Prepared by J. Mabbutt & C. Maynard NaMO September 2008

1. 8.1: Managing Opiate and Psychostimulant Withdrawal Prepared byJ. Mabbutt & C. MaynardNaMO September 2008

2. 8.4: Managing opiate and psychostimulant withdrawal – Objectives 1. During the session nurses & midwives will learn how to identify, assess and manage a patient in opiate and psychostimulant withdrawal 2. By the end of the session nurses & midwives will have an understanding or use of the opiate withdrawal scales 3. At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage opiate & psychostimulant withdrawal

3. 8.1: Managing drug withdrawal This presentation gives general guidelines for managing withdrawal. Refer to Section 9 for specific details of withdrawal symptoms and management for the most commonly used substances For further information, refer to the New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html

4. 8:1 Indications and guidelinesOpioid Withdrawal – Onset & Duration of withdrawal (1) • Heroin is a relatively short-acting drug • Symptoms of withdrawal usually commence 6-24 hours after the last dose, reach a peak at 24-48 hours, & resolve after 5-10 days • Methadone or other long-acting opioids withdrawal usually commences 36-48 hours after the last dose • The peak severity of methadone withdrawal tends to be lower than for heroin withdrawal, but withdrawal may be more prolonged, lasting 3-6 weeks

5. 8:1 Indications and guidelinesOpioid Withdrawal – Onset & Duration of withdrawal (2) • Buprenorphine withdrawal is similar to other opioids but is generally milder than withdrawal from methadone or heroin because of its slow dissociation from the opioid receptors • Symptoms commence generally within 3–5 days of the last dose and can last for several weeks

6. 8:1 Indications and guidelinesOpioid Withdrawal – Onset & Duration of withdrawal (3) • Following acute withdrawal, protracted, low-grade symptoms of discomfort (psychological and physical) may last many months • Table 9.5 shows times of appearance of withdrawal syndrome in dependent opioid users

7. 8:1 Table 9.5: Withdrawal syndrome (Adapted from NSW Dept of Health, (2000) and (2006)

8. 8:1 Indications and guidelinesWithdrawal – Onset & Duration of withdrawal (4) • The opioid withdrawal syndrome can be very uncomfortable & distressing, but not life-threatening unless there is a severe underlying disease • Patients may have a low tolerance to pain due to the effect of long-term opioid use & this needs to be acknowledged & treated effectively • The following Graph – Figure 9.2 shows the progress of the acute phase of opioid withdrawal after last dose

9. 8:1 Figure 9.2: Progress of the acute phase of opioid withdrawal Adapted from NSW Health Withdrawal Clinical Practice Guidelines (2007)

10. 8:1 Table 9.6 Symptoms and signs of opioid withdrawal

11. 8:1 Indications and guidelines Pharmacological treatment for opioid withdrawal • The medical officer or drug & alcohol nurse practitioner may prescribe the preferred pharmacological option for opioid withdrawal: • Buprenorphine • Symptomatic medications

12. 8:1 Buprenorphine Treatment for opioid withdrawal – Hospital Setting (1) • Buprenorphine is well suited in the hospital setting as it alleviates symptoms of withdrawal without significantly prolonging the duration of symptoms • There should be some ability to tailor doses to degree of withdrawal as assessed by the Clinical Opiate Withdrawal Scale (COWS) (see Appendix 4) • Buprenorphine should not be commenced until objective withdrawal is present (COWS score greater than eight) to reduce likelihood of precipitating withdrawal

13. 8:1 Buprenorphine Treatment for opioid withdrawal – Hospital Setting (2) • Commencing buprenorphine before the patient has withdrawal signs can cause them to go into a a rapid withdrawal syndrome & cause great distress to them • Using the COWS as noted can help reduce this risk • Buprenorphine will bind tighter to the opiate receptor sites than the opiate drug (e.g. heroin/methadone) the person is normally on. • This will throw the opiate off the receptor site & put the patient into to a precipitated (severe) withdrawal

14. Table 9.7: Example of buprenorphine dosage

15. 8:1 Table 9.8 Symptomatic treatment Note: Caution is recommended in exceeding stated duration of benzodiazepine use to avoid substituting for heroin dependence. Duration of treatment may need to be longer than stated above for withdrawal from long-acting opioid (e.g. methadone, Kapanol etc).

16. 8:1 Table 9.8 Symptomatic treatment Note: Caution is recommended in exceeding stated duration of benzodiazepine use to avoid substituting for heroin dependence. Duration of treatment may need to be longer than stated above for withdrawal from long-acting opioid (e.g. methadone, Kapanol etc).

17. 8:1 Indications and guidelinesWithdrawal – Psychostimulant withdrawal – Case Study • Present relevant case study for psychostimulant intoxication or other drug withdrawal from Guidelines CD Rom Section 01 • Discuss each section in small groups or as a large group and feedback

18. 8:1 Indications and guidelinesManaging psychostimulant withdrawal (1) • Psychostimulants are: Amphetamines, cocaine & ecstasy • Amphetamines are: amphetamines (speed), methamphetamines (‘ice’) & dexamphetamine (Ritalin), • Repeated and prolonged use of psychostimulants leads to marked tolerance, neuro-adaption & dependence, & withdrawal on cessation • Withdrawal from cocaine or amphetamines is not life-threatening • Depression resulting from withdrawal can lead to suicidal ideation, self-harm and possibly death

19. 8:1 Amphetamines • Three forms of Amphetamines • Powder, Base & Crystal • meth/amphetamine powder approx 10% pure • meth /amphetamine base approx 20% pure • methamphetamine crystal–‘ice’ approx 80% pure Powder Base Crystal

20. 8:1 Indications and guidelinesManaging psychostimulant withdrawal (2) • Suicidal ideation should be managed as per hospital policy & NSW Department of Health Policy Directive No. PD2005_121 Suicidal Behaviour – Management of Patients with Possible Suicidal Behaviour athttp://www.health.nsw.gov.au/policies/PD/2005/PD2005_121.html • Also refer to the Framework for Suicide Risk Assessment and Management for NSW Health Staff athttp://www.health.nsw.gov.au/pubs/2005/suicide_risk.html • See also: NSW Health 2006: Psychostimulant Users – Clinical Guidelines for Assessment and Management: GL2006_001:

21. 8:1 Indications and guidelinesManaging psychostimulant withdrawal (3) Withdrawal is characterised by three phases: • Crash • Withdrawal • Extinction • Table 9.12 shows the phases of amphetamine & cocaine withdrawal

22. Table 9.12 Amphetamine and Cocaine withdrawal

23. Table 9.11 Amphetamine and Cocaine withdrawal

24. Table 9.11 Amphetamine and Cocaine withdrawal

25. 8:1 Indications and guidelinesManaging psychostimulant withdrawal – Monitoring • Four-hourly monitoring is recommended as nurses/midwives need to be aware of changing signs & symptoms that the patient may present with as they pass through the crash & withdrawal phases • Mood & energy levels may fluctuate e.g. a patient may initially present with a low mood and psychomotor retardation & then swing towards being restless & agitated later the same day • Assess for underlying mental health problems as these may have been masked during the crash phase but become evident later in the withdrawal period • Withdrawal scales have not been routinely used in clinical practice

26. 8:1 Indications and guidelinesPharmacological treatment • To date, no broadly effective pharmacological therapy has been identified However, symptomatic medication may be beneficial, for example: • Benzodiazepines for anxiety, agitation, insomnia & aggressive outbursts – not be used for more than two weeks without review • Antipsychotic medication for psychotic symptoms (delusions, hallucinations etc) • Antidepressants for symptoms of depression that persist after stimulant withdrawal