CAPTASA 2009CAPTASA 200999thth Annual Annual

ConferenceConference

Embassy SuitesEmbassy Suites

Lexington, KYLexington, KY

January 23, 2009January 23, 2009

Detox – Then What?Detox – Then What?

““Seek the company of Seek the company of those who are looking for those who are looking for

the truth. the truth. Run from those who have Run from those who have

found it.”found it.”

Vaslav Havel-president of the Vaslav Havel-president of the Czech RepublicCzech Republic

Medical DetoxMedical Detox

A Way That WorksA Way That Works

Why bother?Why bother?

A Safe Withdrawal from Alcohol and A Safe Withdrawal from Alcohol and other Drugsother Drugs

A Withdrawal that is Humane and A Withdrawal that is Humane and Protects DignityProtects Dignity

Prepare the Patient for Ongoing Prepare the Patient for Ongoing TreatmentTreatment

Principles of Addiction MedicinePrinciples of Addiction Medicine

33rdrd Ed. Page 612 Ed. Page 612

The patient is the The patient is the oneone

With the With the problemproblem

Which drugs need Which drugs need medical detox ?medical detox ?

AlcoholAlcohol

Sedative/hypnoticsSedative/hypnotics

OpiatesOpiates

Dopamine Pathways – Pleasure pathways

nucleusaccumbens

hippocampus

striatum

frontalcortex

substantianigra/VTA

cocaineheroinnicotineamphetaminesopiatesTHCPCPketamine

heroinalcoholbenzodiazepinesbarbiturates

alcohol

We should write that spot downWe should write that spot down..

Usual detox approachUsual detox approach

Benzo’s for AlcoholBenzo’s for Alcohol

Benzo’s for Benzo’sBenzo’s for Benzo’s

Opiates for opiatesOpiates for opiates

My Experience with My Experience with BenzodiazepinesBenzodiazepines

Opiates don’t have to be Opiates don’t have to be detoxed, right?detoxed, right?

Only if you want them to stay in TxOnly if you want them to stay in Tx

Only if you care about their dignityOnly if you care about their dignity

How many are pure Opiate users?How many are pure Opiate users?

Alcoholics AnonymousAlcoholics Anonymous, page 22 , page 22 from ‘There is A Solution”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, 3ASAM Textbook, 3rdrd Ed. Page 643 Ed. Page 643

Clinical experience shows that Clinical experience shows that phenobarbital is most useful and phenobarbital is most useful and effective with polysubstance effective with polysubstance dependence, high-dose dependence, high-dose dependence, and in patients with dependence, and in patients with unknown dose or erratic unknown dose or erratic “polyphramacy”“polyphramacy”

““Well, I woke up this morningWell, I woke up this morningAnd I got myself a beer.And I got myself a beer.

The future’s uncertainThe future’s uncertainAnd the end (enemy) is always And the end (enemy) is always

near.”near.”

Roadhouse Blues-Jim MorrisonRoadhouse Blues-Jim Morrison

GABA- the down buttonGABA- the down button

NMDA- the up buttonNMDA- the up button

Here’s what I doHere’s what I do

Hx of Use (What, How much, How Hx of Use (What, How much, How long, other medical conditions…)long, other medical conditions…)

Load with Phenobarb- (stop the train Load with Phenobarb- (stop the train from leaving the station)from leaving the station)

Add on’s depending on drugs usedAdd on’s depending on drugs used

Mg++ for AlcoholMg++ for Alcohol

Clonidine for OpiatesClonidine for Opiates

Phenobarb dosagePhenobarb dosage

LoadLoad

Regular dose taperRegular dose taper

PRN’s based on CIWA scorePRN’s based on CIWA score

DAYS 1&2DAYS 1&2

Phenobarbital 180 mg PO now, thenPhenobarbital 180 mg PO now, then

Phenobarbital 60 mg PO every 6 hours X Phenobarbital 60 mg PO every 6 hours X 8 doses8 doses

Obtain CIWA score every 4 hoursObtain CIWA score every 4 hours

If CIWA score greater than 15, give If CIWA score greater than 15, give Phenobarbital 260 mg IM Phenobarbital 260 mg IM

If CIWA score 8-15, give Phenobarbital If CIWA score 8-15, give Phenobarbital 120 mg PO 120 mg PO

DAYS 3&4DAYS 3&4

Phenobarbital 60 mg PO every 12 hours X Phenobarbital 60 mg PO every 12 hours X 4 doses4 doses

Obtain CIWA score every 6 hoursObtain CIWA score every 6 hours

If CIWA score greater than 15, give If CIWA score greater than 15, give Phenobarbital 120 mg PO Phenobarbital 120 mg PO

If CIWA score 8-15, give Phenobarbital 60 If CIWA score 8-15, give Phenobarbital 60 mg PO mg PO

Magnesium SulfateMagnesium Sulfate

Based on Alcohol use and age of PatientBased on Alcohol use and age of Patient1 Gm IM every 8 hours1 Gm IM every 8 hoursAt least 2 dosesAt least 2 dosesUp to 4 for high volume drinkers and those Up to 4 for high volume drinkers and those with seizure Hx*with seizure Hx*PO Magnesium oxide is poor alternativePO Magnesium oxide is poor alternative, , limit is 400mg BIDlimit is 400mg BID

*Magnesium is not for seizures*Magnesium is not for seizures

Magnesium in Alcohol withdrawalMagnesium in Alcohol withdrawalMg-NMDA connectionMg-NMDA connection

Clonidine dosageClonidine dosage

Clonidine 0.1 mg PO now, then Clonidine 0.1 mg PO now, then

Clonidine 0.1 mg PO every 6 hours X 8 Clonidine 0.1 mg PO every 6 hours X 8 doses, thendoses, then

Clonidine 0.1 mg PO every 8 hours X 3 Clonidine 0.1 mg PO every 8 hours X 3 doses, thendoses, then

Clonidine 0.1 mg PO every 12 hours X 2 Clonidine 0.1 mg PO every 12 hours X 2 dosesdoses

Hold Clonidine if BP less than 90/55Hold Clonidine if BP less than 90/55

Thiamine is critical for Tx Thiamine is critical for Tx of Alcoholismof Alcoholism

Thiamine 100 mg IM now, Thiamine 100 mg IM now, then 100 mg a day x 5 then 100 mg a day x 5

days.days.

Folic acid 1 mg a day for 5 Folic acid 1 mg a day for 5 days.days.

Detox protocol at Schwartz CenterDetox protocol at Schwartz Center

Phenobarb 180 mg Phenobarb 180 mg nownow

Then Phenobarb 60 Then Phenobarb 60 mg every 6 hr x 8 mg every 6 hr x 8 dosesdoses

Then Phenobarb 60 Then Phenobarb 60 mg every 12 hr x 4 mg every 12 hr x 4 dosesdoses

Magnesium oxide 400 Magnesium oxide 400 mg BID x 3 daysmg BID x 3 days

Thiamine 100 mg Thiamine 100 mg daily x 5 daysdaily x 5 days

Folic acid 1 mg daily x Folic acid 1 mg daily x 5 days5 days

Clonidine 0.1 mg TID Clonidine 0.1 mg TID x 2 days and BID x 2 x 2 days and BID x 2 daysdays

Phenobarb equivalentsPhenobarb equivalents

30 cc 100 proof alcohol = 30 mg30 cc 100 proof alcohol = 30 mg

Xanax 1 mg = 30 mgXanax 1 mg = 30 mg

Ativan 2 mg = 30 mgAtivan 2 mg = 30 mg

Klonopin 2 mg = 30 mgKlonopin 2 mg = 30 mg

Valium 10 mg = 30 mgValium 10 mg = 30 mg

Librium 25 mg = 30 mgLibrium 25 mg = 30 mg

What about Delirium?What about Delirium?

This is where dehydration is importantThis is where dehydration is important

First load with Phenobarb and push First load with Phenobarb and push dosedose

AvoidAvoid anticholenergic drugs anticholenergic drugs

Risperdal 2mg + Ativan 2mg PORisperdal 2mg + Ativan 2mg PO

Haldol 5mg +Ativan 2mg+ Benadryl Haldol 5mg +Ativan 2mg+ Benadryl 50mg all IM50mg all IM

Then What?Then What?

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

Albert EinsteinAlbert Einstein

Abstinence and Spiritual Abstinence and Spiritual based Recovery isn’t sexy based Recovery isn’t sexy

nor profitablenor profitable

It can be a lonely and unpopular It can be a lonely and unpopular message, but it is the Truth…message, but it is the Truth…

Addiction is a brain Addiction is a brain diseasedisease

a primary illness, not a symptom a primary illness, not a symptom secondary to a psychiatric disordersecondary to a psychiatric disorder

Brain Reward Center:Brain Reward Center:

Median Forebrain Median Forebrain

Nucleus AccumbensNucleus Accumbens

Ventral Tegmental AreaVentral Tegmental Area

DopamineDopamine

Can Amphetamines Help Can Amphetamines Help Cure Cocaine Addition?Cure Cocaine Addition?

“It’s an idea that really does need to “It’s an idea that really does need to be rigorously evaluated”be rigorously evaluated”

Frank Vocci, director of pharmTx Frank Vocci, director of pharmTx NIDANIDA

Time magazine 12/8/2008Time magazine 12/8/2008

““One of the first duties of One of the first duties of the physician is to the physician is to

educate the masses not to educate the masses not to take medicinetake medicine..””

Sir William Osler, , Aphorisms from Aphorisms from his Bedside Teachingshis Bedside Teachings

Everybody is on drugs Everybody is on drugs except when they except when they

really need them…really need them…

Rita RudnerRita Rudner

“…“…has not been has not been systematically studied in systematically studied in

humans for its potential for humans for its potential for abuse …”abuse …”

From PDR under Effexor, Cymbalta, From PDR under Effexor, Cymbalta, Paxil, Seroquel, Neurontin, Zyprexa, Paxil, Seroquel, Neurontin, Zyprexa, Celexa…Celexa…

Additional Evidence of Additional Evidence of the Abuse Potential of the Abuse Potential of

QuetiapineQuetiapine

Reeves and Brister VA Med Center Reeves and Brister VA Med Center Jackson, MS April 2007 SMA JournalJackson, MS April 2007 SMA Journal

Alcoholics AnonymousAlcoholics Anonymous, page 64 , page 64 from “How It Works”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 The 12-step model of recovery recovery is is the core the core

technology in the short and technology in the short and long term treatment of long term treatment of

alcoholism and addiction… alcoholism and addiction… the standard of care”the standard of care”

Garrett O’Connor, MDGarrett O’Connor, MDCAPTASA 2005CAPTASA 2005

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

www.willingway.comwww.willingway.com

$634.5M settlement for $634.5M settlement for OxyContin makerOxyContin maker

The firm and the current and The firm and the current and

former executives, including the former executives, including the CEO, pleaded guilty in U.S. CEO, pleaded guilty in U.S.

District Court in Abingdon, Va., to District Court in Abingdon, Va., to a felony charge of misleading a felony charge of misleading

doctors and consumers about the doctors and consumers about the drug's risks of abuse and drug's risks of abuse and

addiction, CNN said Wednesday. addiction, CNN said Wednesday.

Alcoholics AnonymousAlcoholics Anonymous, page 58 , page 58 from “How It Works”from “How It Works”

There are those, too, who suffer There are those, too, who suffer from grave emotional and from grave emotional and mental disorders, but many of mental disorders, but many of them do recover if they have them do recover if they have the capacity to be honest.the capacity to be honest.

CDC: Antidepressants CDC: Antidepressants most prescribed drugs in most prescribed drugs in

U.S.U.S.

" Doctors are now medicating " Doctors are now medicating unhappiness” said Dworkin. unhappiness” said Dworkin.

"Too many people take drugs "Too many people take drugs when they really need to be when they really need to be

making changes in their lives." making changes in their lives." CNN 7-9-07CNN 7-9-07

Drugs that are problems for AddictsDrugs that are problems for Addicts

AntidepressantsAntidepressants

StimulantsStimulants

AntihistaminesAntihistamines

Cough suppressantsCough suppressants

AntipsychoticsAntipsychotics

Mood StabilizersMood Stabilizers

Muscle relaxantsMuscle relaxants

Neurophysiology of RecoveryNeurophysiology of Recovery

Extended withdrawal for yearsExtended withdrawal for years

Structural and functional brain Structural and functional brain abnormalitiesabnormalities

Gradual normalization over first Gradual normalization over first recovery decaderecovery decade

Addiction may sensitize for Addiction may sensitize for mental dysfunctionmental dysfunction

•If you understand, If you understand, everything is just as everything is just as

it isit is

•If you don’t If you don’t understand, understand,

everything is just as everything is just as it isit is

Zen proverbZen proverb

Detox ProtocolCIWA

e-mail to physicians interestedgljones@bluegrass.org