Microsoft powerpoint - mhb detoxification and hr (3)
• Dependence• Model of Change• Motivation
The Seven Markers of Dependence
Salience of drug-seeking behaviour (Simply obtaining the drug becomes
increasingly important at the expense of other aspects of the drug users life)
Relief or avoidance of withdrawal symptoms
Narrowing of the repertoire of drug taking behaviour (Drug use becomes a daily activity, an
increasingly strict daily routine of drug taking develops)
Reinstatement of drug taking after a period of abstinence
Matching Interventions to Stages of Change Introduce Conflict Increase Motivation Prepare for
•Detoxification•Developing social support
•Sensitising/Antagonist prescription•Revisit motivation
•High risk situations•Coping skills•Utilising network support
Features of determination & action stages of change Motivation
How do we recognise the motivated patient?
• Problem recognition• Expression of concern• Intention to change• Expression Optimism
In small groups identify the main areas to be
• How will life be better?• Coping with withdrawals• Activities• Support• Differences compared to previous attempts• Identifying risks & coping strategies• Planning for the future
Effects of Opiates Physical • Psychological • Withdrawal from Opiates Dihydrocodeine
• Dihydrocodeine has the benefit of familiarity
for many opiate users so that they are likely to self titrate reasonably well.
• The disadvantage is that detoxification often
becomes stalled and frequently fails. Methadone
• Methadone detoxification, as opposed to slow reduction,
is not recommended but is sometimes the service users
regimen of choice. The problem is a more prolonged withdrawal and a longer wait to initiate naltrexone. Detoxification from methadone poses particular
problems because of its long half life and the preferred methadone regimen is to crossover, either to buprenorphine or dihydrocodeine and then follow the
Buprenorphine crossover and withdrawal regimen
Buprenorphine has a high affinity for opiate receptors and is able to
displace methadone and heroin while at the same time blocking
withdrawal effects. Buprenorphine also resides in the receptor long after elimination from blood, thus there is a mild protracted residual
withdrawal; this is similar to but of less severity than with methadone.
There should be evidence of withdrawal before commencing a
buprenorphine detoxification otherwise withdrawal will be precipitated. The last dose of methadone should be at least 24
hours prior to commencement of a crossover regimen. Total daily dose of buprenorphine Total daily dose of buprenorphine Crossover phase – Crossover phase – methadone 30 methadone 20
*On day one of either crossover or detoxification 2 mg is given as a take home dose to be used if withdrawal symptoms reoccur. Another 2 mg may be added to this if necessary. Withdrawal Withdrawal Withdrawal Withdrawal phase from phase from phase from phase from methadone heroin £30 methadone heroin £20
Two days after the last dose of buprenorphine the service user can be started on naltrexone.
*On day one of either crossover or detoxification 2 mg is given as a take home dose to be used if withdrawal symptoms reoccur. Another 2 mg may be added to this if necessary.
• Naltrexone can be given once the opiate
receptors are opiate free. The receptor will be blocked and prevent any subsequent use of opiates from producing an effect at that site.
• This should be prescribed in conjunction with
appropriate psychosocial interventions such as coping skills / SBNT
2 x 75cl bottles of 15% wine4 x 500ml cans of 9% lager
50cl bottle 40% spirits day ≈ 20.0 units
2 x 75cl bottles of 15% wine ≈ 21.4 units4 x 500ml cans of 9% lager ≈ 18.0 units
13 x 500ml cans of 3.2% Bitter ≈ 19.5 units1x3 litre bottle of 7.5% cider ≈ 21.5 units
• How should these units be consumed over
• Tremor• Nausea• Sweating• Anxiety / agitation
Complications of Alcohol Withdrawal Chlormethiazole Chlormethiazole Should not be used in the
community. Offers marginally better protection against seizures and delirium than benzodiazepines and may be used for the treatment of severe withdrawal on an in-patient basis. This should only be undertaken by experienced physicians. Oxazepam Oxazepam is not metabolised by the liver
and is the drug of choice where there is substantial impairment of liver function. Chlordiazepoxide Chlordiazepoxide is the drug of choice for
most detoxifications. It is long acting, has low reinforcement potential.
should not normally exceed 120mg but may be increased to 160mg where there is a history of alcohol withdrawal seizures. Chlordiazepoxide Regime Total daily Severe withdrawal Moderate withdrawal Supplementary Prescriptions Vitamin supplements
• Healthy, uncomplicated dependent drinkers should
receive thiamine 100 mg tds and vitamin B co Strong two tabs tds until they are eating regularly.
• If Wernicke’s Encephalopathy is suspected then
Pabrinex should be used 500 mg once or twice daily for 3 – 5 days. One pair of Pabrinex ampoules provide thiamine 250 mg and other B and C vitamins. Anti-hypertensives
• If the systolic is ≥ 160mmHg or diastolic is ≥ 90mmHg
consider short term treatment. Beta-blockers or thiazide diuretics are first line treatments.
Supplementary Prescriptions Anti-convulsants • If a seizure occurs during withdrawal it is more
likely to recur in subsequent episodes of
incidence of seizures. Adding anti-convulsants
to this regimen does not confer an advantage. Delirium • If monitoring withdrawal suggests delirium then
hospital admission should be arranged. Post Alcohol Detox
What is harm reduction?• Measures that aim to reduce the negative
• Can be aimed at the population as a whole
and defined by public policy, or at the individual drinker.
increasing motivation to make changes have been unsuccessful.
• Attenuated drinking & Controlled drinking• Diet• Vitamin supplements
A reversible neuropsychiatric condition caused by Thiamine deficiency
1. Ataxia - poor coordination of arms and legs,
3. Abnormal eye movementsAll three symptoms occur together in only 10% of cases
Anterograde amnesia – loss of memory for events occurring after onset of disorder
Retrograde amnesia – loss of memory for events occurring before onset of disorder
• Poor diet • Reduced ability to absorb B Vitamins• Depletion of stores of B vitamins
Commonly begins during detoxification from alcohol
Anyone presenting with otherwise unexplained neurological symptoms during alcohol detoxification should be referred for assessment
Presume a diagnosis of Wernicke’s in any patient undergoing detox who presents with one or more of the following symptoms:
Decreased consciousness level including unconsciousness or coma
eye muscle paralysis causing squint or double vision
Nystagmus (involuntary rhythmic oscillation of one or both eyes)
Unexplained hypotension with hypothermia.
IV glucose administration or requirement for IV glucose
Drinking greater than 15 units/day in a person of normal build
Previous history of severe withdrawal, seizures and/or delirium
• IM Pabrinex• One pair of IM high-potency Pabrinex
ampoules should be administered once daily for 3-5 days
• High risk patients should receive for five
• Thiamine 100mg TDS• Vitamin B compound strong 2 tablets TDS• Taken orally, only 4.5mg of Thiamine will
be absorbed from a 100mg tablet. Increasing the dose will not increase absorption. Balbir 50 year old man who lives alone with no support. Drinks 1-1.5 litres vodka daily. History of bi-polar disorder, prescribed lithium. Describes seeing spiders crawling around the floor and seizures in the past when withdrawing. Has attempted to self harm in the past when intoxicated and withdrawing Has attempted one previous detox when drank on top of medication. Jackie 40 year old female who lives with a non drinking partner who is supportive of abstinence goal. Consuming 8 -10 cans 4% lager daily for past 2 months. Mild tremor, nausea and sweating on waking. Previous successful home detox two years ago, supervised by partner. Angela 24 year old heroin user. Injects £30 heroin daily. Previously detoxified with buprenorphine and started naltrexone. Relapsed after stopping naltrexone following a bereavement. No other illicit drug or alcohol use. Non using partner is supportive of abstinence.
Sectoral networks To improve for students the step from school to the labor market, we have chosen to set up a network of cooperation with certain industries. The sectoral networks bring actors from the educational field and the labor market together, to improve the transition from education to employment in certain industries. Based on a solid analysis we set up incentive