ambulatory detoxification in the 21 century · 2017. 3. 20. · ambulatory detoxification in the...
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AMBULATORY DETOXIFICATION In the 21st Century
Louis E. Baxter, Sr., M.D., DFASAM, DABAM
DMHAS-Addiction Medicine Consultant
Executive Medical Director
Professional Assistance Program of N J
Clinical Assistant Professor Medicine – Rutgers New Jersey Medical School
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LEARNING OBJECTIVES
• What Ambulatory Detoxification Means
• The elements of successful programs
• How to operate a program
• Drug Specific Protocols
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INTRODUCTION
• WHY is Ambulatory Detoxification attractive ?
• Healthcare Cost Addiction Treatment …
• $ 600 Billion/yr
• Declining Healthcare Benefits
• Decreased Number Of Inpatient Days
• Limited Treatment Opportunities/Lifetime
• Advent Of Levels Of Care
• Proven Efficacy in “selected cases”
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TRADITIONAL BELIEFS
• Detoxification = Inpatient Treatment
• Outpatient Treatment = Increased Morbidity
• Outpatient Treatment = Increased Mortality
• Inpatient Treatment > Outpatient Treatment
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HISTORICAL PERSPECTIVE
• First Attempts….”Big Book”
• First Documented Study….1975 Feldman
• Poor Outcomes
• 1. Poor Selection Criteria
• 2. Poor Assessment Process
• 3. Ineffective Protocols
• 4. Lack Of Recognition Of Dual Diagnosis
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HISTORICAL PERSPECTIVE
• What Is “Success Rate”
• # of patients referred for counseling ?
• # of patients that complete treatment ?
• # of “uneventful” detoxifications ?
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WHAT IS AMBUALATORY DETOX ?
• The Beginning Step
• Part Of FULL TREATMENT Experience
• 1. Detoxification
• 2. Rehabilitation
• 3. Maintenance / Continuing Care
• Linkage Opportunity to Counseling and 12 Step Programs
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WHAT AMBULATORY DETOX IS NOT
• It Is Not for Everyone !
• IT IS NOT IN LIEU OF A FULL TREATMENT EXPERIENCE
• It Alone, is Not “Treatment”
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THE PROCEDURE
• INITIAL MEDICAL ASSESSMENT
•PATIENT PLACEMENT CRITERIA
•CRITERIA FOR AMBULATORY DETOX (see Ambulatory Detox Guidelines)
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MEDICAL ASSESSMENT
• Severity And Risk Of Withdrawal
• Coexistence Of Other Medical Problems
• Coexistence of Psychiatric Problems
• Need for Medical Management And Medication
• Pregnant Patients Merit Special Treatment
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PATIENT PLACEMENT TOOLS
• ASAM CRITERIA
• PCPC
• OTHERS
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AMBULATORY DETOX CRITERIA
• No Prior History Of Complicated Detox
• No History of Complicated Medical or Psychiatric Illnesses
• Supportive Recovery Environment
• Transportation Availability
• Ability to Follow Instructions
• Reasonable Treatment Acceptance
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SUCCESSFUL PROGRAMS
• Systematic Screening Procedures
• Admission and Discharge Criteria
• Patient Placement Criteria
• Initial Medical Assessment
• Standardized Protocols
• Psycho-Therapy
• Patient Satisfaction
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THE BASICS - HOW TO DO IT
• Patient Consent Forms
• Treatment Consent
• Full Treatment Agreement
• Severity Assessment Instrument ( ASI; CIWA)
• Laboratory Testing…CBC, LFT’s, Hep B & C
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BASICS - HOW TO DO IT
• MONITOR VITAL SIGNS
• Initially BID/TID until stable
• Then Daily until Complete
• MONITOR USE
• Breathalyzer
• UDS testing
• Oral Fluids Testing
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BASICS - HOW TO DO IT
• Thiamine And Multivitamins (Etoh)
• Medication Monitoring
• Daily Dispensing
• Significant Other Dispensing
• Operational Hours…Mon - Thur (new
patients)
• Early … AM to Noon
• No New Cases on Fri ( unless wkeend hours)
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BASICS - HOW TO DO IT
• Simultaneous Outpatient Counseling
• Evening Program (employed)
• Intensive Outpatient (if available)
• Traditional Outpatient (if indicated)
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BASICS - HOW TO DO IT
• TWO STEPS TO DETOXIFICATION
• Stabilization…neutralize all withdrawal signs and symptoms
• Slowly begin to TAPER so as not to allow emergence of withdrawal symptoms
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Specific Protocols-Alcohol
• ALCOHOL … Librium 25-50mg q6h x 24h
• Increase the Interval daily (e.g. Q8h,Q12h,..)
• Adjunctive Medications • Acamprosate 660mg tid
• Antabuse
• Naltrexone
• Antidepressants
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SPECIFIC PROTOCOLS - Sedatives
• SEDATIVE HYPNOTICS (see Alcohol)
• Only SLOWER Taper….change dose QOD
• Taper over a 10 day period
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SPECIFIC PROTOCOLS - Opioids
• OPIOIDS • Antagonist … Naltrexone … once detoxed*
• Agonist-antagonist Suboxone / Subutex • Agonists … Long Acting … Methadone 30-60mg to
stabilize … split dosing … (DEA / Pain). Taper 5mg per dose per day
• Clonidine …. Trans-dermal (leave on one week) and oral (for 3 days)
• NSAIDS at maximum doses around the clock • Benadryl for sleep… up to 100mg @hs
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SPECIFIC PROTOCOLS
• PREGNANT OPIOID DEPENDENT PATIENTS SHOULD NOT BE DETOXIFIED
• The treatment of choice is METHADONE MAINTENANCE
• BUPRENORPHINE … 16mg-32mg for Maintenance informed consent
• Taper postpartum (if indicated)
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SPECIFIC PROTOCOLS - Stimulants
• STIMULANTS
• Supportive Care
• Craving Management…”Dopamine”
• Bromocryptine @1.25mg bid…40mgqd
• Amantadine 100mg bid
• Desipramine 150-300mg divided doses
• SSRI’s (Zoloft 50-200mg; Paxil up to 60mg; others)
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SUMMARY
• IS NOT FOR EVERYONE
• AMBULATORY DETOX IS SAFE and Effective
• SHOULD BE COUPLED WITH COUNSELING
• IS Not IN LIEU OF a “ FULL TREATMENT ”
• Follow Guidelines … ASAM Criteria and DMHAS Bulletin