Detox Basics in mental health clinical work

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances.

1. Detox Basics

2. •Compulsion: loss of control
The user can’t not do it s/he is compelled to use.
Compulsion is not rational and is not planned.
•Continued use despite adverse consequences
An addict is a person who uses even though s/he knows it is causing problems.
Addiction is staged based on adverse consequences.
•Craving: daily symptom of the disease
The user experiences intense psychological preoccupation with getting and
using the drug.
Craving is dysphoric, agitating and it feels very bad.
•Denial/hypofrontality: distortion of cognition caused by craving
Under the pressure of intense craving, the user is temporarily blinded to the
risks and consequences of using.
Definition of Addiction

3. Neuroadaptation, Tolerance,
and Withdrawal
• Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and
stimulation or intoxication.
• Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure
neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive
(deaf) to normal levels of stimulation.
• In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also
neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy.
• Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug
effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking
energy
• Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure.
When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months
to years, interfering with sobriety, learning, and impulse inhibition.

4. Drug-Specific Neural Dysregulation
Withdrawal
•Withdrawal: Negative symptoms that mirror positive
drug effects AND reflect neuroadaptation (tolerance).
•Cessation of drug use leads to ‘inversion of the high’; sobriety
becomes pleasureless, anxious, sleepless, and lacking energy.
•Under unstimulated conditions (without drugs) interference with
the ability to experience normal pleasure is profound . When sober,
the user feels anhedonia, anxiety, anger, frustration and craving.
•The pleasure system remains impaired for months to years,
interfering with learning, impulse inhibition, and sobriety.

5. Kindling
In tolerant users:
•Progressive nervous system arousal
causing withdrawal symptoms to
worsen each time drug use is
discontinued.
•Also called withdrawal sensitization.

6. C I M Model Treatment
Tolerance/Withdrawal
•Over-stimulation of brain pathways induces
neuroadaptation, requiring the user to escalate
the dose to achieve the effects formerly seen at
lower doses.
•Whenever there is tolerance to drugs/alcohol,
there will always be the appearance of negative
symptoms (withdrawal) when the user is sober;
these negative symptoms are the mirror image
of the drugs’ effects.

7. Physical Dependence
•Physical Dependence
When the user stops the drug, physical illness results.
•Abstinence Syndrome
Name of the illness caused by withdrawal symptoms.
•Tolerance
Neuroadaptation forces the user to increase the dose to maintain the
effect of the drug.
Using an inadequate dose causes withdrawal: symptoms occur when
the amount used is less than the tolerance level.

8. C I M Model Treatment
Causes of Craving
E W M S
•Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by people,
places, things associated with prior drug-use experiences
•Drug Withdrawal
inadequately treated or untreated
•Mental illness symptoms
inadequately treated or untreated
•Stress equals craving

9. Withdrawal Management
Detoxification
Use of medications to treat withdrawal symptoms.
Goals:
Evaluation
Stabilization
Foster readiness for and entry into treatment

10. C I M Model Treatment
Withdrawal Management
Withdrawal management is the use of medications to treat
drug withdrawal symptoms, sometimes called “detox.”
When is withdrawal management needed?
•If the pulse is persistently above 90 beats per minute
•If the blood pressure is persistently above 140/90 or
below 90/60
•If INSOMNIA interferes with function
•If ANXIETY interferes with function.
•If CRAVING threatens to cause relapse

11. C I M Model Treatment
Withdrawal Management
PRINCIPLES
Calculate the dose equivalent per 24 hours
Push medications to achieve “symptom capture”
Maintain Diastolic BP <90 and Pulse <90
Decrease substitute medication in 10% increments
Slow rate of taper to maintain Diastolic BP <90 and Pulse <90
Tremor free
SUBSTITUTION
TAPER

13. Opiate Effects
•Analgesia
•Euphoria
•Anxiolytic- calming
•Sleep Inducing
•Sensation of warmth
•Constipation
•Dry mucous membranes
•Pupils constrict
•Sedation/Sleepiness (nodding)
•Depresses respiration

14. Effects and Withdrawal
Opiates
Effects
•Analgesia
•Euphoria
•Anxiolytic - calming
•Sleep Inducing
•Constipation
•Dry mucous membranes
•Sensation of warmth
•Pupils constricted
Withdrawal
•Pain
•Dysphoria
•Anxiety
•Insomnia
•Diarrhea
•Rhinorrhea
•Chills
•Pupils dilated

15. Opiate Withdrawal
•Pain
•Dysphoria
•Anxiety
•Insomnia
•Diarrhea
•Rhinorrhea
•Chills
•Pupils dilate
•Increases heart rate & blood pressure

16. Prescription Opiates
Generic: Brand Name Non Tolerant 24 hr. dose
Codeine w/acetaminophen 500 mg
Hydrocodone:Vicodin, Lortab, Norco 20mg-60 mg
Hydromorphone: Dilaudid 20 mg-60 mg
Oxycodone: Percodan, OxyContin 20 mg-60 mg
Morphine sulfate: MS Contin 30 mg-60 mg
Fentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg
Tolerant Users only Tolerant 24 hr. dose
Morphine sulfate: MS Contin 60 mg-upward
Fentanyl: Duragesic (transdermal) 75 mcg-300 mcg
Methadone: Methadose 60 mg-300 mg
Buprenorphine: Suboxone, Subutex 6 mg-32 mg

17. Opiate Progression
Pills to the Needle
Historically, untreated dependence on prescription
opiates led to a trajectory from
•Pills ingested orally
•Pills crushed and snorted or smoked
•Heroin snorted or smoked
•Heroin used intravenously

18. Overview of Buprenorphine
Suboxone and Subutex
•Highly safe medication (acute & chronic dosing).
•Primary side effects: like other mu agonist opioids
(e.g.,nausea, constipation) but may be less severe.
•No evidence of significant disruption in cognitive or
psychomotor performance with buprenorphine
maintenance.
•No evidence of organ damage with chronic dosing.
Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds:
Strain EC, Trhumble JG, Jara GB) CSAT. 2001

21. OPTIMUM ANALGESIC
DOSE
The best dose of opiate is the dose
that first, best relieves pain, and
second, relieves pain without
sedation.

22. Special Problems in Former
Opiate Addicts
Persons previously addicted to opiates
•Have low pain tolerance because endogenous analgesic mechanisms
are impaired.
•Will “uncover” their previous level of opiate tolerance over 4 - 6
weeks and require upward dosage titration over an extended time
(despite years of abstinence).
•Require doses 2 to 4 times higher for analgesia than non-tolerant
persons (due to high opiate tolerance).
•Need slower, symptom-driven tapers to discontinue opiates.

23. Withdrawal Management
Opiate Oral Dose
Equivalents
•Buprenorphine (Suboxone®) 8 mg
(sublingual)
•Hydrocodone (Vicodin®) 10 - 20 mg
•Methadone (Methadose®) 20 mg
•Morphine sulfate (immediate release)30 mg
•Morphine sulfate (MS Contin®) 15 mg
•Oxycodone (Percodan®) (Oxycontin®) 10 - 20 mg
•Propoxyphene (Darvon®) 130 - 200 mg
•Adapted from Goodman and Gilman, 9th ed., page 535.

24. Withdrawal Management
Opiate Substitution
•Query: time since last opiate use
•Query: all opiates used in past 7 days.
•Calculate client's usual 24 hour opiate dose.
•Query: prior withdrawal experience(s).
•Query: other drugs used:
alcohol
illicit drugs
prescription medications
over-the-counter preparations
•Determine if client requires other detoxification

25. Withdrawal Management
Substitution Methodology
Opiates
•Calculate Suboxone dose using opiate dose equivalents.
•Give first Suboxone dose (2 - 8 mg) when objective and clear signs of
withdrawal are evident.
•Record Pulse, BP, and withdrawal SX on Symptom Assessment sheet.
•Recheck Pulse & Blood Pressure after 90 minutes.
•Give 1/4 of estimated daily Suboxone dose when withdrawal symptoms
reappear.
•Give the remainder of Suboxone in divided doses every 6 - 8 hours.

26. Withdrawal Management
Completion of Substitution
Phase
Substitution is complete when the patient feels “normal,” and craving goes
away.
Persistence of insomnia, anxiety, pain, or depression indicate need for
separate treatment of these symptoms (dual diagnosis).
The patient is now ready for taper or for maintenance.

27. Withdrawal Management
Taper Phase
There are two variables in tapering:
Dose: how much to taper
Time: how often to taper
Dose reductions are adjusted so that the patient does not re-enter
withdrawal. If withdrawal symptoms develop during taper, return to
previous effective dose, reduce amount of taper (dose) or lengthen
the (time) interval. Do not continue until symptoms subside.
•Monitor Pulse and Blood Pressure daily
•Complete Symptom Assessment sheet daily.
•Adjust amount decreased and time between decreases to maintain
symptom scores at 0-1

28. A 33-year follow-up of narcotics
addicts
.

29. Stimulant Effects
•Improve mood and confidence
•Increase interest/alertness
•Increase sex drive
•Interference with sleep
•Increase anger and aggression
•Suppress appetite
•Pupils dilate
•Increases heart rate & blood pressure
•Fever
•Arrythmia - irregular heart beat
•Seizures

30. Stimulant Withdrawal
•Dysphoria
•Boredom
•Anergia
•Disordered sleep
Anxiety
•Depression
•Hypofrontality

32. Dual Diagnosis
•Mental Illness symptoms interact with drug effects.
•Intoxication: relieves symptoms of mental illness
•Tolerance: exacerbates symptoms of mental illness
•Withdrawal: exacerbates symptoms of mental illness

33. Medications for
Stimulant Dependence
• Antidepressants
(anhedonia/anergia)
Effexor XR 150-300 mg
Cymbalta 60 mg
Wellbutrin XL150-300 mg
Desipramine 100-200 mg
•Anti-Craving Medications
Modafinil 100-
200 mg
Methylphenidate LA 10-40 mg
Buproprion 150-
300 mg
Concerta 18-54 mg
Dexedrine SR20-30 mg
•Disorders of Sleep
Trazedone 50-300 mg
Seroquel 25-100 mg
Imipramine 100-200
mg
•Disorders of Thought
Abilify 2-10 mg
Haldol 1-2 mg
Risperdal 1-3 mg

34. GABA Scale

35. Sedative-Hypnotic Effects
•Calm Euphoria
•Release of Inhibitions
•Sleep Inducing
•Sedation/Sleepiness
•Slurred Speech
•Unsteady gait (Ataxia)
•Confusion
•Forgetfulness
•Slows heart rate
•Decreases blood pressure

36. Sedative-Hypnotic Effects
Effects
•Calm Euphoria
•Release of Inhibitions
•Sleep Inducing
•Sedation/Sleepiness
•Slurred Speech
•Unsteady gait (Ataxia)
•Confusion
•Forgetfulness
•Slows heart rate
•Decreases blood pressure
* Symptom may continue for months
Withdrawal
•Dysphoria *
•Anxiety *
•Insomnia *
•Sweating (Diaphoresis) *
•Tremor
•Tachycardia
•Hypertension
•Hyperventilation
•Elevated temperature
•Hallucinations
•Seizures
•Delirium tremens

37. Spectrum of Sedative-
Hypnotic Withdrawal
1.Acute withdrawal: hypertension, tachycardia, tremors, sweating, pallor,
anxiety/panic, craving
2.Withdrawal seizures: preceded by increasing tremors and myoclonic
jerks
3.Delirium Tremens: medical emergency presentation of combative,
hallucinating, confused; all sedative-hypnotic withdrawal can yield DTs.

38. Sedative-Hypnotic Withdrawal
•Dysphoria * * May
continue for months
•Anxiety *
•Insomnia *
•Sweating (Diaphoresis)
•Tremor
•Increases heart rate & blood pressure
•Hyperventilation
•Elevated temperature
•Hallucinations
•Seizures
•Delirium tremens

39. Prescription Tranquillizers
Dose Equivalent To Alcohol
(2oz liquor or 2 glasses of wine or 2 cans of beer)
•Alprazolam (Xanax®) 0.5- 1mg
•Diazepam (Valium®) 10mg
•Chlordiazepoxide (Librium®) 25mg
•Clonazepam (Klonopin®) 1-2mg
•Lorazepam (Ativan®) 2mg
•Temazepam (Restoril®) 30mg
•Butalbital (in Fiorinal®) 100mg
•Carisoprodol (Soma ®) 350mg
•Zolpidem (Ambien®) 10 mg

41. Withdrawal Management
Sedative-Hypnotics
Substitution
•Obtain seizure history.
•Question client regarding all sedative-hypnotic use:
alcohol / prescription medications / over-the-counter preparations
•Determine client's usual 24 hour sedative-hypnotic dose.
Acute Withdrawal
STAT Phenobarbital 60mg for Pulse >90 or diastolic BP >90
Repeat dose every 2 hours until Pulse <90 & diastolic BP <90
•Calculate Phenobarbital 30mg based on the 24-hour Phenobarbital total.
•Complete sedative-hypnotic Symptom Assessment flow sheet with each dose.
•Give Phenobarbital in divided doses every 6 - 8 hours.
•Hold Phenobarbital for slurred speech, ataxia, or lethargy.
Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer

42. Withdrawal Management
Sedative-Hypnotic
“Uncovering”
Uncovering: the re-appearance of
withdrawal symptoms after initial
stabilization, necessitating re-titration
of the dose.

43. Withdrawal Management
Completion of Substitution
Phase
Substitution is complete when the patient feels “normal,” and craving goes
away.
Persistence of insomnia, anxiety, pain, or depression indicate need for
separate treatment of these symptoms (dual diagnosis).
The patient is now ready for taper or for maintenance.

46. Effects of Increasing Dosage in the Non-tolerant User
Gamma-Hydroxy-Butyrate: GHB
0 10 20 30 40 50 60
Dose (mg/kg)
Coma
Loss of
Consciousness
Euphoria
Somnolence
Vertigo
Amnesia
Sedation

49. Cannabis effects
EFFECTS
•Sleep inducing
•Appetite stimulation
•Induces calm
•Induces ‘mellow’
feelings
•Elevates mood
•Reduces muscle tone
•Produces pleasure
WITHDRAWAL
•Insomnia/nightmares
•Anorexia
•Anxiety
•Irritability/anger
•Depression
•Tremor
•Anhedonia

50. Nicotine Effects
Receptor Activation
•Increase arousal
•Heighten attention
•Influence stages of sleep
•Produce states of pleasure
•Decrease fatigue
•Decrease anxiety
•Reduce pain
•Improve cognitive function
Withdrawal Symptoms
•Mentally sluggish
•Inattentive
•Insomnia
•Boredom and dysphoria
•Fatigue
•Anxiety
•Increase pain sensitivity
•Worsen cognitive function

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•Dackis C, O’Brien C. Neurobiology of addiction: treatment and public
policy ramifications. Nature Neuroscience. 8(11):1431-6 (2005).
•Nestler EJ, Malenka RC. The addicted brain. Scientific American.com
February 9, 2004.
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model for craving identification and management. Journal of
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