Microsoft powerpoint - mhb detoxification and hr (3)

Detoxification
• 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 Prevention
Behaviour
•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 Detox preparation
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 Alcohol Withdrawal
• 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.

Source: http://www.dual-diagnosis.org.uk/Archives/detoxification_and_HR_(3).pdf