the mirror image
of the drugs effects.
 Physical Dependence
Physical Dependence
When the user stops the drug, physical illness results.

Abstinence Syndrome
Name of the illness caused by withdrawal symptoms.

Tolerance
Neuroadaptation forces the user to increase the dose to maintain the
effect of the drug.

Using an inadequate dose causes withdrawal: symptoms occur when the

amount used is less than the tolerance level.
 C I M Model Treatment
Causes of Craving
E W M S
Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by people, places,
things associated with prior drug-use experiences

Drug Withdrawal
inadequately treated or untreated

Mental illness symptoms

inadequately treated or untreated

Stress equals craving

 Withdrawal Management
Detoxification

Use of medications to treat withdrawal symptoms.

Goals:
Evaluation
Stabilization
Foster readiness for and entry into treatment
 C I M Model Treatment
Withdrawal Management
Withdrawal management is the use of medications to treat
drug withdrawal symptoms, sometimes called detox.

When is withdrawal management needed?

If the pulse is persistently above 90 beats per minute
If the blood pressure is persistently above 140/90 or
below 90/60
If INSOMNIA interferes with function
If ANXIETY interferes with function.
If CRAVING threatens to cause relapse
 C I M Model Treatment
Withdrawal Management

PRINCIPLES
SUBSTITUTION

Calculate the dose equivalent per 24 hours

Push medications to achieve symptom capture
Maintain Diastolic BP <90 and Pulse <90

TAPER
Decrease substitute medication in 10% increments
Slow rate of taper to maintain Diastolic BP <90 and Pulse <90
Tremor free
Opiate Effects
Analgesia
Euphoria
Anxiolytic- calming
Sleep Inducing
Sensation of warmth
Constipation
Dry mucous membranes
Pupils constrict

Sedation/Sleepiness (nodding)
Depresses respiration
 Effects and Withdrawal
Opiates
Effects Withdrawal
Analgesia Pain
Euphoria Dysphoria
Anxiolytic - calming Anxiety
Sleep Inducing Insomnia
Constipation Diarrhea
Dry mucous membranes Rhinorrhea
Sensation of warmth Chills
Pupils constricted Pupils dilated
Opiate Withdrawal
Pain
Dysphoria
Anxiety
Insomnia
Diarrhea
Rhinorrhea
Chills
Pupils dilate
Increases heart rate & blood pressure
 Prescription Opiates
Generic: Brand Name Non Tolerant 24 hr. dose
Codeine w/acetaminophen 500 mg
Hydrocodone:Vicodin, Lortab, Norco 20mg-60 mg
Hydromorphone: Dilaudid 20 mg-60 mg
Oxycodone: Percodan, OxyContin 20 mg-60 mg
Morphine sulfate: MS Contin 30 mg-60 mg
Fentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg

Tolerant Users only Tolerant 24 hr. dose

Morphine sulfate: MS Contin 60 mg-upward
Fentanyl: Duragesic (transdermal) 75 mcg-300 mcg
Methadone: Methadose 60 mg-300 mg
Buprenorphine: Suboxone, Subutex 6 mg-32 mg
 Opiate Progression
Pills to the Needle
Historically, untreated dependence on prescription
opiates led to a trajectory from

Pills ingested orally

Pills crushed and snorted or smoked
Heroin snorted or smoked
Heroin used intravenously
Overview of Buprenorphine
Suboxone and Subutex
Highly safe medication (acute & chronic dosing).
Primary side effects: like other mu agonist opioids
(e.g.,nausea, constipation) but may be less severe.
No evidence of significant disruption in cognitive or
psychomotor performance with buprenorphine
maintenance.
No evidence of organ damage with chronic dosing.
Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds:
Strain EC, Trhumble JG, Jara GB) CSAT. 2001
OPTIMUM ANALGESIC DOSE

The best dose of opiate is the dose

that first, best relieves pain, and
second, relieves pain without
sedation.
Special Problems in Former
Opiate Addicts
Persons previously addicted to opiates
Have low pain tolerance because endogenous analgesic mechanisms are
impaired.

Will uncover their previous level of opiate tolerance over 4 - 6 weeks

and require upward dosage titration over an extended time (despite years
of abstinence).

Require doses 2 to 4 times higher for analgesia than non-tolerant persons

(due to high opiate tolerance).

Need slower, symptom-driven tapers to discontinue opiates.

 Withdrawal Management
Opiate Oral Dose
Equivalents
Buprenorphine (Suboxone) 8 mg
(sublingual)
Hydrocodone (Vicodin) 10 - 20 mg
Methadone (Methadose) 20 mg
Morphine sulfate (immediate release) 30 mg
Morphine sulfate (MS Contin) 15 mg
Oxycodone (Percodan) (Oxycontin) 10 - 20 mg
Propoxyphene (Darvon) 130 - 200 mg
Adapted from Goodman and Gilman, 9th ed., page 535.
 Withdrawal Management
Opiate Substitution
Query: time since last opiate use
Query: all opiates used in past 7 days.
Calculate client's usual 24 hour opiate dose.

Query: prior withdrawal experience(s).

Query: other drugs used:
alcohol
illicit drugs
prescription medications
over-the-counter preparations
Determine if client requires other detoxification
 Withdrawal Management
Substitution Methodology
Opiates
Calculate Suboxone dose using opiate dose equivalents.

Give first Suboxone dose (2 - 8 mg) when objective and clear signs of
withdrawal are evident.

Record Pulse, BP, and withdrawal SX on Symptom Assessment sheet.

Recheck Pulse & Blood Pressure after 90 minutes.

Give 1/4 of estimated daily Suboxone dose when withdrawal symptoms

reappear.

Give the remainder of Suboxone in divided doses every 6 - 8 hours.

 Withdrawal Management
Completion of Substitution
Phase
Substitution is complete when the patient feels normal, and craving goes
away.

Persistence of insomnia, anxiety, pain, or depression indicate need for

separate treatment of these symptoms (dual diagnosis).

The patient is now ready for taper or for maintenance.

 Withdrawal Management
Taper Phase
There are two variables in tapering:
Dose: how much to taper
Time: how often to taper

Dose reductions are adjusted so that the patient does not re-enter
withdrawal. If withdrawal symptoms develop during taper, return to
previous effective dose, reduce amount of taper (dose) or lengthen
the (time) interval. Do not continue until symptoms subside.

Monitor Pulse and Blood Pressure daily

Complete Symptom Assessment sheet daily.
Adjust amount decreased and time between decreases to maintain
symptom scores at 0-1
A 33-year follow-up of narcotics
addicts
.
Stimulant Effects
Improve mood and confidence
Increase interest/alertness
Increase sex drive
Interference with sleep
Increase anger and aggression
Suppress appetite
Pupils dilate
Increases heart rate & blood pressure

Fever
Arrythmia - irregular heart beat
Seizures
Stimulant Withdrawal
Dysphoria
Boredom
Anergia
Disordered sleep
Anxiety
Depression
Hypofrontality
 Dual Diagnosis

Mental Illness symptoms interact with drug effects.

Intoxication: relieves symptoms of mental illness

Tolerance: exacerbates symptoms of mental illness

Withdrawal: exacerbates symptoms of mental illness

 Medications for
Stimulant Dependence
Antidepressants
(anhedonia/anergia)
Effexor XR 150-300 mg
Disorders of Sleep
Cymbalta 60 mg Trazedone 50-300 mg
Wellbutrin XL 150-300 mg Seroquel 25-100 mg
Desipramine 100-200 mg Imipramine 100-200 mg

Anti-Craving Medications
Modafinil 100-200 mg Disorders of Thought
Methylphenidate LA 10-40 mg Abilify 2-10 mg
Buproprion 150-300 mg Haldol 1-2 mg
Risperdal 1-3 mg
Concerta 18-54 mg
Dexedrine SR 20-30 mg
GABA Scale
Sedative-Hypnotic Effects
Calm Euphoria
Release of Inhibitions
Sleep Inducing

Sedation/Sleepiness
Slurred Speech
Unsteady gait (Ataxia)
Confusion
Forgetfulness
Slows heart rate
Decreases blood pressure
 Sedative-Hypnotic Effects
Effects Withdrawal
Calm Euphoria Dysphoria *
Release of Inhibitions Anxiety *
Sleep Inducing Insomnia *

Sedation/Sleepiness Sweating (Diaphoresis) *

Slurred Speech Tremor
Unsteady gait (Ataxia) Tachycardia
Confusion Hypertension
Forgetfulness Hyperventilation
Slows heart rate
Decreases blood pressure Elevated temperature
Hallucinations
* Symptom may continue for months Seizures
Delirium tremens
 Spectrum of Sedative-
Hypnotic Withdrawal
1. Acute withdrawal: hypertension, tachycardia, tremors, sweating, pallor,
anxiety/panic, craving

2. Withdrawal seizures: preceded by increasing tremors and myoclonic

jerks

3. Delirium Tremens: medical emergency presentation of combative,

hallucinating, confused; all sedative-hypnotic withdrawal can yield DTs.
Sedative-Hypnotic Withdrawal
Dysphoria * * May continue for months

Anxiety *
Insomnia *
Sweating (Diaphoresis)
Tremor
Increases heart rate & blood pressure
Hyperventilation
Elevated temperature
Hallucinations
Seizures
Delirium tremens
Prescription Tranquillizers
Dose Equivalent To Alcohol
(2oz liquor or 2 glasses of wine or 2 cans of beer)

Alprazolam (Xanax) 0.5- 1mg

Diazepam (Valium) 10mg
Chlordiazepoxide (Librium) 25mg
Clonazepam (Klonopin) 1-2mg
Lorazepam (Ativan) 2mg
Temazepam (Restoril) 30mg

Butalbital (in Fiorinal) 100mg

Carisoprodol (Soma ) 350mg
Zolpidem (Ambien) 10 mg
 Withdrawal Management
Sedative-Hypnotics
Substitution
Obtain seizure history.
Question client regarding all sedative-hypnotic use:
alcohol / prescription medications / over-the-counter preparations
Determine client's usual 24 hour sedative-hypnotic dose.

Acute Withdrawal
STAT Phenobarbital 60mg for Pulse >90 or diastolic BP >90
Repeat dose every 2 hours until Pulse <90 & diastolic BP <90

Calculate Phenobarbital 30mg based on the 24-hour Phenobarbital total.

Complete sedative-hypnotic Symptom Assessment flow sheet with each dose.
Give Phenobarbital in divided doses every 6 - 8 hours.
Hold Phenobarbital for slurred speech, ataxia, or lethargy.

Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer
Withdrawal Management
Sedative-Hypnotic
Uncovering

Uncovering: the re-appearance of

withdrawal symptoms after initial
stabilization, necessitating re-titration
of the dose.
 Withdrawal Management
Completion of Substitution
Phase
Substitution is complete when the patient feels normal, and craving goes
away.

Persistence of insomnia, anxiety, pain, or depression indicate need for

separate treatment of these symptoms (dual diagnosis).

The patient is now ready for taper or for maintenance.

Gamma-Hydroxy-Butyrate: GHB
Effects of Increasing Dosage in the Non-tolerant User

Loss of
Coma
Consciousness

Euphoria
Somnolence
Vertigo
Amnesia
Sedation

0 10 20 30 40 50 60
Dose (mg/kg)
 Cannabis effects
EFFECTS WITHDRAWAL
Sleep inducing Insomnia/nightmares
Appetite stimulation
Anorexia
Induces calm
Induces mellow Anxiety
feelings Irritability/anger
Elevates mood Depression
Reduces muscle tone Tremor
Produces pleasure Anhedonia
 Nicotine Effects
Receptor Activation
Increase arousal
Heighten attention
Influence stages of sleep
Produce states of pleasure
Decrease fatigue
Decrease anxiety
Reduce pain
Improve cognitive function
Withdrawal Symptoms
Mentally sluggish
Inattentive
Insomnia
Boredom and dysphoria
Fatigue
Anxiety
Increase pain sensitivity
Worsen cognitive function
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