Detoxification/Withdrawal

1. Detoxification/Withdrawal

2. Goals • Differences between adolescent and adult patterns of use, effects on brain, concerns with detoxification/withdrawal. • Understand top concerns with particular substances • Alcohol • Opiates/opioids • Cannabinoids • Methamphetamine/cocaine/stimulants

3. Adolescent Brain • Continues to develop until 20s • Back to front

6. Main Points • Different patterns of use • Alcohol: binge vs. daily • Polypharmacy as a general rule • Substances effect adolescent differently • The younger age at initiation the more risk for abuse/dependence

7. Alcohol • Pattern of Use • Binge type • Less likely to be daily drinkers • Less sensitive to the sedating effects of alcohol • Higher BAC • More blackouts • More damage

9. What does this mean in corrections? • More likely to overdose than go through medically significant withdrawal • What happens with alcohol overdose? • Increasing BAC leads to increasing sedating effects • Loss of muscle control, stupor, coma, death • Death from aspiration, choking, respiratory depression

10. What happens with Alcohol Withdrawal • Requires significant duration of daily drinking with tolerance • 60% who meet criteria for dependence will experience some symptoms of withdrawal (>90% mild to moderate) • 6-24 hours from last drink • Changes to major neurotransmitters in brain • Enchances GABA-major inhibitory neurotransmitter • Homeostatic changes • Increase in blood pressure, heart rate, anxiety, n/v, seizure, death

11. CIW-A • Clinical Institute Withdrawal Assessment • Questionnaire /Assessment done by clinician/nurse • Score 10 or more needs medical treatment/evaluation • What to do if limited nursing?

12. Nausea and Vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache, fullness in head Disorientation CIWA-Ar Scale J Clin Psychopharmacol 1991; 11:291-295

13. Opioids/opiates • Heroin • Prescription Drugs • Hydrocodone (vicodin, norco) • Oxycodone • Morphine • Methadone

14. CDC- National Epidemic of Overdose Deaths

15. Rates of Opioid Pain Reliever (OPR) overdose deaths, OPR treatment Admissions and Kilograms of OPR sold

16. Drug overdose death rate and rate of opioid pain relievers sold in the US- 2008

18. Effects of Opioids • Sedation • Pupil Constriction • Slurred speech • Impaired attention/memory • Constipation/ urinary retention • Nausea • Confusion/delirium • Seizures • Slowed heart rate • Respiratory depression

19. What does this mean for corrections? Overdose potential • Depends on which opiate: • Onset of action. • Hydrocodone (peak .5hr, duration 3-4 hours) • Methadone (peak: 2-4 hours, duration 24 hours) • Tolerance of individual • Tolerance to respiratory depression may be slower than tolerance to euphoric effects • Symptoms of overdose: • Triad: • Altered LOC • Respiratory Depression (RR<12) • Miotic Pupils • Withdrawal • Cows

20. Management of Opioid Overdose • Basic life support • Assess Ventilation • Support ventilation • Naloxone hydrochloride – opioid antagonist • .4mg to .8mg, may have to be repeated • May need higher doses and multiple repeated doses over time

21. Opioid Withdrawal • Not life-threatening but so uncomfortable prompts relapse. • Onset of symptoms depends on the duration of use and ½ life of drug used • Heroin: onset 4-6 hours • Methadone: onset: 36 hours • Neurophysiologic rebound in target organs • The generalized CNS suppression during use is replaced by CNS hyperactivity.

22. Clinical Opiate Withdrawal Scale- COWS

23. Treatment • Supportive measures • Medication assisted • clonidine

24. Psychostimulants

25. Medical Morbidity-Acute Intoxication • CVS • Ventricular irritability • Hypertension • Tachycardia • Myocardial Infarction • Neurologic • Seizure • Stroke • Hyperthermia • Rhabdomyolysis • Acute Renal Failure • Insomnia

26. Chronic Methamphetamine Use • CVS • Cardiomyopathy • Myocardial Infarction • Strokes • Pulmonary • Pulmonary Hypertension • COPD • Neurologic • Memory Impairment • Deficits in judgment • Poor impulse control • Infectious • HIV/Hepatitis C • Skin infections • Complications IVDA

27. MA Psychiatric Morbidity • Psychosis • Acute: • Classically paranoid • Persecutory delusions • Ideas of Reference • Heightened awareness • Chronic: • Psychosis can persist after acute episode or recur with little or no further MA use. • Sensitization • Mood Disorder • Mania during intoxication • Depression during withdrawal • Anxiety

28. Management of Intoxication • Confirm diagnosis by urine toxicology screen • Gastric lavage or activated charcoal for ingestion • Seizures: Diazepam • Psychosis /Agitation: Diazepam +/- antipsychotic • Hyperthermia: external cooling

29. Withdrawal from Methamphetamine • Hyperarousal • Agitation, severe craving, nightmares • Vegetative Symptoms • Decreased energy, craving sleep, increased appetite • Anxiety-related symptoms • Anxiety, loss of interest, anhedonia, psychomotor retardation • Severe dysphoria, mood volatility, irritability and sleep pattern disruption

30. Cannibinoids • Drug of choice- most daily marijuana use • Intake: • Adverse events: paranoia, increased blood pressure/HR • Withdrawal • Symptoms similar to nicotine withdrawal • No real treatment for withdrawal

31. Synthetic Cannibinoids

32. Synthetic Cannibinoids- spice, KQ • Mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC • Street names: Spice, K2, Black Mamba, Blaze, JWH-018, 073, Kronic(added BZ), krypton (added opioid) • Typically smoked • Sold in Europe since 2002-2004. Widely available for purchase on Internet in 2006

33. 2010: states began banning product • 2011: schedule 1 drug • First cannibinoid identified was JWH-018 and CP47,497. Now there are well over 20 new synthetic cannabinoids. • 10 -100 more potent than THC • Strong affinity to CB1 receptors • Responsible for psychoactive effects • Central and peripheral nervous sx, • Cardiovascular system

34. Some of herbal ingredients added may have psycho-active potential (opioid-like, Bz,etc) • Onset 3-5 minutes • Duration of action: 1-8 hours

36. Physiologic Response- CB1 Activation • Depends on dose • Mood effects • Euphoria and dysphoria • Hyperactivity, anxiolysis and anxiety • Perceptual effects • Change in time perception • Hallucinations/psychotic states • Paranoia • Depersonalization/dissociation

37. Cognition effects: • Fragmented thinking • Short term memory impairment • Motor effects • Ataxia, loss of coordination, slurred speech • Immunosuppressive • Cardiovascular effects • Increased heart rate, orthostatic hypotension

38. Toxicology effects • Unpredictable toxicology • Adverse effects are dose dependent • Emerging evidence that adverse effects are more severe • Especially in teens (as is Marijuana)

39. Seizures • Psychosis • Growing acceptance that cannabis use may increase the risk of psychosis and/or psychosis like conditions. Cannabis risk is mild. • 41% increased risk in developing psychosis for cannabis users v. non-cannabis users • 109% increase for heavy cannabis users • Commonly reported in SC users • Clearly associated with both the onset and exacerbation of recurrent psychotic episodes

40. Mood and Anxiety • Anxiety • Catatonia • Cardiovascular effects • Increased heart rate • Pediatrics: Adolescents presenting with chest pain, confirmed myocardial infarction.