Title : KK-tip19 8-31-01ph.qxd (Page 1) Description : Keywords : Author : ----------------------------------------------- KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs CSAT’s Knowledge Application Program KAP Keys For Clinicians Based on TIP 19 Detoxification from Alcohol and Other Drugs U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov ----------------------------------------------- KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs These Kap Keys were developed to accompany the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. These KAP Keys are based entirely on TIP 19 and are designed to meet the needs of the busy clinician for concise, easily accessed "how-to" infor mation. For more information on the topics in these KAP Keys, readers are referred to TIP 19. Introduction TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (1994) BKD138 TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Use (1994) BKD139 TIP 9, Assessment and Treatment of Patients With Coexisiting Mental Illness and Alcohol and Other Drug Abuse (1994) BKD134 TIP 22, LAAM in the Treatment of Opiate Addiction (1995) BKD170 TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (1997) BKD234 TIP 28, Naltrexone and Alcoholism Treatment (1998) BKD268 TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (1999) BKD306 TIP 32, Treatment of Adolescents With Substance Abuse Disorders (1999) BKD307 TIP 33, Treatment for Stimulant Use Disorders (1999) BKD289 Other Treatment Improvement Protocols (TIPs) that are relevant to these KAP Keys: ----------------------------------------------- Signs and Symptoms of the Acute Phase of Alcohol Abstinence Syndrome 1 KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs • Restlessness, irritability, anxiety, agitation • Anorexia, nausea, vomiting • Tremor, elevated heart rate, increased blood pressure • Insomnia, intense dreaming, nightmares • Impaired concentration, memory, and judgment • Increased sensitivity to sounds, alteration in tactile sensations • Delirium (disorientation to time, place, situation) • Hallucinations (auditory, visual, or tactile) • Delusions (usually paranoid) • Grand mal seizures • Elevated temperature ----------------------------------------------- Signs and Symptoms of Opiate Abstinence 2 KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs Early Signs • Anxiety • Increased respiratory rate • Sweating • Lacrimation (tearing or crying) • Yawning • Rhinorrhea (runny nose) • Piloerection (goosebumps) • Restlessness • Anorexia • Irritability • Dilated pupils Advanced Signs • Insomnia • Nausea and vomiting • Diarrhea • Weakness • Abdominal cramps • Tachycardia • Hypertension • Muscle spasms • Muscle and bone pain ----------------------------------------------- Withdrawal From Benzodiazepines and Other Sedative-Hypnotics 3 KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs For therapeutic use, barbiturates and the older sedative-hyp notics have been largely replaced by the benzodiazepines. The withdrawal syndromes from benzodiazepines and other seda tive-hypnotics are similar, and the pharmacotherapy treatment strategies apply to both. High-Dose Sedative-Hypnotic Withdrawal Syndrome Signs and Symptoms of High-Dose Sedative-Hypnotic Withdrawal Syndrome • anxiety • tremors • nightmares • insomnia • anorexia • nausea • vomiting • orthostatic hypotension • seizures • delirium • hyperpyrexia The syndrome is qualitatively similar for all sedative-hypnotics; however, the time course of symptoms depends upon the par ticular drug. Low-Dose Benzodiazepine Withdrawal Syndrome In the literature of addiction medicine, low-dose benzodi azepine withdrawal may be referred to as "therapeutic-dose withdrawal," or benzodiazepine-discontinuation syndrome. Signs and symptoms of patients treated with benzodiazepine • anxiety • insomnia • muscle tension Note: These symptoms may reappear when the patients stop taking the benzodiazepine. ----------------------------------------------- Withdrawal From Stimulants (Cocaine, Crack Cocaine, Amphetamines, and Methamphetamine) 4 The two most commonly abused stimulants are cocaine and methamphetamine. Intermittent binge use of both agents is common. The withdrawal symptoms of both agents is common. The withdrawal symptoms that occur after a 2- to 3-day binge are different than those that occur after chronic, high-dose use. The withdrawal syndromes are similar. Following regular use, the withdrawal syndrome consists of • dysphoria • irritability • difficulty sleeping • intense dreaming Often stimulant abusers experience signs and symptoms of the abuse of multiple drugs. The symptoms subside over 2 to 4 days of drug abstinence. KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs ----------------------------------------------- Withdrawal From Other Drugs 5 Marijuana There is no acute abstinence syndrome associated with with drawal from marijuana. Some patients are irritable and have difficulty sleeping for a few days when they discontinue chronic use of marijuana. Persons withdrawing from marijuana, like those withdrawing from cocaine, benefit from a supportive environment during detoxification. Nicotine Two issues regarding tobacco smoking merit consideration by staff of substance abuse detoxification programs. The first is the program management's desire to establish a smoke-free treatment environment to comply with workplace ordinances and to safeguard the health and comfort of patients from expo sure to second-hand smoke. The second issue is the patient's dependence on nicotine as a drug of abuse. Drugs that do not produce a withdrawal syndrome Chronic use of PCP can cause a toxic psychosis that takes days or weeks to clear; however, PCP does not have a withdrawal syndrome. LSD, DMT, and ecstasy do not produce physical dependence. Polydrug Use Addicts rarely use just one substance. Typical combinations and the preferred modes of treatment are as follows: • Alcohol and stimulant: Treat alcohol abuse. • Alcohol and benzodiazepine: Treat with phenobarbital. • Cocaine and benzodiazepine: Treat benzodiazepine withdrawal. • Cocaine and opiate: Treat opiate dependence. • Cocaine and amphetamine: No detoxification protocol is known. Opiate-Barbiturate Dependence Symptoms of withdrawal from opiates and barbiturates have some common features, making it difficult to assess the patient's clinical condition when both drugs are withdrawn at the same time. Many clinicians prefer to gradually withdraw the sedative-hypnotic first, while administering methadone to pre vent opiate withdrawal. When the patient is barbiturate-free, the methadone is withdrawn at a level of 5 mg per day. If the sedative-hypnotic was a benzodiazepine (diazepam or chlor diazepoxide), some clinicians prefer to begin with a partial reduction of the sedative-hypnotic. While the patient is still receiving a partial dosage of the sedative, methadone is with drawn. Finally, the sedative-hypnotic is withdrawn. KAP KEYS Based on TIP 19 Detoxification From Alcohol and Other Drugs ----------------------------------------------- Ordering Information TIP 19 Detoxification from Alcohol and Other Drugs Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889. 2. Visit CSAT’s Website at www.csat.samhsa.gov Do not reproduce or distribute this publication for a fee with out specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. DHHS Publication No. (SMA) 01-3574 Printed 2001