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Ambulatory Withdrawal Management

Ambulatory Withdrawal Management. Ambulatory Detoxification & more SAMHSA: outpatient treatment services providing for safe withdrawal in an ambulatory setting. - Managing acute and post-acute withdrawal symptoms in an outpatient setting. What is it?.

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Ambulatory Withdrawal Management

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  1. Ambulatory Withdrawal Management Greg Sutmiller MS, LPC, LADC

  2. Ambulatory Detoxification & more • SAMHSA: outpatient treatment services providing for safe withdrawal in an ambulatory setting - Managing acute and post-acute withdrawal symptoms in an outpatient setting. What is it?

  3. “Opiates are outranked only by alcohol as humanity’s oldest, most widespread, and most persistent drug problem.” • Harvard Mental Health Letter, 2004 • Dr. Leo Kadehjian Why is it needed?

  4. Drug Overdose (OD): 2nd leading cause of unintentional deaths after motor vehicle fatalities • CDC, 2010 • Opioids: 93% of prescription OD deaths • JAMA 2008 • Prescription OD deaths increased x4 since 1999 (>heroin + cocaine combined) • CDC, 2013 • Heroin OD deaths +45% 2006–2010 • SAMHSA, 2013 • Dr. Leo Kadehjian Why is it needed?

  5. United States’ Drug Consumption • 4.6% of world population • Consumes 2/3 of illicit drug supply • Consumes 80% of global opioid supply • Consumes 99% of global hydrocodone supply • L. Manchikanti and A. Singh, 2008 • Dr. Leo Kadehjian Why is it needed?

  6. Oxycodone per Capita • DEA 2013 Oxycodone Production Quota: 135,000 kg • 2011 U.S. Population: 311,591,917 • 135,000 kg / 311,591,917 persons = 422 mg/person! • Dr. Leo Kadehjian Why is it needed?

  7. Tolerance builds up significantly and quickly. • Tolerated dose can increase 10x in as little as two weeks and up to 35x ultimately. • Opiate drugs are becoming more potent. • OxyContin • Heroin • 60%-80% currently vs. 10% or less in 1970’s • More people are abusing opiates and becoming opiate dependent. • The age of initiation is getting lower. • Baby boomers are becoming dependent. • Steve Hanson Why is it needed?

  8. Why is it needed?

  9. Lots of people are opiate dependent! • Lots of people need to get off opiates! • What happens when opiate dependent people come off opiates? Why is it needed?

  10. Why is it needed?

  11. Key Component #4 • “Drug courts provide access to a continuum of alcohol, drug, and other related treatment rehabilitation services.” • Includes detoxification Why is it needed?

  12. NADCP Best Practice Standards • Part of the continuum of care • Determined by standardized assessment (not phase or professional judgment) • ASAM-PPC • Participants cannot be sanctioned for substance use if they are at a lower level of care than they need. Why is it needed?

  13. ASAM • Least Restrictive • Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring • Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring • Requires specific medical staff: RN/LPN, PA, NP, Physician • Requires daily monitoring Why is it needed?

  14. Alcohol and Opiates • Focus on Opiate Withdrawal • Opiate Dependent • Mild to Moderate Withdrawal Symptoms • COWS • ASAM Dimensions • Assessment Driven Who’s it for?

  15. COWS Who’s it for?

  16. Stabilization • Manage Withdrawal Symptoms • Eliminate Illicit Opiate Use What’s the goal?

  17. Get Started • Feel better • Engage in treatment • Manage responsibilities What’s the goal?

  18. Regular Office Visits • Every few days to every day based on need • ASAM Level I-D • ASAM Level II-D • Check in • Vital signs • Assessment • Medication • Drug Screens • Therapy and/or other psychosocial services What’s the process?

  19. Assessment • COWS • Physical • Psychological • Case Management What’s the process?

  20. Medication • Managing Symptoms • Clonidine, nausea & diarrhea meds, hypertension meds, etc. • Full Agonist • Methadone • Partial Agonist • Buprenorphine (Subutex) • Partial Agonist w/ Antagonist • Buprenorphine-Naloxone (Suboxone) • Full Antagonist • Naltrexone (Revia, Depade, Vivitrol) What’s the process?

  21. Medically Assisted Treatment (MAT) • NADCP Best Practice Standards • “Participants are prescribed psychotropic or addiction medications based on medical necessity as determined by a treating physician with expertise in addiction psychiatry, addiction medicine, or a closely related field.” • MAT can… • Improve outcomes • Increase engagement in treatment • Reduce illicit drug use • Reduce other program violations What’s the process?

  22. Buprenorphine and Medically Supervised Withdrawal • BUP can be used to cease opiate use or to transition out of agonist (methadone) treatment. • Cease opiate use • Withdrawal symptoms present • 1-2 initial doses on first day • Build up dose over next couple days • Make sure consumer is compliant and stable • Reduction of dose over next few days • Some consumers may need to take longer in reduction phase or enter maintenance treatment What’s the process?

  23. Drug Screens • Screen for the Standards • Screen for Specific Opiates • Screen for Metabolites What’s the process?

  24. Therapy and Other Psychosocial Services • VITAL • Outpatient (ASAM Level I) • Intensive Outpatient (ASAM Level II) • Daily if necessary • Individual, Group, Case Management, Recovery Support • Coordination is key! What’s the process?

  25. Coordination • Communication • Team members • Other service providers • Adequate Team Representation • Medical professional(s) • Innovation • Creativity • Caution What does a specialty court need to consider?

  26. Hallford, J. (2014, July 25). Personal interview. • http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/10-addiction-vs-dependence • http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_095.htm • http://www.nadcp.org/sites/default/files/nadcp/KeyComponents_0.pdf • http://www.ncbi.nlm.nih.gov/books/NBK64109/ • http://www.ncbi.nlm.nih.gov/books/NBK64158/ • http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140220/ • http://www.norcen.org/addiction/ambulatory-detoxification • http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NChp4.htm • http://www.windmoor.com/programs/ambulatory-opiate-detox.stml • National Association of Drug Court Professionals. Adult Drug Court Best Practice Standards: Volume I. 2013, Alexandria, VA. • Substance Abuse and Mental Health Services Administration. TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004, Rockville, MD. • Substance Abuse and Mental Health Services Administration. TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. 2005, Rockville, MD. References

  27. Greg Sutmiller gsutmiller@ctioklahoma.org (918) 384-0002 Contact

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