Basic Principles of Detoxification

Mark Menestrina, MD, FASAM

Medical Director, SEMCA National Field Medical Advisor, Reckitt

Benckiser Pharmaceuticals

April 30, 2012

Credit where credit due…

•  Detoxification and Substance Abuse Treatment Training Manual: Based on a Treatment Improvement Protocol (TIP#45) SAMHSA, 2008

•  Priniciples of Addiction Medicine, R Ries et. al., 4e, Lippincott Williams and Wilkins, 2009

•  Addiction Medicine: An Evidence-Based Handbook, Rastegar and Fingerhood, Lippincott Williams and Wilkins, 2005

•  Principles of Addiction Medicine: The Essentials, C Cavacuiti, Lippincott Williams and Wilkins, 2011

Integration of Detoxification and Substance Abuse Treatment

•  Detox patients are in a crisis, providing a window of opportunity to acknowledge substance abuse problem and seek treatment

•  Research shows that detox is often followed by a reduction in drug use and a desire to seek treatment

•  Detox staff can facilitate patient’s entry into treatment

Addiction is a Brain Chemistry Disease

•  Involves the Meso-Limbic System (Primitive and not conscious)

•  Neurotransmitter Mediated •  Denial is a Hallmark Feature •  Emotional, Physical, Psychological •  Chronic, Progressive, potentially Fatal •  Affects Family, Community, Society •  Different than Abuse, anyone can Abuse

Drugs or Alcohol.…A Preventable Behavior

6

7

Chemical Dependence 8

Behavioral Dependence 9

Detox DOES NOT equal Treatment…

But it is often the first step in the Recovery Process

Withdrawal Syndrome and Detoxification

•  WITHDRAWAL SYNDROME is the predictable constellation of signs and symptoms following abrupt discontinuation of, or rapid decrease in, intake of a substance that has been used consistently for a period of time.

•  DETOXIFICATION is the management of the Withdrawal Syndrome

“First, do no harm”

Hippocrates

Loeb’s Laws of Medicine

•  1) If what you are doing for the patient is helping the patient, keep doing it.

•  2) If what you are doing for the patient is not helping the patient, stop doing it.

•  3) Never ever let your patient see a surgeon.

Goals of Detoxification CSAT 1995a

•  Provide a safe withdrawal and enable the patient to become free of non-prescribed medications

•  Provide a withdrawal that is humane and protects the patient’s dignity

•  Prepare the patient for ongoing treatment of his or her dependence

Module 1 Objectives •  Define detox as distinct from substance

abuse treatment •  Describe the three essential components of

detox: evaluation, stabilization, and fostering entry to treatment

•  Distinguish the six different DSM-IV-TR definition of terms relating to detox and treatment

•  Identify at least two challenges to providing effective detox

History of Detoxification Services

•  AMA declares alcoholism a disease in 1958

•  The Uniform Alcoholism and Intoxication Treatment Act (1971)

•  Emergence of humanitarian views of those who are substance use dependent

•  Emergence of new treatment models

Three Components of Detoxification Process

•  Evaluation: screening and assessment •  Stabilization: assisting the patient

through detox and withdrawal •  Fostering readiness and entry into

treatment

Review of Terms

•  Substance •  Substance-related disorders •  Substance dependence •  Substance abuse •  Substance intoxication •  Substance withdrawal

Fostering and Maintaining Abstinence

•  Fostering abstinence includes: - Ongoing assessment of physical,

psychological and social status - Identification of relapse triggers - Primary medical and psychological care as

needed

•  Maintaining abstinence includes: - Continuation of counseling and support - Refinement and strengthening of strategies

for relapse prevention

7 Key Assumptions and Guiding Principles for Detox and

Substance Abuse Treatment 1)  Detox is not complete treatment 2)  Detox process includes evaluation,

stabilization and fostering treatment readiness

3)  Detox takes place in a wide variety of setting

4)  All treatment must be of the same quality and thoroughness

7 Key Assumptions and Guiding Principles for Detox and

Substance Abuse Treatment

5)  Insurance coverage for complete detox is cost-effective

6)  Detox programs must be culturally competent in order to address the unique needs of all patients

7)  Success depends on continuation of treatment after detox

Linkages to Treatment Services

•  Linkages from detox to treatment leads to an increase in recovery and a decrease in repeated detox and treatment services

•  Recovery leads to reductions in crime and reductions in expensive medical and surgical treatments

•  Effective linkage to treatment services remains a signficant challenge to detox providers

Module 2 Objectives

•  Define the types of settings for detox and treatment services

•  Describe the role of the settings in the delivery of services

•  Identify at least five issues to consider in determining whether inpatient or outpatient detox is preferred setting

Five Settings for Detoxification Services

1)  Physician’s office 2)  Freestanding urgent care center or

emergency department 3)  Freestanding substance abuse

treatment or mental health facility 4)  Intensive outpatient and partial

hospitalization programs 5)  Acute care inpatient services

Six ASAM Assessment Criteria for Patient Placement

1)  Acute intoxication and/or withdrawal potential

2)  Biomedical conditions and complications 3)  Emotional, behavioral or cogntive

conditions and complications 4)  Readiness to change 5)  Relapse, continued use or continued

problem potential 6)  Recovery/living environment

Setting #1: Physician’s Office •  Ambulatory Detox Without Extended Onsite

Monitoring - Trained clinicians - Medically supervised evaluation, detox and

referrals - Patients regularly monitored - Patients must have positive social support - Services delivered in office, treatment

facility or patient’s home

Setting #1: Physician’s Office •  Ambulatory Detox With Extended Onsite

Monitoring - Services provided by RNs or LPNs - Include medically supervised evaluation,

detox and referrals - Patients monitored for several hours each

day - Patients must have positive social support

network - Services provided in treatment setting such

as a day hospital

Setting #2: Freestanding Urgent Care Center or Emergency Dept •  Patients who require primary medical and/or

nursing care services •  Include physician managed procedures and

protocols •  Medically directed assessments and acute

care include initiation of detox •  Not likely to include biomedical stabilization

or 24 hour observation •  Triage to inpatient can be facilitated •  Staffing is typically physicians and nurses

Setting #3: Freestanding Substance Abuse Treatment or

Mental Health Facility…Inpatient •  Medically managed intensive patient

detoxification •  24 hour supervision, observation and

support for intoxicated or withdrawing patients

•  Stabilization and facilitation of linkages to other services

•  Multidisciplinary staff: physicians, nurses, counselors, social workers, psychologists

Setting #3: Freestanding Substance Abuse Treatment or

Mental Health Facility..Residential •  Medically managed or social detox •  24 hour supervision and support •  Emphasize peer and social support •  Staffing: credentialed personnel using

physician-approved protocols for observation, monitoring and supervision

•  Medical consultation available 24/7 •  Some provide supervision of self-

administered medication

Setting #4: IOP and Partial Hospitalization Programs

•  Regularly scheduled detox sessions •  Follows established protocols •  Onsite patient monitoring •  Linkages to treatment services •  Staffing includes interdisciplinary team

of physicians, RNs, LPNs, counselors, social workers and psychologists

Setting #5: Acute Care Inpatient Settings

•  Medically monitored inpatient detox •  24 hour medically supervised eval and

monitoring •  Follows established protocols •  Staffing includes interdisciplinary team

of physicians, RNs, LPNs, counselors, social workers, psychologists

•  Counselors available 8 hours a day for planned interventions

Module 3 Objectives •  Identify overarching principles for patient

care during detox •  Describe strategies for evaluating/addressing

psychosocial/medical issues for detoxing patients

•  Address issues with special populations •  Describe strategies for engaging/retaining

detox patients •  Identify effective referral techniques

promoting initiation of substance abuse treatment

Biomedical Evaluation Domains

•  General health history •  Mental status •  Physical assessment •  Use and patterns of substance abuse •  Past treatments for substance abuse

Psychosocial Evaluation Domains

•  Demographics •  Living conditions •  Violence/suicide risk •  Transportation availability •  Financial situation •  Dependent children •  Legal status •  Physical, sensory or cognitive abilities

Conditions Requiring Immediate Medical Attention

•  Change in mental status •  Increase in anxiety or panic •  Hallucinations •  High body temperature •  Increase/decrease in blood pressure •  Insomnia •  Abdominal pain •  Gastrointestinal bleeding •  Changes in responsiveness of pupils

Conditions Requiring Immediate Psychiatric Attention

•  Suicide risk •  Anger •  De-escalating aggressive behaviors •  Co-occurring mental disorders

Nutritional Considerations During Detoxification

•  Malnutrition can interfere with detox process •  Stress of detox requires additional nutrients •  Nutritional evaluation is necessary for detox •  New routines for mealtime and diet are

crucial •  Important to manage gastrointestinal

symptoms during detox •  Nutritional therapy may be required

Detoxification Considerations for Adolescents

•  Binge drinking is common and can cause escalating alcohol levels

•  Some drugs taken are not identifiable, routinely screen for illicit drugs

•  Nondisclosure of drug use: (multiple substances with alcohol) establish rapport and obtain thorough history

•  Screen for suicide potential

Detox Consideration for Parents with Dependent Children

•  Barriers to Treatment: •  Parents, especially mothers, fear for

the safety of their children •  Some children experience distress

while parent is in treatment •  Ensure children have a safe place to

stay •  Social services may need to be

involved

Detox Considerations for Domestic Violence Victims

•  Both men and women may be vicitims •  Increased risk for female drug abusers to be

victims •  Develop safety plan when violence is

disclosed •  Avoid communications between abused and

abuser during detox •  Vicitms may need help with parenting skills •  Know local childcare resources

Detox Consideration for Culturally Diverse Patients

•  Patient’s detox expectations may vary •  Patient’s experience in health care

system may vary •  Patient’s cannot be defined by their

culture/ethnicity •  Use open-ended questions to gain

understanding •  Important to have bilinual staff if

possible to avoid language barriers

Detox Consideration for Chronic Relapsers

•  Relapser may feel hopeless and vulnerable

•  Acknowledge progress made before relapse

•  Reassure that gains from prior progress have not been lost

•  Reinforce the importance of recovery

Strategies to Engage and Retain Patients in Detoxification

•  Offer hope •  Provide atmosphere with comfort, relaxation,

cleanliness and security •  Educate patients on withdrawal process •  Utilize support systems •  Maintain a drug-free enviornment •  Consider alternative approaches •  Enhance patient motivation •  Foster a therapeutic alliance

Enhancing Patient Motivation •  Focus on strengths •  Show respect for autonomy •  Avoid confrontation •  Provide individualized treatment •  Avoid using labels •  Use empathy •  Recognize small steps toward achieving

goals •  Raise awareness of discrepancies •  Use reflective listening

Stages of Change •  Precontemplation: no consideration for

change, unaware of problem •  Contemplation: some awareness of problem,

willing to consider change but ambivalent •  Preparation: aware of problem, decision

made to change, goal setting •  Action: takes steps to achieve goals to

change •  Maintenance: works to maintain changes

made

Fostering a Therapeutic Alliance

•  Be supportive and empathetic •  Refer when patient cannot be engaged •  Establish rapport, discuss confidentiality

issues, be cognizant of challenges for patient •  Be consistent, trustworthy, reliable, calm and

cool, confident and humble •  Be able to set limits without power struggle •  Be cognizant of patient’s progress •  Encourage patient’s self-expression

Common Barriers to Referral After Detox

•  Patient’s may believe they are “cured” once eliminating substance

•  Patient’s may feel they no longer need help after detox

•  Insurance may only provided partial or limited coverage

•  Paperwork for insurance may be overwhelming

•  Patients may struggle with insurance system

Evaluating Rehab Needs

•  Psychosocial needs •  Special needs may limit access to rehab •  Limitations or conditions may limit

suitable treatment settings •  Support system may influence referral •  Dependent children may impact needs •  May be need for gender-specific

treatment

Areas for Assessment •  Medical •  Motivation •  Physical, sensory or

mobile limitations •  Relapse history and

potential •  Substance abuse/

dependence •  Developmental or

cognitive issues

•  Family/social support •  Co-occurring issues •  Dependent children •  Trauma/violence •  Treatment history •  Cultural background •  Strengths and

resources •  Language

Treatment Settings •  Inpatient programs •  Residential treatment programs •  Therapeutic communities •  Transitional/halfway houses •  PHP and day programs •  Intensive outpatient programs •  Traditional outpatient services •  Recovery maintenance activities

Following Through with Treatment Referral

•  Patients are more likely to initiate treatment if they:

- Believe they will be helped - Are employed - Motivated beyond precontemplation - Have family and social support - Have co-occurring psychiatric

conditions

Strategies to Promote Initiation of Treatment After Detox

•  Assess degree of urgency •  Reduce appointment wait times •  Call to reschedule missed appointments •  Provide information to show expectations •  Offer tangible incentives •  Engage support of family members •  Introduce patient to counselor •  Offer referral/services to address other needs •  Minimize accesss to treatment barriers •  Maintain motivation during waitng list period •  Facilitate coordination of co-occurring treatment •  Ensure medical appointments are being made •  Some patients may require non-traditional treatment

Module 4 Objectives •  Identify biochemical markers and their use

for screening and assessment •  Describe key concepts for treatment

regimens for detox from specific substances •  Explain why management of polydrug abuse

and use of alternative approaches to detox are important

•  Identify special considerations for special populations in the detox process

Biochemical Markers •  Lab tests that detect the presence of alcohol

or other drugs •  Used to support a diagnosis •  Used for forensic purposes •  Used to detect the use of alcohol or other

drugs during treatment •  Can serve as motivational enhancement •  Can help in moving patient from

contemplation to action

Most Common Types of Biochemical Markers

•  Blood alcohol levels •  Breath alcohol levels •  Urine drug screens •  Gamma-glutamyltransferase GGT •  Carbohydrate-deficient transferrin CDT •  Mean corpuscular volume MCV •  Ethylglucoronide EtG

Alcohol Intoxication •  20-100mg%: Mood, behavior changes,

reduced coordination, impaired driving •  101-200mg%: Reduced coordination,

speech, gait, judgment impaired •  201-300mg%: Marked impairment of thing,

memory, alertness. Blackouts •  301-400mg%: Reduction of BP and temp.

Sleepiness, amnesia, N&V •  401-800mg%: Coma, incontinence, death

Alcohol Withdrawal •  Restless, irritable,

anxiety, agitation •  Anorexia, N&V •  Tremors, increased

HR and BP •  Insomnia, intense

dreams/nightmares •  Poor concentration,

impaired memory and judgment

•  Increased sensitivity to sound, light, tactile sensations

•  Hallucinations—auditory, visual or tactile

•  Delusions •  Seizures •  Hyperthermia •  Delirium

Alcohol and other Sedatives •  Alcohol and other Sedatives exert their

effects by directly or indirectly enhancing GABA (inhibitory)

•  With abstinence there is a relative deficiency of GABA

•  Alcohol also inhibits the sensitivity of autonomic adrenergic systems with resulting upregulation with chronic alcohol intake

•  Discontinuation leads to rebound overactivity of brain and peripheral noradrenergic systems

Alcohol/Sedative Withdrawal Signs and Sx

•  Begin 6-24 hours after alcohol cessation, variable for other sedatives, depending on half-life

•  Early s/s include anxiety, sleep disturbances, vivid dreams, anorexia, nausea and headache

•  Tachycardia, hypertension, hyperactive reflexes, diaphoresis, hyperthermia

•  Seizures most often occur within 48 hours •  Delirium Tremens (DTs) typically begins

48-72 hours after last drink, preceded by typical signs and symptoms of early withdrawal

CIWA-Ar •  Nausea and Vomiting •  Tremor •  Paroxysmal Sweats •  Anxiety •  Agitation •  Tactile Disturbances •  Auditory Disturbances •  Visual Disturbances •  Headache •  Orientation/Sensorium

•  Scored from 0-7 (0-4 for Orientation

•  Maximum Score 67 •  <10 generally don’t

require meds, >20 do

•  Between 10-20, follow closely for worsening withdrawal

Pharmacological Management

•  Suppression of Withdrawal through use of a cross-tolerant medication, usually with a longer duration of action

•  Reduction of signs and symptoms of withdrawal through alteration of another neuropharmacological process

•  May use one or the other or both

Benzodiazepines for Detox •  Safer Therapeutic

Index •  Anxiolytic •  Better with hepatic

dysfunction (lorazepam and oxazepam)

•  Euphorogenic •  Abuse Potential and

Cross Addiction •  Many Alcoholics are

also using/dependant on Benzos

Phenobarbital for Detox

•  Not very euphorogenic

•  Long half-life •  Lower abuse

potential

•  Therapeutic Index not as favorable as benzos

•  Not as anxiolytic •  Caution with

hepatic disease, porphyria

Benzodiazepines and Other Sedative Hypnotics

•  Important Factors for Success: •  Start detox during period of low

external stressors •  Patient must be committed to taper off

substance •  Develop plan for managing underlying

anxiety disorders •  Frequent patient contact

A Protocol for Benzodiazepine Withdrawal

(+/- Alcohol) •  Phenobarb Protocol, with phenobarb taper

after detox (3-6 days?) •  Begin valproic acid 1000 mg +/- daily unless

contraindication, in which case consider gabapentin or other anticonvulsant mood stabilizer…continue 6 weeks or more, taper?

•  Significant withdrawal symptoms may be treated with propanolol, quetiapine, etc

•  Insomnia usually treated with trazodone, occasionally atypical antipsychotics

Seizures and Alcohol / Benzodiazepine Withdrawal

•  The number one predictor of w/d seizures is a previous history of w/d seizures…get a good history!

•  For alcohol w/d only (no hx of benzos) consider adding valproic acid to phenobarb

•  Brighton Hospital: ~2-3 seizures per year (~2500 admissions), usually non-disclosed significant benzo dependence and occur after detox and transfer to rehab

Opioid Intoxication •  Lowered HR, BP, body temperature •  Sedation •  Pinpoint pupils (miosis) •  Slowed movement •  Slurred speech •  Head nodding •  Euphoria, calmness, imperviousness to

pain

Opioid Withdrawal Syndrome

•  Usually begin within 12 hours after cessation of short acting opiates (heroin, hydrocodone, immediate release or crushed oxycodone), later with longer acting drugs (methadone, oxycodone)

•  Rarely life-threatening…the “Safest Withdrawal”, or is it?

Opioid Withdrawal •  Increase HR, BP, body temperature •  Insomnia, increased reflexes •  Enlarged pupils •  Sweating, increased respirations •  Tearing, runny nose, muscle spasms •  Abdominal cramps, N&V, diarrhea •  Bone and muscle pain •  Anxiety

Clinical Opioid Withdrawal Scale (COWS) Wesson & Ling 2003

•  Resting Pulse •  Sweating •  Restlessness •  Pupil Size •  Bone/Joint Aches •  GI symptoms •  Tearing/Rhinorrhea •  Tremor •  Yawning •  Anxiety •  Gooseflesh

•  Like CIWA, numerical values given and score totaled

•  Various Scales exist, all serve to measure withdrawal and guide need for treatment

Common Medications Used to Manage Opioid Withdrawal

•  Methadone •  Clonidine (Catapress®) •  Buprenorphine (Suboxone®) •  Rapid and Ultra-rapid opioid

detoxification

Stimulant Withdrawal (Cocaine, Crack, Amphetamines)

•  Depression, fatigue, anxiety, irritability •  Hypersomnia or insomnia •  Poor concentration •  Psychomotor retardation •  Increased appetite •  Paranoia •  Drug craving

Cocaine and other Stimulants •  Regular users seem to experience

withdrawal, but not as clear cut as sedatives or opioids

•  Symptoms include dysphoria, fatigue, insomnia or hypersomnia and psychomotor agitation or retardation, cravings, increased appetite and vivid unpleasant dreams (“using dreams”)

•  Peak at 2-4 days, longer for amphetamines •  Treatment generally supportive

(amantadine?)

Symptoms of Inhalants and Solvents

•  Delirium, tremors, weakness, weight loss, inattentive behavior, depression

•  Impaired cognitive, motor and sensory functioning

•  Internal organ damage, including heart, lungs, kidneys and liver

Medical Management of Inhalant Abuse and Dependence

•  Provide safe environment that is free of inhalants

•  Supportive care, including ample sleep and well-balanced diet

•  Determine if patient is abusing other substances

•  Access mental status •  Provide appropriate therapy and

interventions

Nicotine Withdrawal Symptoms

•  Depressed mood, anxiety •  Insomnia, irritability, frustration, anger •  Difficulty concentrating •  Restlessness •  Decreased heart rate •  Increased appetite or weight gain

Medical Management of Nicotine Withdrawal

•  Self-help interventions •  Behavioral interventions •  Nicotine replacement therapy •  Bupropion (Wellburtin®) •  Combination therapy •  Varenicline (Chantix®)

USPHS Nicotine Intervention: The 5 A’s

•  ASK about tobacco use •  ADVISE to quit •  ASSESS willingness to make a quit

attempt •  ASSIST in the quit attempt •  ARRANGE a follow up

Marijuana

•  THC abstinence syndrome •  Symptoms include: - Anxiety - Restlessness, irritability - Sleep disturbance - Change in appetite No medical complications of withdrawal

Anabolic Steroids •  Subject to abuse •  Aggressive, manic-like behavior •  W/D includes fatigue, depression,

restlessness, insomnia, anorexia, reduced sex drive, headache, nausea

•  Side Effects can be reversed and may include: UTIs, skin redness and blistering, edema, behavior changes

•  No detox protocol for steroids

Club Drugs

•  A diverse class including GHB, Ecstasy, Rohypnol

•  Used in nightclubs and “raves” •  Withdrawal symptoms may include

intoxication and overdose •  Destructive effects on nervous system

and mental health

Best Practices for Management of Polydrug Abuse

•  Prioritize substances according to withdrawal severity

•  Alcohol and sedative hypnotics (benzos) have the most severe w/d

•  Opioid detox is the next priority •  Some substances will not require

treatment during detox, including stimulants, marijuana, hallucinogens and inhalants

Considerations for Pregnancy •  Detox on demand, women-centered •  Transportation, child care issues •  Counseling and case management •  Access to safe housing •  Legal, nutritional, social needs •  Ensure health and safety of both infant and

mother •  Clarify risk/benefit of any medications •  Protocol for w/d may vary with each

pregnancy

Considerations for Elderly •  Supportive, nonconfrontational age-

specific group •  Screen for depression, grief, loss •  Linkages to specialized services •  Alcohol and drug issues more severe

with elderly •  At risk for co-occurring disorders •  Ongoing assessments and monitoring

for medical problems common in aged

Considerations for Disabled •  Eliminate barriers: attitudinal,

discriminatory, communication and architectural

•  Impairment categories include physical, sensory, cognitive, affective

•  Detox programs must screen for disabilities, be compliant with federal laws, provide access to services, coordinate treatment and know local and national disability resources

Considerations for Minorities •  African Americans are at greater risk for DM

and HTN, may display distrust with counselors of different culture and may be at greater risk of toxic side effects with antidepressants

•  Hispanic/Latinos are largest minority in US. Access level of acculturation, language competency helpful, family is important, substance use often viewed as moral weakness

Considerations for Minorities

•  Native Americans, great diversity, highest rate of alcohol and drug use. Fables and Healing Circles may be helpful. Frame 12 steps in terms of circle, not a ladder

•  Avoiding eye contact is traditional •  Tend to seek treatment later with more

medical complications •  Fetal Alcohol Syndrome 33x US average

Considerations for Minorities •  Asians and Pacific Islanders, also a very

diverse group •  May show concern for counselor credibility,

trustworthiness •  Higher sensitivity to alcohol •  Smoking rates tend to be high •  Some detox meds may be metabolized more

slowly •  Important to use traditional healing methods

and ask attitude toward Western medicine

Considerations for Other Populations

•  Gay, Lesbian, Bisexual and Transgender - Monitor staff attitude - Help patients with previous negative experiences and

accept personal power

•  Adolescents - Physical dependence not as severe, more rapid

response to detox - Retention is a problem - Higher club drugs and steroids - Peer relationships play a large role in treatment

Considerations for Incarcerated or Detained Individuals

•  Substance use common, 70-80% of inmates have used or committed drug offenses

•  Abrupt w/d from alcohol or sedatives can be life-threatening

•  W/D from opioids can cause great stress •  Substance abuse can continue during

incarceration •  Access to detox can be major problem

Summary

•  Detoxification is not treatment, but it often may be the first phase of engaging a person, and can serve as an entry point to facilitate ongoing change and entry into the recovery process

•  “A teachable moment”

Selected Cases… •  Male alcoholic, with severe cirrhosis,

who states his doctor told him to stay away from liquor, just drink beer or wine

•  Alcoholic, relapsed after chemo nurse told him to have a glass of wine after txs

•  Alcoholic, on alprazolam for 3 months after doctor told him to take a pill each time he wanted to drink

•  Gentleman who said his doctor of 17 years didn’t know he drank

Warren L.

•  51 yo wm, presents intoxicated but walking and talking, BAT of 0.43

•  Except for hx of HTN, no other problems

•  What would you be concerned about in addressing and treating his withdrawal?

Shirley B.

•  63 yo wf, hx of multiple admissions for alcoholism w/o sustained recovery

•  Denies any other drug use, but UDS on admission is positive for benzos…which, when questioned, she says she “got something in the ER” 2 days previously

Lawrence T.

•  44 yo AA male, presents with hx of heroin, hydrocodone and oxycodone

•  20 hours after admission, he c/o of being “dope sick”, and buprenorphine is started

•  He becomes violently ill, with sweats, vomiting, diarrhea, refuses to take any further Rx and leaves AMA

ADDICTION TREATMENT MADE EASY…. “A” to “B” M Menestrina

NEGATIVE Consequences:

The job, liver, judge, wife, boss, friend get the individual’s attention!

POSITIVE Reinforcement: The individual actually begins to like and enjoy “recovery”

While this process is achievable, it is not likely to all make sense to the patient. It may involve 12 step, counseling, treatment of co-morbid conditions, Medication Assisted Treatments and other modalities.

“NEVER DOUBT THAT A SMALL GROUP OF

DEDICATED CITIZENS CAN CHANGE THE WORLD…INDEED IT IS THE ONLY THING THAT EVER HAS”

Margaret Meade