bezo/etoh/opiate abuse withdrawal protocols

[myironlung]

Wanted to know what you guys use for these w/d's. At my facility we are limited with what we are allowed to give:

 

Benzos: librium 25mb bid po x3 days then 25mg qd po x2 days

Etoh: same as benzo plus vitamin b1 and folic acid

Opiates(excluding methadone): clonidine 0.1mg bid po x5 days, loperamide 2mg bid prn x5days, vistaril 25-50mg bid po x5 days.

Methadone: same as above except we give vicodin 5/500 2 tabs bid po x3 days then taper to 1 tab bid po x2days.

[Contrarian]

Thats about right...

IF the patient doesn't have a legitemate reason to continue those meds (REAL chronic pain issues)

 

 

Without getting deep into it .... keep in mind that most of the anti-convulsants can be used also too... if you are concerned about contributing to abuse but also worried about unoppossed glutamate (by GABA) seizures.

[deborah212]

Is this an addiction or psych facility?

 

For the heavy drinkers, the Librium protocol doesn't seem like a lot and would make me nervous that a patient would decompensate. Do you have prn as well based on objective symptoms (tachycardia, HTN, tremors)?

 

It's been a couple of years since I've used librium (standing ativan then CIWA took its place) but I believe we were doing Librium 50 mg q6hr with 25 prn. If no prn were needed in 24hrs, then standing dose reduction.

[foreveryoung]

I work in psych so there are many factors, so very individualized. Our CIWA protocol recommends either ativan or valium. If I really have reason to be concerned about withdraw, I do a scheduled taper. Also use a lot of gabapentin. Use a lot of vistaril, clonidine in meth/opiods depending on what other medications/medical issues are going on...

[Contrarian]

What I use in My private Addiction Medicine Practice:

 

Nicotine Dependence

Varenicline • Buproprion • Clonidine

1. Varenicline (trade name Chantix), is a prescription medication used to treat smoking addiction. Varenicline is a nicotinic receptor partial agonist. As a partial agonist it both reduces cravings for and decreases the pleasurable effects of cigarettes and other tobacco products. Through these mechanisms it can assist some patients to quit smoking. The FDA has approved its use for twelve weeks. If smoking cessation has been achieved it may be continued for another twelve weeks. Varenicline dose = 1mg twice daily
   
2. Bupropion (trade names; Wellbutrin, Zyban, Voxra, Budeprion, or Aplenzin) is an atypical antidepressant and smoking cessation aid. Initially researched and marketed as an antidepressant, bupropion was subsequently found to be effective as a smoking cessation aid. Bupropion reduces the severity of nicotine cravings and withdrawal symptoms. The bupropion treatment course lasts for seven to twelve weeks, with the patient halting the use of tobacco about ten days into the course. Bupropion also slows the weight gain that often occurs in the first weeks after quitting smoking. Bupropion approximately doubles the chance of quitting smoking successfully after three months.
   

A Cochrane systematic review concluded that both varenicline and bupropion improved smoking cessation. More people quit with varenicline than with bupropion, but the difference was not statistically significant.

1. Clonidine can be used to decrease nicotine craving. If the clonidine patch is used to treat nicotine craving and withdrawal symptoms, dosages that deliver 0.1–0.2 mg daily are used. For oral therapy (tablets), a total dosage of 0.2–0.4 mg daily is taken in divided doses.
   

Alcohol Dependence

Disulfiram • Acamprosate • Naltrexone • Clonidine • Baclofen

1. Disulfiram (trade name Antabuse) is a drug used to support the treatment of chronic alcoholism by producing an acute sensitivity to alcohol. Disulfiram produces immediate and severe negative reaction to alcohol intake. Some 5–10 minutes after alcohol intake, the patient may experience the effects of a severe hangover for a period of 30 minutes up to several hours. Disulfiram should not be taken if alcohol has been consumed in the last 12 hours. There is no tolerance to disulfiram: the longer it is taken, the stronger its effects. As disulfiram is absorbed slowly through the digestive tract and eliminated slowly by the body the effects may last for up to two weeks after the initial intake.
   

The usual initial dose is 500 mg a day for 1 to 2 weeks, followed by a maintenance dose of 250 mg (range 125 mg–500 mg) per day. The total daily dosage should not exceed 500 mg.

 

1. Acamprosate (trade name Campral) is a drug used for treating alcohol dependence. It is sold as 333 mg tablets. In addition to its apparent ability to help patients refrain from drinking, some evidence suggests that acamprosate is neuroprotective (that is, it protects neurons from damage and death caused by the effects of alcohol withdrawal.)
   

1. Naltrexone has been shown in a number of studies to reduce the frequency and severity of relapse to drinking. Naltrexone has two effects on alcohol consumption. The first is to reduce craving while naltrexone is being taken. The second, referred to as the Sinclair Method, occurs when naltrexone is taken in conjunction with normal drinking, and this reduces craving over time. The first effect persists only while the naltrexone is being taken, but the second persists as long as the alcoholic does not drink without first taking naltrexone. The standard regimen is one 50 mg tablet per day
   

Depot injectable naltrexone (trade name Vivitrol,) was approved by the FDA on April 13, 2006 for the treatment of alcohol dependence. The recommended dose of Vivitrol 380 mg is delivered intramuscularly once a month. The injection should be administered by a healthcare professional.

1. Clonidine is used to ease withdrawal symptoms associated with the long-term use of narcotics, alcohol and nicotine (smoking). Dosages of 0.4–0.6 mg have been used for the treatment of alcohol withdrawal.
   

1. Baclofen is used in the treatment of alcohol dependence and withdrawal, by inhibiting both withdrawal symptoms and cravings. Baclofen has been shown to be as effective as diazepam in uncomplicated alcohol withdrawal syndrome. Typical effective doses are between 15mg and 360 mg of baclofen per day.
   

Opioid/Opiate Dependence

Buprenorphine • Naltrexone • Clonidine • Baclofen

1. Buprenorphine (trade-names of Subutex, Suboxone) are sublingual tablets and/or film used for the treatment of opiate addiction. Buprenorphine's high-dose sublingual preparations are indicated for detoxification and/or long-term replacement therapy in opioid dependency.
   

1. Naltrexone helps patients overcome urges to abuse opiates by blocking the drugs’ euphoric effects. Depot injectable naltrexone (trade name Vivitrol,) was approved by the FDA on on October 12, 2010 for the prevention of relapse to opioid dependence, following opioid detoxification. The recommended dose of Vivitrol 380 mg is given as an injection, by a healthcare professional once a month.
   

1. Clonidine is regularly prescribed to help alleviate opiate withdrawal symptoms. It is mainly used to combat the sympathetic nervous system response to opiate withdrawal, namely tachycardia and hypertension, in the initial days of withdrawals. It helps take away the sweating, hot/cold flushes, and general restlessness. The sedation effect is also useful although its side effects can include insomnia, thus exacerbating an already common feature of opiate withdrawal. Total daily dosage for the treatment of opiate withdrawal ranges between 0.5 and 1.4 mg, depending on the stage as well as the severity of withdrawal symptoms.
   
2. Baclofen is used in the treatment of opiate dependence and withdrawal, by inhibiting both withdrawal symptoms and cravings. Baclofen has been shown to be as effective as diazepam in uncomplicated opiate withdrawal syndrome. Typical effective doses are between 15mg and 360 mg of baclofen per day.
   

 

 

 

ETOH/Benzo withdrawal explained-

Alcohol inhibits activity of biochemical receptors called N-methyl-D-aspartate receptors, or NMDARs, so that chronic alcohol consumption leads to the overproduction (up-regulation) of these receptors . Thereafter, sudden alcohol abstinence causes the excessive numbers of NMDARs to be more active than normal and to produce the symptoms of delirium tremens and excitotoxic neuronal death. Withdrawal from alcohol induces a surge in release of excitatory neurotransmitters like glutamate, which activates NMDARs.

 

Gabapentin

Gabatril

 

Most anti-convulsants can be used for both Etoh/Benzo withdrawal....

[deborah212]

Librium has a longer half life than Ativan but I was taught that 25 mg of Librium roughly equals 1mg of Ativan give or take. most of the etoh withdrawal patients I've cared for have needed a minimum of 6mg of Ativan/day.. Some upwards in high teens. Have you been working at this place long? What has your experience been withis regimen?

[deborah212]

Contarian, have you treated alcohol withdrawal on the psych unit with baclofen in place of benzos or is this when managing outpatients? I think it's a game changer when people are hospitalized/committed and we completely eliminate their ability to drink. Have seen people end up one the unit despite Ativan ATC which is why I feel strongly.

 

Also, to the OP, make sure you tailor your benzo taper to the individual patient. If they've been taking an obscene amount of Ativan or Xanax, a standardized protocol might not cut it. Worse case scenario is that they seize.

[myironlung]

Librium has a longer half life than Ativan but I was taught that 25 mg of Librium roughly equals 1mg of Ativan give or take. most of the etoh withdrawal patients I've cared for have needed a minimum of 6mg of Ativan/day.. Some upwards in high teens. Have you been working at this place long? What has your experience been withis regimen?

 

I work in corrections, so obviously this has an affect on treatment. These protocols are approved by my sp which are approved by corporate. Believe me, I'd love to have more space to work with, but it's very difficult with all the restrictions. The point of my original post was to try and see exactly how far off our protocols are compared to the real world. My sp doesn't seem to have a problem with people seizing. He just says if they seize, they seize...and if they don't stop seizing, give them IM ativan..and if that doesnt work, we send them out 911. There doesn't seem to be any sense of urgency or anxiety about the management of these people. Very difficult for me to grasp but it is how it is..they are my employer.

 

Even though I know we don't give much compared to the real world management of these, it actually amazes me how sometimes the less you do the better the outcome. Or maybe another way of saying it is, sometimes with giving so little, you can see how giving any more isn't that much more advantageous. A bit of a contradiction with my comments earlier about being anxious myself about how little we give. But it's all a learning process for me. Some people we do change the protocol for. We may give librium 50mg bid instead of 25mg bid. And then we may extend it by a few days. We sometimes house them in the prison medical unit as opposed to a general population cell. Another thing which is extremely challenging is the fact that these people will lie all day long about everything from symptoms, to how much they take, to what they take etc..some even fake seizures...we even had a girl who urinated herself , just to get some ativan. Thanks for the replies though, I'll keep them in mind.