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Detoxification

Detoxification. Dr Gholam Reza Kheirabadi Assistant Professor of Psychiatry Behavioral Sciences Resaerch Center Isfahan University of Medical Sciences kheirabadi@bsrc.mui.ac.ir. Detoxification ( Medically supervised withdrawal). - opioid Agents for treating opioid withdrawal.

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Detoxification

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  1. Detoxification Dr Gholam Reza Kheirabadi Assistant Professor of Psychiatry Behavioral Sciences Resaerch Center Isfahan University of Medical Sciences kheirabadi@bsrc.mui.ac.ir

  2. Detoxification( Medically supervised withdrawal) • -opioid Agents for treating opioid withdrawal. • (Methadone, buprenorphine , LAAM & Tramadol) • Non opioid Approach for Detoxification. • (clonidine & lofexidine)

  3. مردي ميان سال – كارمند يك شركت دولتي وزن 76 كيلو- با همسرش به روان پزشك مراجعه كرده است .مشكل خانواده اعتياد مرد به ترياك است. زن جوان اشك ريزان خواهان تجويز داروهائي است كه همسرش بتواند با كمك آنها ترك اعتياد كند . مرد مي گويد مشكل چنداني ندارد. هروقت بخواهد مي تواند ماده مصرف نكند. به حد افراط از مكانيسم انكار و ريز نمائي مشكل استفاده مي كند. توصيه شما چيست؟ الف- موكول كردن شروع درمان به زماني كه معتاد انگيزه كافي پيداكند. ب –انجام مصاحبه انگيزشي ج –شروع مسموميت زدائي باهدف كمك به خانواده واين واقعيت كه اگر انها بروند- ممكن است هرگز بر نگردند د –به همسر بيمار مي گوئيم به شوهرش اعتماد كند ومشكل در حد اعتياد نيست.

  4. آيا اعتياد واقعا درمان پذير است؟ آيا اين درمان سريع و آسان است؟ درمان آسان اعتياد در 48 ساعت بدون درد با ايجاد بيزاري؟؟ مسموميت زدائي= درمان ؟؟ پرهيز = درمان؟؟

  5. مراحلدرمان وابستگي مواد: 1-ايجاد انگيزه –آغاز پرهيز 2- مسموميت زدائي 3- ادامه پرهيز و آغاز درمان ا صلي :شروع روان درماني شركت در گروه هاي خودياري (معتادين گمنام)تغيير سبك زندگي – تغيرات شخصيتي –تغيير عادات ونگرش به زندگي

  6. اصل اول در درمان وابستگي مواد : انفرادي كردن اصل دوم : از مواد اعتياد آور استفاده نكنيد. بنا بر اين استفاده از مواد افيوني وبنزو ديازپين ها استثنا است ونه قاعده كدام روش براي كدام بيمار؟ روش ها 1- روش سنگاپور 2- كلونيدين + آمي تريپ تيلن 3-متادون و ديگر آگونيست هاي مواد افيوني Individualization

  7. Outpatient Treatment Program • Initial stabilization up to cessation of illicit opioids( initial period of abstinence). • Gradual dose reduction(3%/week is Superior to 10%/week reduction). • Timetable is superior to free reduction. • More gradual reduction= more successfulness ) • More supervision after 20-30mg/day of methadon

  8. Inpatient Treatment Program • Initial stabilization fore 24-48 hours( up to 60 mg). • 10-20% reduction of methadone/day(or 5mg/day) • Close supervision & supportive resources • Termination with in 7-10 days

  9. MEHTADONE • Stabilization on Methadone: -Initial dose: A:10-20mg→ if withdrawal persist → Repeat the dose( 2 hours later ) [ no more than 40mg during first day]. B: Calculation of equivalent withdrawal suppressing dose of methadone? (Methadone is 3time potent than morphine). C: Add 10mg/2-3day or week( different for outpatient V.S inpatient detoxification?) up to final stabilization(more gradual and upper final dose in outpatient setting).

  10. Buprenorphine: • Introduction: • developed in 1970 • Agonist-antagonist( or partial agonist)? analgesic. • Low dependency • Substitution of heroin and morphine with lower withdrawal symptoms • Significant drug of abuse (IV injection form) • Favorable for detoxification and maintenance therapy

  11. Pharmacology and pharmacokinetics • HL: 48-72 hours. • Partial µ agonist (pure agonist in lower doses) • Weak Ќ antagonist (agonist-antagonist in higher doses) • Safe and little chance of lethal doses • Ceiling effect and safety: =8-12 mg →maximum clinical effect =↑8-12mg(16-32mg) →: -no increase of clinical effect and side effect -increase duration of clinical effect (suitable for maintenance therapy)

  12. Drug forms • Solution: buprenorphine + alcohol • Tablet:(0.2,0.4, 2 & 8mg) buprenorphine only (subutex) • Tablet:(2 & 8mg) buprenorphine + naloxone (4/1) (subuxone)…superiority? • Injection form? • 4 mg of sublingual tablet=40 mg methadone • 8 mg of sublingual tablet=50-60 mg methadone

  13. Protocol: outpatient Setting Protocol • Initial dose:2-8 mg( first dose withdrawal) • Stabilization of patient next days(2-4mg/day up to 8-32mg) • Stabilization for 24-48 hours( or more) • Decreasing 2mg of drug/ days- week.

  14. Protocol: Inpatient Setting 8mg of Buprenorphine on the first day and 2mg/day reduction on the next days.

  15. Tramadol • Mechanism: serotonin & nor-epinphrin reuptake inhibitor(Parent compound) + µ agonist(metabolize compound-desmethyltramadol). • Withdrawal control with200-400mg for modest and 600 mg for sever withdrawal) • Seizure in high doses CNS suppressant Using with B.Z & seretonergic syndrome with SSRI.

  16. α2 Agonists - Clonidine -Lofexidine (Less Hypotensive)

  17. Mechanism & Sideffects • It has specificity towards the presynaptic alpha-2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone • This drug may cause drowsiness, lightheadedness, dry mouth, dizziness, or constipation. Clonidine may also cause hypotension. It can also cause inhibition of orgasm in women

  18. Clonidine • Patient stabilized on low dose of opioids (30 – 40 Methadone/ day). • starting dose 0/1 – 0/3. *Maximum dose (1/mg/day) In outpatient & 1.5-2.0mg/day In hospitalized patients. *Adjusting Dose based On Hypotension & sedation. Contraindication: acute or chronic cardiac disease, Renal & metabolic disease, Hypotension).

  19. Clonidine • More effective in: =stabilization on Methadone. =good Relationship with therapist. • Effective in suppressing of : Sweating, cramps, nusea, vomiting and diarrhea • Ineffective In suppressing of (Muscle aches – Lethargy – Insomnia – restlessness and Craving). • Non – effective on relapse after complete detoxification. • Facilitation of detoxification of Methadone Maintained patients & subsequent stabilization on naltrexone.

  20. Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms

  21. Rapid & Ultrarapid detoxification • Naloxone + clonidine • Naloxone + clonidine + sedatives • Naltrexon + clonidine and/ or sedatives • Full Anesthesia For 3-4 hours.

  22. other techniques * Symptomatic treatments (Healthy & Motivated). • Abrupt withdrawal withought Intervention. * Abrupt withdrawal with Emotional support • Acupuncture • Herbal Medication

  23. Opioid Dependence Treatment in Special Populations • Criminal Justice Patients • Pregnant Women • Health professionals • Psychiatric Patients • HIV-positives & hepatitis-c positives

  24. Opioid Dependence Treatment in Special Populations =Criminal Justice Patients *Opium use and criminal activity: -This relation is complex and reciprocal. -There is no direct relation between opioid use and criminal behavior( except in withdrawal periods for ……... ) . *Opium dependents in justice system: -Direct coercion to treatment -Incarceration and opium dependence

  25. Opioid Dependence Treatment in Special Populations =Pregnant Women: • Poor prenatal care • Low birth weight • Elevated risk of morbidity & mortality • No teratogenicity reported • Cautious detoxification( before 14 & after 32 weeks) • Methadone in pregnancy( dose adjustment). • Buprenorphine in pregnancy. • Health professionals:

  26. Opioid Dependence Treatment in Psychiatric Patients =Mood Disorders: -Mood disorders as most prevalent disorders among opium dependence. -Routine Vs selected antidepressant administration. -Opium treatment program and control of depressive symptoms. = Bipolar Disorder and opium dependence: -Management principles………………….. - Drug interactions( carbamazepine & methadone). -MMT & Bipolar Disorder. =Anxiety Disorders: comorbidity and principles of drug treatments.

  27. Opioid Dependence Treatment in Psychiatric Patients =Psychotic Disorders: -comorbidity of psychotic disorders and opium dependence • Antimanic & antipsychotic effects of opioids (Methadone) =Alcohol Abuse: -Comorbidity of Opioid and alcohol abuse( up to 50%) -Balance of Alcohol & Opioid use -Disulfiram & Methadone -naltreoxone with dual benefits. =Nicotine dependence in opium users =Polysubstance abuse: -more psycopathology than single users and poor outcme -more suitable for maintenance program -more suitable for TC or NA groups

  28. Hivpositves • Only 33% of study participants received concurrent treatment for MI and SA, • CONCLUSION: Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.  • The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug dependence and HAART. • highly active antiretroviral treatment (HAART). • injecting drug users (IDUs) • Improving treatment adherence in drug abusers who are HIV-positive.

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