M.  Admit To Inpatient Detoxification
Initiate Ambulatory Detoxification

 

OBJECTIVE

 

Provide a safe withdrawal from alcohol or sedative-hypnotics and prepare the patient for ongoing addiction treatment.

 

ANNOTATION

 

Alcohol detoxification

Facilities should develop local alcohol detoxification pathways, taking into consideration the following principles:

1.            Use either of the following two acceptable pharmacotherapy strategies for managing alcohol withdrawal symptoms:

·           Symptom-triggered therapy, where patients are given medication only when signs or   symptoms of withdrawal appear (e.g., PRN dosing).

·         A predetermined fixed medication dose, with gradual tapering over several days.

2.            Consider standardized assessments, such as the CIWA-Ar scale for alcohol withdrawal, to guide dosing decisions (e.g., if and when to dose).

3.            Consider the following empirically validated procedures for ambulatory alcohol detoxification monitoring as safe and effective alternatives to inpatient approaches:

·             Medical or nursing staff should assess the patient in person, either daily or every other day (patient contact may be made by telephone on other days), to include:

— Patient report of any alcohol use the previous day

—Reported medication intake compared to the medication dispensed the previous day

— Tremor, restlessness, and previous night's sleep

— Skin (e.g., color and turgor)

·             Urine toxicology or a breathalyzer test of BAC should be completed.

·             The patient should be medically cleared before initiating or continuing outpatient detoxification, if the daily screening is positive for any one of the following:

— Blood sugar ³ 400 or positive anion gap

— History of recent hematemesis or other GI bleeding disorder

— Bilirubin ³ 3.0

— Creatinine ³ 2.0

— Systolic blood pressure ³ 180 or diastolic blood pressure ³ 110

— Unstable angina

— Temperature ³ 101 degrees

— BAC ³ 0.08 on two outpatient visits

4.              For the treatment of alcohol withdrawal, use benzodiazepines over non-benzodiazepine sedative-hypnotics because of documented efficacy, decreased abuse potential, and a greater margin of safety.  Benzodiazepines are the drug of choice because they reduce withdrawal severity, incidence of delirium, and seizures.  All benzoidiazepines appear to be effective.

5.             For geriatric patients, start with lower doses of benzodiazepines than for younger adults.

6.             For managing alcohol withdrawal, carbamazepine can be used as an effective alternative to benzodiazepines.

7.             Other agents, such as beta-blockers, dilantin, and clonidine, are generally not considered as appropriate monotherapy for alcohol withdrawal, but may be considered in conjunction with benzodiazepines in certain patients.

8.              During and after detoxification, emphasis should be placed on engagement in ongoing addiction treatment.

 

Sedative-hypnotics detoxification (e.g., benzodiazepines)

There are three general treatment strategies for patients withdrawing from other sedative-hypnotic medications at doses above the therapeutic range, for a month or more:

1.               Substitute phenobarbital for the addicting agent and taper gradually.

·        The average daily sedative-hypnotic dose is converted to a phenobarbital equivalent and divided into 3 doses per day for 2 days.  Detailed information on phenobarbital equivalencies for sedative hypnotics can be fond in Goodman and Gilman’s The Pharmacological Basis of Therapeutics-Ninth Edition (1996).

·        Phenobarbital dose should be reduced by 30 mg per day, beginning on day 3.

2.           For patients on a shorter acting benzodiazepine, substitute a longer acting benzodiazepine (e.g., chlordiazepoxide) and taper 10% per day, over 1 to 2 weeks.

3.          Gradually decrease the dosage of the long-acting substance the patient is currently taking.

 

Opioid detoxification

1.       Focus treatment of opioid withdrawal on facilitating entrance into comprehensive long-term treatment, as well as alleviating acute symptoms.

2.       The preferred method of opioid detoxification remains short-term substitution therapy with methadone:

·               Use initial doses sufficient to suppress signs and symptoms of withdrawal, usually 30-40 mg/day.

·               Set the length of the taper period based on the treatment setting and goal of the detoxification.  Dose decreases of more than 5 mg/day are generally poorly tolerated.

3.       Detoxification can usually be accomplished in 4-7 days in an inpatient setting, to quickly achieve opioid abstinence prior to treatment in a drug-free setting.

4.       Longer taper periods should be used in the outpatient setting to minimize patient discomfort and maximize chances of success.

5.       A period of 21 days is generally sufficient for short-term outpatient detoxification in the most stable and motivated individual.  However, many patients presenting for treatment have very chaotic lives and should receive OAT for a period of extended stabilization, before they can realistically hope to maintain a drug-free lifestyle.  Frequently, long-term detoxification occurs in the setting of an OAT program.  Longer-term detoxification protocols frequently allow for a 21-day or 180-day detoxification.

6.       The 180-day stabilization/detoxification regimen, done within an OAT program, should be considered to work on patients’ early recovery problems, while stabilized on a relatively low dose (50-60 mg/day) of methadone.  Stabilization is followed by short-term detoxification from methadone and transition to a drug-free rehabilitation program (for details refer to Table 3).

7.       Clonidine, an alpha-adrenergic agonist, can be considered as an effective alternative for inpatient opioid detoxification; however, outpatient success is much lower.

 

 

Table 3.  Example Methadone Dosing Schedules for Withdrawal From Illicit Opioids

 

Day(s) in Treatment	21-Day Schedule Dose (mg)	90-Day Schedule Dose (mg)	180-Day Schedule Dose (mg)
1	30	30	30
2	20	40	40
3	30	50	50
4 – 6	25	60	60
7 – 10	20	60	60
11 – 13	15	60	60
14 – 17	10	60	60
18 – 21	5	55	60
22 – 28		50	60
29 – 35		45	55
36 – 42		40	50
43 – 49		35	45
50 – 56		30	40
57 – 63		25	40
64 – 70		20	35
71 – 77		15	35
78 – 84		10	30
85 – 90		5	30
91 – 100			25
101 – 110			25
111 – 120			20
121 – 130			20
131 – 140			15
141 – 150			15
151 – 160			10
161 – 170			10
171 - 180			5

(Adapted from Strain & Stitzer, 1999)

 

 

DISCUSSION

 

Alternative detoxification methods have been sought, due to concern that tapering regimens using opioid agonists prolong the problem by prescribing an addictive medication.  Many of the symptoms of opioid withdrawal (e.g., diaphoresis, hyperactivity and irritability) appear to be mediated by over-activity in the sympathetic nervous system.  This resulted in trials that attempted to depress the over-activity and ameliorate the withdrawal syndrome, using adrenergic agents, such as clonidine and lofexidine, that are without abuse potential (Gold et al., 1978; Gold et al., 1980).

 

Clonidine, an alpha-adrenergic agonist with inhibitory action primarily at the locus ceruleus, is effective in decreasing the signs and symptoms of opioid withdrawal in inpatient populations.  Inpatient studies reported an 80-90% success rate in detoxifying patients from methadone or heroin, while outpatient studies have reported success rates as low as 30-35% (Cornish et al., 1998).

 

The problems identified in outpatient clonidine detoxification include easier access to heroin and other opioids, lethargy, insomnia, dizziness, and over-sedation.  All of these problems are more easily managed in the inpatient setting.

 

EVIDENCE TABLE

 

	Recommendations	Sources of Evidence	QE		R
1	Use symptom-triggered therapy or gradual dose tapering over several days for alcohol withdrawal management.	Hayashida et al., 1989 Mayo-Smith, 1997 Saitz et al., 1994 APA, 1995 CSAT, 1995	I		A
2	Consider ambulatory alcohol detoxification, when indicated.	Hayashida et al., 1989	I		B
3	Use benzodiazepines over non-benzodiazepine sedative-hypnotics for alcohol withdrawal management.	Mayo-Smith, 1997	I		A
4	For managing alcohol withdrawal, carbamazepine can be used as an effective alternative to benzodiazepines.	Malcolm et al., 1989	II		B
5	Gradually decrease the dosage of the sedative-hypnotic or substitute phenobarbital for the addicting agent and taper gradually.	CSAT, 1995 Smith & Wesson, 1994	III		A
6	During opioid detoxification, facilitate engagement in comprehensive long-term treatment.	Simpson & Sells, 1990 Magura & Rosenblum, in press	II-2		A
7	Use short-term agonist substitution therapy for opioid detoxification.	Strain & Stitzer, 1999	III		A

QE = Quality of Evidence; R = Recommendation (See Introduction)