# Presentation: 207120

## Module 4: Physical Detoxification Services for Withdrawal From Specific Substances

## Module 4 Objectives

- Identify biochemical markers and their use in patient screening and assessment
- Describe key concepts for treatment regimens for detox from specific substances
- Explain why the management of polydrug abuse and the use of alternative approaches to detox are important
- Identify special considerations for special populations in the detox process

## Biochemical Markers

- Lab tests that detect the presence of alcohol or other drugs
- Used to *support* a diagnosis
- Used for forensic purposes
- Used to detect use of alcohol or drugs during treatment
- Can serve as a motivational enhancement
- Can help in moving patient from contemplation to action

## Most Common Types of Biochemical Markers

- Blood alcohol levels
- Breath alcohol levels
- Urine drug screens
- Gama-glutamyltransferase (GGT)
- Carbohydrate-deficient transferrin (CDT)
- Mean corpuscular volume (MCV)

## Alcohol Intoxication

**Blood Alcohol Level**
- 20–100 mg percent
- 101–200 mg percent
- 201–300 mg percent

**Clinical Picture**
- Mood and behavior changes
- Reduced coordination
- Impaired ability to drive a car
- Reduced coordination
- Speech impairment
- Trouble walking
- General impairment in thinking and judgment
- Marked impairment of thinking, memory, and coordination
- Marked reduction in level of alertness
- Memory blackouts
- Nausea, vomiting, blackouts

## Alcohol Intoxication

**Blood Alcohol Level**
- 301–400 mg percent
- 401–800 mg percent

**Clinical Picture**
- Reduction of body temp and blood pressure
- Excessive sleepiness
- Amnesia
- Nausea and vomiting
- Coma
- Serious decrease in pulse, temp, blood pressure, and breathing
- Incontinence
- Death

## Alcohol Withdrawal

- Restlessness, irritability, anxiety, and agitation
- Anorexia, nausea, and vomiting
- Tremors, elevated heart rate, and increased bp
- Insomnia, intense dreaming, and nightmares
- Poor concentration, impaired memory, and judgment

- Increased sensitivity to sound, light, and tactile sensations
- Hallucinations—auditory, visual, or tactile
- Delusions
- Grand mal seizures
- Hyperthermia
- Delirium

## Opioid Intoxication

**Opioid Intoxication Signs**
- Slow pulse
- Low blood pressure
- Low body temp
- Sedation
- Pinpoint pupils
- Slowed movement
- Slurred speech
- Head nodding

**Opioid Intoxication Symptoms**
- Euphoria
- Imperviousness to pain
- Calmness

## Opioid Withdrawal

**Opioid Withdrawal Signs**
- Fast pulse
- High blood pressure
- High body temperature
- Insomnia
- Enlarged pupils
- Heightened reflexes
- Sweating
- Increased respiratory rate
- Tearing
- Runny nose
- Muscle spasms

**Opioid Withdrawal Symptoms**
- Abnormal cramps, nausea, vomiting, diarrhea
- Bone and muscle pain
- Anxiety

## Common Medications Used to Manage Opioid Withdrawal

- Methadone
- Clonidine
- Buprenorphine
- Rapid and ultrarapid detoxification (narcotics)

## Benzodiazepines and Other Sedative Hypnotics

- Important factors for success in detox:
- Start detox during period of low external stressors
- Patient must be committed to taper off substance
- Develop a plan for managing any underlying anxiety disorders
- Frequent patient contact

## Stimulants: Cocaine, Crack Cocaine, AmphetaminesWithdrawal symptoms:

- Depression
- Hypersomnia or insomnia
- Fatigue
- Anxiety
- Irritability

- Poor concentration
- Psychomotor retardation
- Increased appetite
- Paranoia
- Drug craving

## Inhalants/Solvents

**Types****	****	****	**** Example****	****	**** Chemicals Present**
- Adhesives		 Airplane Glue	 Ethyl Acetate
- Aerosols		 Spray paint		 Butane, propane, 						   fluorocarbons
- Cleaning agents	 Spot remover	 Xylene
- Solvents and gases	 Paint thinner		 Toluene, methylene 						    chloride
- Food products	 Whipped cream	 Nitrous oxide

## Symptoms of Inhalants and Solvents

**Withdrawal symptoms:**
- Delirium and tremors
- Weakness
- Tremors
- Weight loss
- Inattentive behavior
- Depression

**Other medical complications:**
- Impaired cognitive, motor, and sensory functioning
- Internal organ damage, including heart lungs, kidneys, liver

## Medical Management of Inhalant Abuse and Dependence

- Provide safe environment
- Provide environment free from inhalants
- Provide supportive care, including ample sleep and well-balance diet
- Determine if patient is abusing other substances
- Assess mental status
- Provide appropriate therapy and interventions

## Nicotine Withdrawal Symptoms

- Depressed mood (dysphoria)
- Insomnia
- Irritability, frustration, anger
- Anxiety
- Difficulty concentrating
- Restlessness
- Decreased heart rate
- Increased appetite or weight gain

## Medical Management of Nicotine Withdrawal

- Self-help interventions
- Behavioral interventions
- Nicotine replacement therapy
- Bupropion SR/Sustained Release
- Combination therapy

## The U.S. Public Health Service’s Nicotine Intervention: The 5 “As”

**Ask **about tobacco use
**Advise** to quit
**Assess** willingness to make a quit attempt
**Assist** in the quit attempt
**Arrange** follow-up

## When a Patient in Detox or Substance Abuse Treatment is a Smoker

- Present a supportive nonjudgmental attitude
- Develop a therapeutic alliance
- Emphasize relapse (from not smoking) is common
- Discuss withdrawal symptoms from nicotine
- Provide strategies to avoid weight gain
- Stress the importance of smoke-free environment
- Refer patient to a smoking cessation program

## Marijuana

- THC abstinence syndrome
- Symptoms include:
- Anxiety
- Restlessness
- Irritability
- Sleep disturbance
- Change in appetite
- No medical complications of withdrawal

## Anabolic Steroids

- Subject to abuse
- Aggressive, manic-like behavior
- Withdrawal symptoms include:
- Fatigue, depression
- Restlessness, insomnia
- Anorexia
- Reduced sex drive
- Headaches, nausea
- Side effects can be reversed and may include:
- Urinary tract infections
- Skin blistering
- Redness
- Swelling of hands and feet (edema)
- Behavioral disturbances
- There is no detox protocol for steroids

## Club Drugs

- A diverse class including
- GHB
- Ecstasy
- Rohypnol
- Used in nightclubs and “raves”
- Withdrawal symptoms may include
- Intoxication
- Severe intoxication with overdose
- Have destructive effects on the nervous system and on mental health

## Best Practices in the Management of Polydrug Abuse

- Prioritize substances for each patient according to withdrawal severity
- Alcohol and sedative hypnotics have the most severe withdrawal symptoms
- Opioid detox is the next priority
- Some substances will not require treatment during detox, including:
- Stimulants
- Marijuana
- Hallucinogens
- Inhalants

## Considerations for Pregnant Women

- Detox on demand
- Women-centered medical services
- Transportation
- Childcare
- Counseling and case management
- Access to drug-free, safe, affordable housing

- Help with legal, nutritional and other social service needs
- Ensure health and safety of both mother and fetus
- Clarify risks and benefits of any medications (informed consent)
- Protocol for withdrawal may vary with each pregnancy

## Considerations for Older Adults

- Supportive, nonconfrontational age-specific group
- Screen for depression, grief, and loss
- Provide linkages to specialized services
- Alcohol and drug disorders are more severe with elderly
- Older adults are at risk for co-occurring disorders
- Ongoing assessments and monitoring for medical problems common to older adults

## Considerations for People with Disabilities

- Elimination of barriers to treatment:
- Attitudinal barriers
- Discriminatory policies, practices, and procedures
- Communication barriers
- Architectural barriers
- Clarify definitions of terms:
- Disease
- Impairment
- Disability
- Functional capacities
- Functional limitations

- Four main categories of impairments:
- Physical
- Sensory
- Cognitive
- Affective
- Detox programs must:
- Routinely screen for disabilities and co-occurring medical and/or psychiatric conditions
- Be compliant with all Federal laws
- Provide access to needed services
- Coordinate treatment needs outside of program’s expertise
- Know local and national disability resources

## Considerations for Racial/Ethnic Minorities

- African Americans:
- Are at greater risk for diabetes and high blood pressure
- May display distrust with counselors of a different culture
- May be at greater risk of toxic side effects with antidepressants
- Asians and Pacific Islanders:
- Diverse group with many languages, beliefs, practices, and values
- May show concern for counselors’ credibility, trustworthiness, and cultural sensitivity
- Asians have greater sensitivity to alcohol than whites
- Smoking rates tend to be high
- Some detox meds are metabolized more slowly for those of Asian descent
- Important to use traditional healing methods
- Discuss how patients feel about Western medicine

## Considerations for Racial/Ethnic Minorities

- Native Americans:
- Have great diversity in practices, languages, traditions, beliefs, and values (more than 500 American Indian tribes)
- Have the highest rates of alcohol and drug use among all racial/ethnic groups
- Gain trust by not rushing the process; be nonconfrontational
- Use fables, illustrative stories, and “Talking Circles”
- Avoiding eye contact is traditional
- Fetal Alcohol Syndrome is 33 times higher than national average
- Frame 12 Steps in terms of a circle, not a ladder
- Tend to seek treatment later and have more medical complications
- Hispanic/Latinos
- The largest racial ethnic minority group in the U.S.
- Helpful to assess patient’s level of acculturation
- Language competency is helpful
- Family is very important
- Alcohol and drug use is often viewed as a moral weakness

## Considerations for Other Populations

- Gay, Lesbian, and Bisexual Individuals:
- Monitor feeling among staff
- Important that staff not impose their beliefs and values on patients
- Help patients heal from negative experiences of homophobia and heterosexism
- Help patient accept personal power over their own lives
- Adolescents
- Physical dependence not as severe; response to detox is more rapid than for adults
- Retention is a problem
- Peer relationships play a large role in treatment
- 75% of those reporting steroid use are adolescents
- Use of club drugs is higher

## Considerations for Incarcerated or Detained Individuals 

- Substance use disorders are common
- 70–80% of inmates have experienced regular drug use or had committed drug offenses
- Abrupt withdrawal from alcohol can be life-threatening
- Abrupt withdrawal from opioids or benzos can cause great stress
- Restrictions on methadone are common
- Substance abuse continues during incarceration
- Access to detox continues to be a problem