1. Detox Basics

2. Definition of Addiction
Compulsion: loss of control
The user can’t 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.

3. Neuroadaptation, Tolerance, and Withdrawal
Neuroadaptation is the brain’s 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.

4. 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.

5. Kindling In tolerant users:
Progressive nervous system arousal causing withdrawal symptoms to worsen each time drug use is discontinued.
Also called withdrawal sensitization.

6. 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.

7. Physical Dependence Physical Dependence Abstinence Syndrome Tolerance
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.

8. 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
Stress equals craving

9. Withdrawal Management Detoxification
Use of medications to treat withdrawal symptoms.
Goals:
Evaluation
Stabilization
Foster readiness for and entry into treatment
Goals from TIP 45, Page 16

10. 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

11. C I M Model Treatment Withdrawal Management
PRINCIPLES
Calculate the dose equivalent per 24 hours
Push medications to achieve “symptom capture”
Maintain Diastolic BP <90 and Pulse <90
Decrease substitute medication in 10% increments
Slow rate of taper to maintain Diastolic BP <90 and Pulse <90
Tremor free
SUBSTITUTION
TAPER

13. Opiate Effects Analgesia Euphoria Anxiolytic- calming Sleep Inducing
Sensation of warmth
Constipation
Dry mucous membranes
Pupils constrict
Sedation/Sleepiness (nodding)
Depresses respiration

14. Effects and Withdrawal Opiates
Analgesia
Euphoria
Anxiolytic - calming
Sleep Inducing
Constipation
Dry mucous membranes
Sensation of warmth
Pupils constricted
Withdrawal
Pain
Dysphoria
Anxiety
Insomnia
Diarrhea
Rhinorrhea
Chills
Pupils dilated

15. Opiate Withdrawal Pain Dysphoria Anxiety Insomnia Diarrhea Rhinorrhea
Chills
Pupils dilate
Increases heart rate & blood pressure

16. 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

17. 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

18. 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
Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001

21. OPTIMUM ANALGESIC DOSE
The best dose of opiate is the dose that first, best relieves pain, and second, relieves pain without sedation.

22. 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 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.

23. Withdrawal Management Opiate Oral Dose Equivalents
Buprenorphine (Suboxone®) 8 mg (sublingual)
Hydrocodone (Vicodin®) mg
Methadone (Methadose®) 20 mg
Morphine sulfate (immediate release) 30 mg
Morphine sulfate (MS Contin®) 15 mg
Oxycodone (Percodan®) (Oxycontin®) mg
Propoxyphene (Darvon®) mg
Adapted from Goodman and Gilman, 9th ed., page 535.

24. 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

25. 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 hours.

26. 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.

27. 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

28. A 33-year follow-up of narcotics addicts.
Hser YI, Hoffman, V, Grella CE, Anglin D. A 33-year follow-up of narcotics addicts. Archives of General Psychiatry. 2001;58:

29. 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
Methamphetamine is a long-acting central nervous system stimulant that is highly addictive. It comes in a variety of forms, and its effects vary depending on whether ingested orally, snorted, smoked or injected intravenously. Smoking or injecting methamphetamine increases the potential for addiction and its subsequent consequences because the drug is absorbed in the brain more rapidly. Although the eurphoric effects can be felt in 3-5 minutes when snorted, and ingestion is noticeable within minutes, neither compares to the immediate intense RUSH response produced when methamphetamine is smoked or injected intravenously Lasting only a few minutes this initial RUSH described as extremely pleasureable, is the result of a rapid increase in the concentration of dopamine in the brain’s reward centers.

30. Stimulant Withdrawal Dysphoria Boredom Anergia
Disordered sleep Anxiety
Depression
Hypofrontality

32. 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

33. Medications for Stimulant Dependence
Antidepressants (anhedonia/anergia)
Effexor XR mg
Cymbalta 60 mg
Wellbutrin XL mg
Desipramine mg
Anti-Craving Medications
Modafinil mg
Methylphenidate LA mg
Buproprion mg
Concerta mg
Dexedrine SR mg
Disorders of Sleep
Trazedone mg
Seroquel mg
Imipramine mg
Disorders of Thought
Abilify 2-10 mg
Haldol 1-2 mg Risperdal 1-3 mg

34. GABA Scale

35. 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

36. 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
* Symptom may continue for months
Withdrawal
Dysphoria *
Anxiety *
Insomnia *
Sweating (Diaphoresis) *
Tremor
Tachycardia
Hypertension
Hyperventilation
Elevated temperature
Hallucinations
Seizures
Delirium tremens

37. Spectrum of Sedative-Hypnotic Withdrawal
Acute withdrawal: hypertension, tachycardia, tremors, sweating, pallor, anxiety/panic, craving
Withdrawal seizures: preceded by increasing tremors and myoclonic jerks
Delirium Tremens: medical emergency presentation of combative, hallucinating, confused; all sedative-hypnotic withdrawal can yield DTs.

38. 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

39. Prescription Tranquillizers
Dose Equivalent To Alcohol
(2oz liquor or 2 glasses of wine or 2 cans of beer)
Alprazolam (Xanax®) mg
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

41. 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 hours.
Hold Phenobarbital for slurred speech, ataxia, or lethargy.
Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer

42. Withdrawal Management Sedative-Hypnotic “Uncovering”
Uncovering: the re-appearance of withdrawal symptoms after initial stabilization, necessitating re-titration of the dose.

43. 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.

46. Effects of Increasing Dosage in the Non-tolerant User
Gamma-Hydroxy-Butyrate: GHB
Effects of Increasing Dosage in the Non-tolerant User
Coma
Loss of
Consciousness
Euphoria
Somnolence
Vertigo
Amnesia
Sedation
Dose (mg/kg)

49. Cannabis effects WITHDRAWAL EFFECTS Sleep inducing Insomnia/nightmares
Appetite stimulation
Induces calm
Induces ‘mellow’ feelings
Elevates mood
Reduces muscle tone
Produces pleasure
WITHDRAWAL
Insomnia/nightmares
Anorexia
Anxiety
Irritability/anger
Depression
Tremor
Anhedonia

50. Nicotine Effects Withdrawal Symptoms 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

51. REFERENCES
--- Responsibility and choice in addiction. Psychiatric Services. 53(6): (2002).
Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005)
Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005).
Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004.
Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006
Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10: (2003).
Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.