1. Novel Opiate Detoxification Techniques Ken Roy, MD Tulane Department of Psychiatry Addiction Recovery Resources of New Orleans 504-780-2766 www.arrno.com

3. Topics The Physiology of Opiate Detoxification The Natural History of Detoxification Novel detoxification techniques Management of Detoxification induced by Naltrexone Treatment and Long Term Recovery

4. Physiology of Opiate Detoxification Limbic System Locus Ceruleus Gut and Smooth Muscle Skeletal Muscle

5. Limbic System Opiate Agonist Euphoria Sedation Satiety Detoxification Dysphoria Agitation Craving

6. Locus Ceruleus Opiate Agonist Unconcerned Anergic Hypotensive/Bradycardic Detoxification Hypervigilant Hyperalert Hypertensive/Tachycardic

7. Gut and Smooth Muscle Opiate Agonist Relaxed tone Reduced sensation Constipation Detoxification Spasm Hypersensitive Diarrhea

8. Skeletal Muscle Opiate Agonist Relaxed tone Reduced sensation Comfortable Detoxification Spasm Painful Akathisia

9. Principles of Detoxification Use a drug with a long half-life and low abuse potential Use a drug that is smoothly eliminated Replace the abused drug with the detox drug Initiate drug free treatment Taper the detox drug

10. Natural History of Detoxification Scared, Anxious, Desperate, Agitated (days) Sick, Whinny, Needy (days to weeks) Pain, Cramps, Spasms, Nausea, Diarrhea (days) Angry, Drug seeking, Hungry, Craving (weeks) Chronic Euphoric Recall (weeks to months)

11. Severity of Detoxification Depends on the potential for addiction Darvon may be low grade but long Vicodin/Percodan usually moderate Heroin is severe Methadone is the worst

12. Length of Acute Detoxification Depends on the half life of the drug Fentanyl may be very short Vicodin/Percodan lasts a week or so Heroin about the same Methadone lasts a month

13. Subacute Detoxification Length depends on the half life of the drug Methadone may be months to a year Chronic nagging craving Chronic euphoric recall Chronic dysphoria Most frequent period of relapse

14. Drugs to use Limbic system Geodon, Zyprexa, anticonvulsants Dysphoria, agitation, craving Responsible for anger Locus Ceruleus Catapres (Clonidine) Most important drug in the first phase Need to train staff to give enough Can give up to 2.4mg in 24 hours Zanaflex

15. More Drugs to use Gut and smooth muscle Bentyl, Sandostatin, Zofran Vistaril Skeletal muscle Zanaflex, Flexaril NSAID’s General agitation Xanax, Ativan, Zyprexa, Geodon

16. Types of Novel Detoxification Ultra Rapid Detoxification under anesthesia Rapid induction of detoxification using Naltrexone Brief detoxification with Buprenorphine Ibogaine

17. Detoxification With Buprenorphine Now, if you apply for an exemption to prescribe, rational detoxification is possible Some will tolerate rapid detoxification (one to two weeks) Some will require stabilization prior to detoxification Buprenorphine is a great detoxification medication

18. Maintenance With Buprenorphine Partial agonist Binds to and activates receptor, but increasing dose only results in partial activation More competitively bound than almost all mu receptor drugs Blocks Heroin and other opioids Induces detox in Heroin/Methadone patient unless they are already sick

19. Maintenance With Buprenorphine Because of firm binding to receptor is literally metabolized from the site Detoxification symptoms are much more tolerable Patients may become involved in treatment, NA and Recovery and simply “drop off” into continued Recovery

20. Rationale for Rapid Detoxification With Naltrexone Shorten acute detox Over in hours to days Eliminate subacute detox Evidence for increased Beta Endorphins while taking Naltrexone Group participation while in very early treatment Patients aware that detox is over Reduce drug seeking behavior

21. Natural History of Detoxification Following Naltrexone Protocol Scared, Anxious, Desperate, Agitated (obscure) Sick, Whinny, Needy (4-24hrs) Pain, Cramps, Spasms, Nausea, Diarrhea (4- 24hrs) Angry, Drug seeking, Hungry, Craving (hours to a day) Chronic Euphoric Recall (don’t see it)

22. How it Goes Stabilize on Buprenorphine One or more days Give loading doses Treat detoxification symptoms in advance in 1/2 hour give Naltrexone 150mg Vigorously treat emerging symptoms with PRN’s

23. ON ADMISSION – IN ADDITION TO ROUTINE ADMIT ORDERS Buprenorphine 0.6 mg SL now and Q2h while awake. Thorazine 50mg IM or PO Q6h prn nausea or vomiting or agitation. Bentyl 20mg IM or PO Q6h prn cramping abdominal pain. Zanaflex 8mg Q4h prn skeletal muscle cramps, diaphoresis, piloerection or signs or symptoms of opiate detoxification. Imodium caps 2 Q6h prn diarrhea. Seroquel 100mg PO qhs. Observe for orthostatic hypotension. Catapres 0.1mg q1/2h prn pulse >80 up to 2.4mg/24 hrs. Sandostatin 100mcg SC q4h prn nausea, vomiting or diarrhea. Phenobarbital 90 mg q2h prn tremor or pulse > 110.

24. IF SEDATIVE AND/OR ALCOHOL DEPENDENCE ALSO PRESENT 1. Change admit Phenobarbital order to 90mg PO on admit and Q8h @ 6am, 2pm and 10pm

25. WHEN READY TO START DETOX Xanax 2mg PO now. Zanaflex 8mg PO now. Bentyl 20mg IM now. Thorazine 50mg IM now. Sandostatin 100mcg SC now. Imodium caps 2 now. Buprenorphine 0.6mg SL now. Naltrexone 150mg PO in ½ hour and 50mg qam. DC Buprenorphine after above. Catapres 0.2mg with first dose of Naltrexone and continue previous prn Catapres order. Notify for pulse over 90 or diastolic over 90. Xanax 2mg PO q2h prn agitation in next 12 hours only, up to four prn doses total. DC all prn’s 72 hours following first dose of Naltrexone

26. What to expect Initial sleepiness Emerging profound acute detoxification symptoms Lasting 4 to 24 hours Period of lethargy and exhaustion 2nd day Period of anger Group readiness

27. Following Detoxification Now treatment can start Should be criteria based IOP (ARRNO, NFI, etc.) RTC (ARRNO) Support system involvement crucial Recommend Naltrexone for 6-12 mos.

28. Experience More than 4000 cases Four transfers to ER Two for dehydration Two for over sedation None in last four years No deaths (within the month following detox) or permanent morbidity Perceived equal success in drug free recovery to persons addicted to other drugs