Well, greetings everyone. My name is Tony Decker and I'm a practitioner in Phoenix, Arizona. I'm board certified in addiction medicine and pain medicine, in addition to family practice and adolescent young adult medicine. Our topic today is on the management of withdrawal, specifically alcohol, benzodiazepines, and opioids. Keeping in mind that alcohol and benzo withdrawals have a great significant similarity. So I'm currently the chief medical officer of the Division of Developmental Disabilities in the Department of Economic Security in Arizona. I went to Michigan State University for my osteopathic degree, graduated in 78, did an internship in family medicine residency at the Chicago College of Osteopathic Medicine, and a two-year fellowship at Press St. Luke's in Chicago in adolescent young adult medicine. I served on the South Side of Chicago for 14 years, was a professor and chair of family medicine at Kansas City from 94 to 98, and went to the Indian Health Service in 98 to 2010, went to Fort Belvoir and was the chief of addiction medicine and had a clinical professorship at GW. And currently I'm a professor at Burrell University and A.T. Steele University. I have no financial or professional conflicts for this topic. I don't take money from anybody except my employer. I do not represent any federal or state organization, and the opinions for this educational program are simply my opinions. So first off, we want to cover issues of detoxification and look at the set of interventions, first diagnostic, then therapeutic services, managing acute intoxication and withdrawal and detoxification. We want to remember that supervised detoxification may prevent life-threatening complications, and especially with alcohol and benzodiazepine, these may cause serious complications, including death. Detoxification is not substance abuse treatment. That's an important concept to understand. We'll talk a little bit about that when we talk about opioid detoxification and the short stays that people participate in. There are three phases of detoxification, which includes evaluation first, stabilization, and fostering the patient's entry into treatment. So when we look at the medical withdrawal from a historical standpoint, it's been treated in a variety of ways. The old drunk tanks and incarceration were used for many years, not only in this country but in other countries too. Detoxification was common, and we still do this with driving under the influence and possession of illegal drugs and things like that. Shaming was a common intervention that was used in the mid-ages, and even into the early years of this country, shaming was still a popular intervention to get people to stop drinking or using other chemicals. Detox tanks, where you put people going through the withdrawal process, where they can urinate, defecate, and go through the withdrawal process, they usually would have those in a lower level area so they could spray down or wash down all of the emesis and excrement. We have alcohol being used as a detox protocol, and in reality, the vast majority of Americans and Canadians who withdraw from alcohol treat their withdrawal process with alcohol. Most people who are using significant amounts of alcohol realize that if they can just get three or four ounces of alcohol, that'll cut the edge of their withdrawal. Paragoric was used in the past from the standpoint of opioid withdrawal. Benzodiazepine abarbital is an old medication, but still used today in regard to alcohol withdrawal and can be used also for seizure prevention in regard to benzodiazepine withdrawal. 1958, the American Medical Association recognized that alcoholism is a disease and it was a treatable intervention. It should be known from the osteopathic standpoint that Bill Wilson, one of the founders of His mother was an osteopathic physician and his brother-in-law was also a DO who admitted him to the town's hospital for his first admission, second admission, and third admission for alcohol detox. We are now moving towards a social model and social supports. We'll talk about that a little further down. The ASAM patient placement criteria includes interventions on six different dimensions. So they take into consideration acute intoxication or withdrawal potential, the biomedical conditions and complications. So other problems, dehydration, diabetes, cardiovascular disease, pulmonary disease, the emotional behavioral and cognitive conditions or complications that go along with substance use disorders, a readiness to change and assessing a patient's readiness to change. Loss of recovery, commonly called relapse. We're trying to keep it on the positive side, though. Continued use or continued problem potential and recovery and living environment as the sixth issue. So we look at dimension one, ASAM patient placement criteria for adult detoxification placement. We know that level 1D is an ambulatory detoxification. Level 2D is ambulatory detoxification with extended on-site monitoring. Level 3, 2D is clinically managed residential detoxification. Level 3, 7D, 3.7D is medically monitored inpatient detoxification, which would be in a hospital setting. The difference between 3.2D is typically a residential treatment center, which may have nursing staff present but do not have full medical services. Sometimes they'll provide intravenous fluids. Other times they will not. And a level 4D would be intensive care inpatient detoxification, patients who have rising SILA scores or seizure potential. Freestanding substance abuse treatment facilities, which would be your residential treatment centers, can provide an assessment. It is typically in the least restrictive environment. It's cost-effective from the standpoint of being cheaper than being an inpatient. However, the effectiveness of long-term 28-day stays has been questioned, especially when other types of intervention strategies, partial hospitals, intensive outpatient programs, have become into significant play. So 24-hour supervision, observation, and support with at least one RN in the facility. Medical stability is important. So you don't want a patient who is medically compromised or has a prior history of seizures or delirium tremens in a freestanding facility unless you have significant capacity for IV fluids and IV medications. And there's typically biopsychosocial support in these programs and a 24-hour physician availability. Exclusionary criteria for a residential treatment center or substance abuse treatment facility would be a history of DTs or poorly controlled withdrawal seizures. They typically get worse with each subsequent event when you're looking at patients going through detoxification from alcohol. Unable to sign or understand informed consent. Suicidal, homicidal, or some other psychotic condition in which the patient would not be seen as safe in an unlocked facility. A willingness to follow treatment recommendations. Minimally complicating co-occurring medical diseases. Diabetes in control, cardiovascular disease without angina, pulmonary disease without hypoxia. And a person who's not going to be contagious. And this is an issue for us in the time of COVID. Patients who have intensive pain palliation either because of withdrawal of opioids or because of an ongoing chronic pain or acute pain issue. So patients who have been in a motor vehicle accident who have acute neck pain need to make sure they have full diagnostic evaluation before working with them in a residential treatment center. Although many of them have injuries which wakes them up enough to say I need to get help. Typically we have alcohol related seizures, grand mal seizures, which terminology has changed, which includes the old major motor seizures, are seen in somewhere between 10 to 15% of patients going significant alcohol withdrawal. Old studies based on this. And in the old days when we used to use either incarceration or minimal intervention, oral benzodiazepines and things like that, patients who had rapidly rising signs of withdrawal, now we recognize as rapidly rising SIWA scores, they had a very high rate, up to 20 to 30% of people would die if they developed DTs. Usually in the first 48 hours, but it can happen over the course of 10 days. This typically is, the longer it is, is when a person continues to drink but has cut back, where they'll start to drink beer or wine instead of distilled spirits. Seizures may be multiple. They rarely develop status. And they will require diazepam or lorazepam. Diazepam, typical dose is 10 milligrams, IV push, or lorazepam, one milligram. And you may need to repeat that three, four, five times in the first hour, depending on the response the patient has. If you wait for the patient to seize, you'll be chasing all kinds of spirits from the standpoint of trying to catch up with a patient who's gotten into DTs. If a patient has their first seizure episode or an atypical seizure, you want to look for other causes, subdural hematomas, electrolyte imbalance, things like that. And ongoing pharmacotherapy would not be indicated for withdrawal seizures if the patient is able to navigate that process quickly and respond well to the benzodiazepine, phenobarbital, or other anti-seizure interventions. Delirium tremens are acute. They can be reversible with aggressive treatment. There may be an organic psychosis that occurs with that, with a variety of hallucinations, visual, auditory, tactile. There is a significant morbidity and mortality. They usually begin 72 hours after significant reduction in alcohol intake or after termination of alcohol intake. But they may last two to six days longer, and sometimes even up to 10 days, depending on the status of the patient and what other medications the patient's on. Severe alcohol withdrawal symptoms include a clouded sensorium, rapidly rising CEWA score, hallucinations. And like I said, those can be visual, auditory, or tactile. And panic and severe agitation may be part of their withdrawal process. Mortality increases with delayed diagnosis, inadequate treatment, and concurrent medical complications or disorders, especially in the area of electrolyte imbalance, lack of thiamine, lack of folate that can precipitate and cause more problems. Now, when you're working with a patient who is realizing that they have a problem with a substance of abuse, you're already halfway there. Pre-contemplation is where many, many people are from the standpoint of not understanding that their disorder is changing the trajectory for their life. So going from pre-contemplation to contemplation is part of our enhanced or motivational enhancement that we try to recommend that you use. It's very difficult to talk to someone who's got a blood alcohol 400. So you may want to reserve some time in a stable, cohesive, caring, compassionate intervention because the patients may be amnesic from intervention that time. But once a person realizes that they have a problem and that they should consider intervention services, that their attempts to stop drinking or stop using drugs have failed, you can help them in the preparation phase. When are they able to move from pre-contemplation to contemplation to preparation to action? I really need help to stop. And we use that motivational enhancement from the standpoint of talking to patients in the and trying to work with them to realize that their injury or their illness may be related to their substance use. And when they get to the action phase, I really need to get help. I need help getting through this. I can't do it myself. That's when you really want to provide that supportive care, non-pejorative contact, and make sure that the patient is going to be medically safe in that process. Maintenance of recovery is a challenging thing. Many patients who have gone through treatment will lose their recovery in the first 30 days without ongoing support and intervention. This cycle is important to consider when you're working with a patient at the onset of their presentation and identifying where they are in the change process. Clinical Institute Withdrawal Assessment is when we use the CIWA score. And it's a 10-item scale. It allows you to do a rapid assessment. It's easily scored. They're typically pre-printed forms. You just circle the identified time and date it and circle the identified score. And it can be administered by nursing staff. And most emergency rooms and most hospitals will have a CIWA protocol as part of their intervention for alcohol withdrawal. So looking at this in detail, nausea and vomiting. Do you feel sick to your stomach? Have you vomited? Observe. And so a person without symptoms would be scored a zero. Mild symptoms would be a one. Intermittent nausea with dry heaves and muscle contractions and persistent nausea would be a four. And then dry heaves and vomiting, in other words, intractable vomiting, would be a seven. So on that spectrum, you'd score people. Tremors, arms extended, fingers apart like this. Now, you're not going to ask them to raise their hands up because that's going to give you the liver flap in patients who have chronic liver disease. But just having their fingertips extended so that you can see if the patient's having any type of tremor that's visible. Now, if you feel tremor but you cannot see it, it would be a one. If you have a person who's having significant shaking but they can try to control it, they go from shaking to non-shaking to shaking, that would be a moderate, four. And then severe would be they're shaking even with their arms at their sides or on their laps. They can't stop the shaking. And you want to look at this closely because if a patient has a progressive increase in these findings, that means that you have a rising CEWA score. That's where you need to be very concerned. Agitation, looking again at none is normal activity. Now, when the patient's intoxicated, they may not be as agitated, but as you watch them over the course of an hour to two hours, and so let's say you have a patient who has some lacerations from hitting their head against a windshield, you're taking care of all those intervention strategies, but you're still watching. And then if you're a consultant and the ER calls you up and says, well, this patient seemed to be okay when his blood alcohol was 300, but he's down to 80 right now, I'd like to send him home, but he's shaking pretty bad. He's very agitated, trying to get out of bed, keep on telling me he sees things on his skin. Those would be very significant findings, and you want to watch that closely and start to aggressively treat the alcohol withdrawal process. So agitation can also result in patients getting out of the bed. You are responsible for that person if they are not in full capacity to make informed consent for, in other words, they're leaving AWOL against medical advice. But thrashing, shaking, myoclonic jerks are all things that we need to be concerned about. Now, you want to take into consideration also that the person may be using more than one substance. So you could see the result of an opioid withdrawal and an alcohol withdrawal together. The old feeling was that alcohol, benzodiazepine, and phenobarbital withdrawal can kill you, but opioid withdrawal will not, but you wish it did. And the reality is opioid withdrawal has not been associated with untimely death, with the exception of significant seizure disorder that precipitates with opioid withdrawal, or a person who's got ischemic heart disease and their cardiac output doubles, triples during the withdrawal process. And then the person could have an ischemic event that could actually cause a loss of life because of myocardial infarction. Tactile disturbances, do you feel itching, pins and needles? Do you have a sensation that there's something on your skin or crawling? That's the tactile hallucinations. So mild itching is not unusual. Moderate with hallucinations, there's bugs on my skin, would be a four to five. And then continuous hallucinations, they're scratching at their skin. Now, a person who is intoxicated with methamphetamine and is going through alcohol withdrawal could present with a variety of findings. I would always err on the side of safety, which is to give a higher score in the process rather than a lower score, even if the patient has methamphetamine on board or cocaine, which can cause the same thing. All those stimulants, the cathinones, bath salts can cause this too. Auditory disturbances, are you hearing things that are not there? Are they harsh? Are there voices that are telling you anything? So command hallucinations would be more concerning. Is there a prior history of the patient having a psychiatric, severe mental illness, SMI disturbance? Sometimes you have to go into the chart, go backwards and see. If there's no presentation, the score is zero. Moderate, severe hallucinations would be a four. Continuous hallucinations, seven. Visual findings. Does light appear to be too bright? Now that's not unusual because pupillary dilation from alcohol intoxication can happen. In addition to that, opioid withdrawal typically will give you significant pupillary dilation. Does it hurt your eyes? Do you see different colors? Are you seeing things that you know are not there? So again, if a lack of visual hallucinations would be a zero, moderate severe hallucinations, seeing things, being scared, hearing things, command hallucinations, but they're not continuous, a four and continuous hallucinations would be a seven. Headaches, fullness in the head, keep in mind that you should be doing an excellent evaluation from the standpoint of trauma. Many patients may not remember that they fell backwards and hit the back of their head and they have a large hematoma there. Skull fractures are not uncommon. And in alcoholics with a history of alcohol withdrawal, lack of coordination is high and memory is low. So subdural hematomas are a possibility. A change in sensorium in a patient who has any evidence of trauma should result in a CT scan without contrast to make sure that they don't have an intracranial bleed. Mild findings would be a one. Moderate to severe findings would be a four and extremely severe headache, fullness in the head, not feeling well in your head is a seven. Orientation and clouded sensorium. What day is this? Who are you? Where are you? Who am I? Who's the president of the United States? All those things become part of the process. But notice in this one here, we only go from oriented and they can do serial additions and subtractions. What's 100 minus 7? What's 93 minus 7? And work with the patient. If they are disoriented by date, but no more than two calendar days, what day is today? I'm dictating this on February 8, 2022. And the patient tells me it's February 12. Then what happens is I would say that that patient is a three and they don't know where they are and or who they are would be a four. Diaphoresis, no visible sweat compared to a small amount of sweat in the palms of their hands. Beads of sweat on their forehead would be a four and soaking wet, drenching sweats, dripping would be a seven. Anxiety, asking did the patient feel anxious or nervous? Mild anxiety would be a one. Moderate anxiety or feeling very guarded. I don't want to talk to anybody. Don't talk to me. Leave me alone. Avoiding eye contact, a four. And then panic states. I got to leave here. I got to go back. I got to figure out what happened. A severe delirium or even a psychotic reaction would all be a seven. Vital signs, typically the pulse would be greater than 90 during alcohol withdrawal. The blood pressure would be greater than 140 and temperature would be over 101. I want to state that hypertension and hyperthermia are late signs in alcohol withdrawal. Those are typically signs that you need to really ramp up your intervention because when you have a hypertensive and hyperthermic patient in the absence of an infection, that's different if they have a history of injection drug use, they have a big abscess in their armpit, that's a different story. But in a person in the absence of an infection, those are things that you need to be very worried about. So what are our goals? Our goals in alcohol withdrawal clearly are a smooth, efficient, clinical course. So the more benzodiazepine you give without over sedating them, the better it's going to be. You would try to have no seizures. You would like to minimize their agitation and their discomfort. And you do not want them to walk out of your treatment saying, I don't care what happens to me, you can't tell me what to do. So you have to engage the patient in a non-pejorative, positive way to try to enhance the likelihood they would go into a recovery program. So when we look at this, again, matching patients to the appropriate care, going back to the patient placement criteria from the American Society of Addiction Medicine, level 1D, ambulatory detox without extended on-site monitoring. So that could be keeping the patient in a day hospital, monitoring them all day long, and then discharging them with a benzodiazepine taper or an intervention strategy based on clear past medical history, no DTs, no seizures, no injuries. A level 2D is ambulatory detox with extended on-site monitoring. That could be an overnight stay. That could be having a loved one with the person as they're going through the detox protocol and administering the medications. Keep in mind though that in the ambulatory setting, the vast majority of people going through alcohol withdrawal, treat their withdrawal with alcohol because it will decrease the agitation, irritability, tremors very quickly. Level 2.2D would be clinically managed residential detoxification versus level 3.7D, which is medically monitored inpatient detox. A medically monitored residential treatment or clinically managed residential treatment is common. Some of these programs will allow oral medications to help them navigate this. So either Librium or Valium, Diazepam or Lorazepam, Padavan, orally has been used in the residential setting. As soon as you put them in the hospital, IV rehydration, ivethiamine, multivitamin, IV, and folate. In addition to rehydration, treatment of nausea, vomiting, treatment of dehydration, cardiac monitoring if you have a patient who's older or has a history of cardiac abnormalities, and then obviously all the laboratory evaluations to assess where the patient's at, including urine toxicology, which may tell you what other things you need to be worried about. Medically managed intensive inpatient detoxification, patient has a rising CEWA score, rising temperature, rising blood pressure, patients actively hallucinating with command hallucinations, patient exhibits suicidal or homicidal ideation, and patients that get to this level need to have fairly aggressive. And the reason you want intensive care nursing is you have one nurse per patient or one nurse for two patients, and you can really ramp up intervention services based on the CEWA score and based on the clinical findings. Recently, I had a patient in the intensive care unit where I gave this patient 14 milligrams of IV lorazepam in the first hour. The patient was still jerking, walking around, urinating in the ER. I gave the patient 260 milligrams of IV phenobarbital, followed up an hour later with another 130, still agitated, finally decided to just give him a bolus of Presidex and then put him on a Presidex drip. Now keep in mind, Presidex is not indicated for the treatment of alcohol withdrawal, but it is a standard of care in most intensive care units and emergency rooms. It is not an antiepileptic, so you still need to have the patient on benzodiazepines, but if you're going to be using a drip that's an anesthetic, you want that patient in the ICU for management of their airway and to make sure that no other complications or over sedation occurred. So when do we use short half-life sedatives? Well, when a patient has advanced liver disease. Keep in mind that end-stage liver disease is not an uncommon finding in patients who have a long history of alcohol use disorder. If the patient obviously is jaundiced or has a significant elevation of their bilirubin above 4 and seeing these patients come in with anisarka or bilirubin at 12, 15, 18, you're going to need to be very careful as to how aggressively you treat their withdrawal, but you do not want them to seize. The patient is severely intoxicated and agitated. If they're severely intoxicated, but alcohol is above 350, above 400, that patient will not need as much benzodiazepine at the front end. However, as they drop their blood alcohol and if they have a history of going through significant either DTs or withdrawal seizures, you're going to need that patient in the ICU for hands-on and eyes-on during their withdrawal process. Multiple drug use, opioid intoxication, opioid withdrawal, benzodiazepine use, cathinones, stimulants, the amphetamines, and cocaine are all things that complicate the withdrawal, but if you understand what the patient's been using, and sometimes they'll just come right out and tell you, other times you'll find out when you do the urine tox. Or if you feel that the patient, you're uncertain if this patient could be in early DTs or early portal systemic encephalopathy. And so that end-stage liver disease or hepatoencephalopathy, those are things that require a higher level of care. And no one will fault you if you put the patient in a higher level of care, including transferring the patient or having the intensive care unit, if the patients are deteriorating. So what's the high risk of complicated withdrawal? Well, you have to understand that patients going through withdrawal could have compromised vitals. So we need to monitor those on a fairly regular basis, if not continuous monitoring. You have mental health issues with a wide spectrum of presentations from hallucinations to acute psychosis, to severe depression, to suicidal ideation, to homicidal ideation, cardiac decompensation, holiday heart, where the patient goes into CHF because of the myocardial toxic reaction to high levels of alcohol. You can have the patient in stupor or delirium, secondary to intoxication or secondary to withdrawal. Head trauma, I've already said that you need to make sure you do a reasonable diagnostic assessment. Seizures should be, especially if this is a first-time seizure, patient needs a full workup for seizure events. DTs in the past 24 hours or seizures in the past 24 hours would be an indication, even if the patient was in the ER, detox, left, got intoxicated again, withdrawal again, another seizure, that patient needs to be monitored. If the patient has a history of seizures, recurrent seizures, or withdrawal seizures, daily sedative use, and many times you'll see this where patients were treated in an outpatient setting, given Librium 50, and they were given 12 tablets, or Ativan 1, given 12 tablets, and told to take them spiraled over three days, and they used them all in the first day. So they could be benztoxic at the same time going through withdrawal, and that will mask a rising CEVA score. Daily therapeutic sedatives and alcohol, in other words, they went home, they continued drinking, they can have complicated withdrawals even as great as six weeks later. In other words, they're decreasing their alcohol use, or abuse, and using therapeutic sedatives with a slow detoxification protocol, so they don't really have a very difficult withdrawal process, but they stop abruptly, run out of money, doctor decides not to treat them anymore because they're non-compliant, that patient can go from stable to unstable very quickly. So a CEVA score greater than 15, or a blood alcohol greater than 0.3, with acute withdrawal syndrome would be a reason to have the patient in a monitored setting. A CEVA score between 10 and 15, plus a pulse greater than 110, blood pressure greater than 160, systolic or 110, diastolic, you want to consider having the patient in the ICU, and I add on that list, hyperthermia greater than 38 to 39 degrees, and hyper, well we already have the tachycardia listed there. So, what are the criteria for medically managed detox? High risk for medical or psych complications, medical condition has a significant or substantial risk with elevated blood pressure, unstable angina, unstable lung disease, acute COVID infection with hypoxia, all these things would be used. I've seen unfortunately hundreds of cases of COVID, and many of them have lost their recovery because of the lack of sober support programs across the reservation, and our community does not have Wi-Fi, and so what ends up happening is many of them have lost their ability to get telemedicine services, which we've all depended on for the past two years. Other criteria that can be a problem is stimulant intoxication. So what happens is you need to have very close monitoring in a patient who's been using methamphetamine, cocaine, or the cathinones, and the edge of their intoxication is minimized so that they seem more alert, and it complicates your assessment process. Obviously, we already talked about acute psychoses, impulsive threats to staff or to themselves, and suicidal ideation. When we start looking at opiates and antagonist reaction, keep in mind that buprenorphine, if you give buprenorphine to a patient who's using opioids, and they have exogenous opioids on their immune receptor, you can precipitate a withdrawal, which is a very uncomfortable situation for the patient, but also a reason for patients to walk out of treatment. Pregnant patients requiring detox or stabilization are very complicated, especially if the pregnancy is in the second trimester, where you can put the pregnancy at significant risk, or they are less than 34 weeks and put them into premature delivery. Appropriate for outpatient detoxification would be minimal risk of complicated withdrawal. Patient is likely to complete the detoxification and enter into treatment. Patient responds positively to emotional support and treatment, and it's a safe place. The patient has recovering adults present, and the patient's able to understand instructions and follow instructions, and whoever's with that person would be able to call. So it's important to make sure that if the spouse says, I'll be able to take care of him, he does this a lot, that you identify what's happened in the past, because if he just walks out and goes back to a alcohol using scenario, you're not helping him in the long run. So when we look at the alcohol withdrawal syndrome fixed dose regimen, that would be the use of Librium 50 to 25 every six hours, or Ativan 2 milligrams or 1 milligram PO every six hours for mild withdrawal symptoms. Typically on three days of meds, and if you have a patient who no history of complications, no history of seizures, no history of head trauma, medically cooperative, this is a reasonable protocol, as long as you have a receiving provider. So if they tell you, I haven't seen a doctor in the past year, they don't have a receiving provider. Urgent care won't provide ongoing care, but a substance abuse treatment center definitely would. So look at all the possibilities, and how can we provide intervention in the least restrictive environment for a safe medical detoxification? One of the good things about Ativan is that if you have difficulty administering because of dehydration, poor peripheral circulation, Ativan is well absorbed with an IM administration. Ancillary medications to work with the patient, one of them obviously is you want the patient to get thiamine, you want the patient to get vitamins, and you want the patient to get folate, especially if they've had a long history of alcohol use or binge event. You want to make sure the patient is reasonably hydrated. Active urination is a good sign, but many times the patients are too intoxicated, and they have not, and alcohol is a diuretic. So if they can't urinate, and they have a blood alcohol 300, they're probably going to be significantly dehydrated, and electrolyte imbalance is high, which will facilitate or enhance the likelihood of withdrawal seizures. So alcohol withdrawal syndrome symptom-driven regimen is the CWEP protocol. So instead of giving them the standard medications, you're actually looking at where is this patient right now, and it's measured serially. You want to see that CWEP score dropping before the patient is discharged from care. So patient is medicated based on the CWEP score, the withdrawal and delirium scores. The pros is that you will use less medication, a shorter length of stay. The cons is that people have to be trained to use this. It is not a difficult assessment tool, and many people in the healthcare field have been trained on that, and that's typically the standard operating procedure in most facilities. So start off with the chlorodiazepoxide or librium, 50 milligrams for CWEP scores greater than 9. You can also use Ativan, 2 milligrams for CWEP scores over 9. Repeat the CWEP every hour. You want to see that CWEP start to drop. You may repeat every 2 hours the chlorodiazepoxide or the librium or the lorazepam. You do not want to exceed 300 milligrams in 24 hours, and keep in mind you're giving 50 milligram doses, so that's only 6 doses in 24 hours. When we start looking at the lorazepam protocol, I'll go to 2 milligrams, but at least 1 milligram for CWEP scores greater than 9, and again, you can repeat this every hour, and you can repeat the CWEPs every hour, and you can repeat the lorazepam dose every 2 hours for CWEP scores that continue to be over 9, unless they're rising rapidly, and if they're rising rapidly, that changes everything. So we'll get to that in the next slide. So no more than 10 milligrams of lorazepam or 10 doses over 24 hours if you're giving 1 milligram doses or 5 doses if you're giving 2 milligrams. Now, lorazepam is safe to use in patients who have liver disease, so you can utilize that. Now, some of the other benzodiazepines, thiazepam and chlorazepam, is may not be as effective and can cause some liver changes when you start increasing the doses. Same thing goes with phenobarbital. So phenobarb withdrawal process, and this is for patients who are not responding to the benzodiazepines, you monitor the patient, hold the dose as indicated, but if you need to use it, you use it. So it comes as 16.2, 32.4, or 64 in the tablet formation, and so you can give 64 milligrams every 6 hours continued on 8 doses if there's no indication for over sedation. 32.4 milligrams, 8 hours, 3 doses beginning 2 days after the initial dose start, and you're dropping your dose of phenobarbital as the patient's having less and less symptomatology of alcohol withdrawal. Now, for moderate alcohol withdrawal syndrome, you may need to give more intervention, and this would be looking at the benzodiazepine withdrawal. Now, there's different ways to address benzodiazepine withdrawal, and that is realizing the patient could be tapered down off their benzodiazepines as long as they haven't registered seizures. I've had people that were being prescribed 14 to 16 milligrams of L-Prazolam that would present to my office, and the reason they presented was because the doctor was contacted by the DEA when they sent a little report out, says it's a dangerous combination, and they just stopped the medications. Well, you can't go from 14 milligrams of L-Prazolam or Xanax a day and stop abruptly, so we start looking at the withdrawal process. This is, again, looking at either benzo or alcohol withdrawal syndrome. You can give the patient a one-time dose of 200 milligrams, drop it down to 100 milligrams every four hours, 60 milligrams every four hours, 60 every eight hours, hold sedation if the patient is becoming sedate. Now, remember I told you that the vials come as 130 milligrams of phenobarbital in a vial, and so if you're going to treat that patient, initially, if you've worked with benzodiazepines, like I said, you've given this patient anywhere between 50 to 60 milligrams of IV Valium or between 10 to 14 milligrams of IV Lorazepam, and the patient's still agitated, you can complement that with IV phenobarbital. So, 260 milligrams in the first dose, 130 milligrams IV now every 30 minutes until the patient is becoming sedated. The Prosodex dose, it's an alpha-2 receptor agonist. It's for uncontrolled serious alcohol withdrawal syndrome or delirium. The first dose is between 1 to 1.4 micrograms, 1 to 1.4 micrograms per kilo, and then drip as titrated, typically between anywhere between 10 to 40 micrograms per hour, but your ICU system and your nursing staff are very familiar with this process of titrating to the point of sedation. The Minnesota Detoxification Scale has a score from 0 to 46. It's another scale that can be used for severe withdrawal. The SEWA scores are used uniformly in most of the hospitals I've been at, but some schools, we use the MIND score too. Carbamazepine or Tegretol, 400 milligrams, twice a day for seven days for a person who's in mild to moderate ambulatory withdrawal, 600 milligrams at bedtime. Do not use with patients who have cirrhosis. Do not use in women of childbearing age unless you have a negative pregnancy test, and you'll need to get a CBC at the beginning of treatment and once a week because of the possible bone marrow suppression. Let's move on to opiate detox, and we're going to talk a little bit about assessment, about buprenorphine pharmacology and treatment. When we look at the opiate withdrawal assessment, we have a thing called the Clinical Opioid Withdrawal Scale. Tom Wesson at Cal Berkeley developed that and then provided it to the public. You typically have an enhancement of your vital signs, so tachycardia, tachypnea, elevated blood pressure, restlessness, irritability, insomnia, craving and yawning, pupillary dilation, exception would be from meparidine or Demerol, and lacrimation, rhinorrhea, piloerection, chills, nausea, vomiting, diarrhea, and pain. So what I normally say is that if you have an orifice, something is coming out of it, the only exception would be your ears unless you're sweating out of your ears, which is possible, and a vagina. Everything else, micturation, diarrhea, rhinorrhea, lacrimation, vomiting, all part of significant opioid withdrawal. So when we start to evaluate this process, we want to look at other medical problems that could complicate the withdrawal. There is a poor correlation between the amount of opioid that's used and the amount of buprenorphine to treat that withdrawal process. The majority of my patients in 2022 that are going through opioid withdrawal are using street oral fentanyl mixed with methamphetamine, cocaine, and rarely do I see cathinones out in rural Arizona and rural New Mexico. Fentanyl has changed the entire way that we look at treatment for opioid withdrawal. Typically, people will start to go into withdrawal anywhere between four to six to eight hours after their peak event with the diacetylmorphine, which is heroin. But I can tell you that most of my patients that were using heroin have stopped heroin and have gone to the oral fentanyl. Long-acting opioids such as methadone and the formulations that are longer acting, oxycontin, MS content, or morphine sulfate content, you can expect a longer onset in regard to going into withdrawal, typically 24, 48, even 72 hours later. Whereas most people who have short-acting opioid withdrawal would be including the fentanyl withdrawal will be anywhere between six to 24 hours. Now, you can ask the patient and using the vernacular on the street, when do you feel yourself jonesing? And they can predict, they can tell you just when they start getting sick, and that gets them on the hustle to try to find another opioid. Now, in the process of treating a patient with buprenorphine, you want that patient in withdrawal. We'll talk about that detail. Fentanyl seems to be a drug that we are having a difficult time with. And when I say a difficult time, not only is it causing significant overdose events because the pill-to-pill variation is huge, but your typical dose in the emergency room for a person with a fracture will be anywhere between 50 to 100 micrograms IV. The fentanyl tablets may hold as much as a milligram and as little as 50 micrograms. So, you have a 20 point to as much as a 50 point variation times, variation from pill-to-pill. This is one of the reasons why we have such a high rate of opioid overdose deaths is because of patients using fentanyl one time and thinking that it's safe using the same tablet, same blue OC30 and overdosing on that tablet. We do need to be aware also that the withdrawal process of fentanyl is difficult to predict. It's a very short-acting, it has a very short half-life medication, but people who are using fentanyl orally over the course of time, chronic users, many of them are storing active metabolite or fentanyl itself in other areas, bone marrow, omentum, places that we have not been clearly identified where this is stored. This is one of the reasons why a person may say the last time I used fentanyl was yesterday and I'm having withdrawal right now. You do a cow score on the patient, you end up with a 12 or 13, you think it's safe to put the person on buprenorphine, you give them two milligrams or four milligrams of buprenorphine and they go into withdrawal. So, some people are microdosing the first dose of fentanyl. I personally am having some difficulty with that because it doesn't seem to address the withdrawal process and having a reserve, first off, you're basing your statement of when to time my withdrawal based on what the patient says and their opioid withdrawal score, but those things may be inaccurate. So, fentanyl has changed the landscape from that standpoint. So, tolerance and withdrawal. Tolerance develops differently to different opioid effects. So, some people may say that the pain relieving quality of the opioid has diminished, but the sedating quality is maintained or that the constipation is maintained, but the joint pain continues. So, keep that in mind that tolerance is needing to use more and more to have the same effect. Withdrawal is you stop using it and you feel sick. So, narcotic withdrawal syndrome, you need to identify as a short or long acting medication, methadone being very long acting. It's really the only medication that's long acting that's commonly used today. We don't use the LAM. It's not legal in the US at this point in time, but it is used in the EU countries, which could be a dose that's given every three days. The alpha adrenergic inhibitors, such as clonidine, can help decrease the agitation, irritability, anxiety that goes along with opioid withdrawal. Patients who have diarrhea, loperamide or imodium could be helpful. There have been a variety of people who've tried to solve this problem quickly, and ultra rapid opioid detox and rapid opioid detox are the use of anesthesia to take away the impact of acute withdrawal syndrome. So, a group of doctors in New Jersey would rent four or five rooms from Holiday Inn, have the anesthesiology consultant come in and with their equipment, put them under anesthesia, do IV naloxone administration, and then put the patient into acute opioid withdrawal, keep them under anesthesia, and then as they come out of anesthesia, treat them with clonidine, loperamide, and other sedatives to help them navigate through the acute withdrawal event. Problem is that many of those patients, although their physical dependence was addressed, their psychological dependence was not, and they would go out and use, unfortunately, they would use the same amount of opioid they did before, and they would have a terminal event. Injections of naltrexone, which is 380 milligrams of naltrexone depo and polyglycinate spheres, that may be a candidate for opioid detox in patients who do not want to go into ongoing treatment but need to be covered. But keep in mind that that only gives them three to four weeks of protection from overdose, and the addictive behaviors, the addictive diagnosis is not going to be gone in three or four weeks. You can use non-buprenorphine treatment symptomatically for the first 24 hours, although if the patient's in significant withdrawal, having a PAL score greater than eight, I typically like to get it greater than 10 or 11. The bup dose typically does a very good job at addressing these opioid withdrawals from morphine, hydrocodone, hydromorphone, and heroin, diacetyl morphine. The old protocol was a max dose of eight milligrams on day one, typically split in two four milligram doses. Newer protocols are looking at 12 to 16 milligrams. A study that was just done by the VA published in December 2021 looked at higher dose intervention strategies without any complications in patients who are appropriately scored and treated with a higher dose buprenorphine. You want to decrease your doses slowly over time if you're only going to use detox, but I've already told you that detox alone is not a safe approach because patients' addiction or their opioid dependence has not been adequately treated. I typically tell my patients they have to commit to three months of treatment. It's ambulatory, but they need to come in once a week for the first four weeks. They come in every other week. The second four weeks, they come in a month, and then we start talking about if they want to stay on the medication, and most of my patients will stay on buprenorphine. However, if a patient wants to stop, we go back to once a week to help them go through the detox process. Most patients do not have difficulty going from 16 milligrams to 8 milligrams. Some patients have problems going from 8 milligrams to 4 milligrams. Everybody has a problem from 4 milligrams to 2 milligrams, and I do have some patients who have stabilized on 2 milligrams and stay there. That person still counts on your monthly count, so if you have a cap of 30, you can only treat that many patients, but if you have a cap of 100 or 275, just keep track of that because that is something that you need to address, and talking about opioid treatment is in another lecture. Buprenorphine, I mean, withdrawal using buprenorphine shows that we're able to suppress opioid withdrawal symptoms significantly. It has very significant success. However, in the use of opioid withdrawal from fentanyl, we're finding out more and more data that patients have a wide variation withdrawal presentations when they're withdrawing from fentanyl, and that buprenorphine can be overcome with a higher dose of fentanyl, so some people will try to break through the mu receptor blockade that buprenorphine exhibits by use of fentanyl, and they can still have a reward, so that's become a challenge. At this point in time, buprenorphine, sublingual, buccal, subdermal are all the treatments we have with an agonist therapy. There may be other things coming down the road. So, we know that buprenorphine withdrawal can be primarily treated, or there's been a termination of ongoing care that buprenorphine can address that. Typically, the patient will be in withdrawal over three days. I want to make sure that you understand, I'm not in favor of just detox protocols. So, the first day, they get between eight and 12 milligrams with a combo formulation, and the last day, they get six milligrams of the three two milligram tablets. However, the CDC and the DEA, I'm sorry, CDC and SAMHSA have published other protocols. This is looking at an 11-day withdrawal protocol. Again, I feel strongly that buprenorphine should be an ongoing treatment, and it's with, especially with fentanyl, it's very dangerous to detoxify a person's chemical need, but not treat their psychological needs with ongoing recovery intervention. So, here's a call score looking at resting pulse, diaphoresis, restlessness or irritability, pupillary size, bone and joint pains, achiness, rhinorrhea, and lacrimation, GI upset with diarrhea, nausea, vomiting, tremor, myoclonal jerks, and yawning. Anxiety, irritability, and pyloerection from the withdrawal process. Call scores mild is five to 12, moderate is 13 to 24, moderately severe 25 to 36, and severe is over 36. Keep in mind, when you push a patient into moderately severe or worse, the patients will most likely lose their recovery and get some opioid to blunt their withdrawal experience. Clonidine, 0.1 milligrams. As long as their systolic blood pressure is greater than 100 millimeters, and the patient is asymptomatic, in other words, they can still stand up without getting dizzy. You can give clonidine 0.1 milligrams every six hours for eight doses, then every eight hours for three doses, and then 0.1 to 0.2 every 12 hours on day four. The buprenorphine naloxone withdrawal schedule, typically you're going to treat the patient when their cal score is greater than 11. Repeat the two milligrams every two hours, as long as the cal score stays above eight. Again, this is looking at reducing the doses quickly over the course of a few days, and this is a detox lecture, not a treatment lecture, but I don't recommend that we just use detoxification only. There's a whole variety of events and combinations of drugs that the DEA reported in October of 2021. This is the holy trinity, which is an opioid, a benzodiazepine, and soma. It gives a heroin-like euphoric high. The stimulant trinity, which is an opioid, a benzodiazepine, and a stimulant like methamphetamine, cocaine, or a cathinone, and it gives another euphoric high. It releases a large amount of dopamine. The GABA trinity, which is an opioid, a benzo, and gabapentin, a euphoric high. Patients many times will have difficulty with ambulation and loss of coordination. The zolpidem, or ambien trinity, which is an opioid, a benzodiazepine, and zolpidem, downer, depressant trinity. And then there's the speedball, which is the opioid and stimulant. It's a little tees and blues from the 1960s. Heroin and cocaine from the 1960s, 70s, and 80s. And hardball, which is methamphetamine and heroin, or methamphetamine and fentanyl. Alcohol and an albuterol inhaler. These are potentiators for patients who are using opioids, and that's why if you have a person in alcohol withdrawal and opioid withdrawal, treat the alcohol withdrawal first, because it's more serious. And that you're using IV benzodiazepine, so you want to be careful with buprenorphine. Adderall, albuterol, sleep deprivation, and Adderall, Lexapro, and cannabis, all are polypharmacy potentiators. So these are medications that can be obtained from both pharmaceutical prescriptions, but they can also be obtained for people who are incarcerated. And so we have Abilify and quetiapine, Seroquel, and it's called Jailhouse Heroin. Soma and codeine, the soma coma, gabapentin, and oxycodone, which is stacking gabapentin, and the quetiapine, which can be snorted, Suzy Q, gabapentin, and Tegretol, Marantin, quetiapine, olanzapine, lorazepam, alcohol, cocaine, again, looking at stimulants and suppressants. Some of the HIV highly active antiretroviral therapies, protease inhibitors, plus oxycodone, can cause a high caffeine, alcohol, called the eyeball. So thank you, we've covered alcohol withdrawal, benzodiazepine withdrawal. We talked very briefly that it's just a gradual taper, monitor the patients for signs of withdrawal, use of benzodiazepines, phenobarbital, opioid withdrawal, obviously with buprenorphine. And we also have talked about some of the other concomitant non-opioid medications, clonidine, loperamide can be used too. Thank you very much, and if you have questions, I'll be happy to address them. Thank you.

addiction

withdrawal management

supervised detoxification

alcohol withdrawal

benzodiazepine withdrawal

opioid withdrawal

ASAM criteria

CIWA

COWS

buprenorphine