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Substance Abuse

I. Alcohol Detoxification

A. General Principles of Detoxification

1. Establish baseline vital signs; assess and follow with alcohol withdrawal scales such as the Clinical Institute Withdrawal Assessment (CIWA-Ar).

Each item graded 0 [not present] to 7 [most extreme]
1. Nausea and vomiting

2. Tremor

3. Paroxysmal Sweats

4. Anxiety

5. Agitation

6. Tactile disturbances

7. Auditory disturbances

8. Visual disturbances

9. Headaches, fullness in head

10. Orientation and clouding of sensorium

Range: 0 to 67

<8: no medication needed

8 to 14: medication optional

15 to 20: must medicate

>20: impending DTs requires higher doses

2. Choose a cross-tolerant medication; orally effective drug. If using a short-acting drug, doses must be tapered to avoid

3. Adjust dose by monitoring Physical signs, and CIWA scale, not subjective complaints.

4. Titrate dose to avoid either intoxication or withdrawal.

B. Treatment of mild-to-moderate alcohol withdrawal (CIWA-Ar: 8 to 20)

1. Outpatient detoxification is possible for stable, compliant patients with no medical or psychiatric complications, and no concurrent abuse of other classes of drugs.

2. Long-acting benzodiazepines: The drugs of choice for most uncomplicated detox.

Provides slow, gradual detoxification. Drugs will self-taper if initial doses are high enough: >60 mg diazepam or >300mg chlordiazepoxide over 24 - 36 hours. Chlordiazepoxide (Librium) 50 to 100 mg po q 6-8 hrs.; taper over 3 days. Diazepam (Valium) 10 to 20 mg po q 6-8 hrs.; taper over 3 days, if necessary.

3. Short-acting benzodiazepine: requires closer patient monitoring and a drug taper Lorazepam (Ativan) 2 to 4 mg po q 4 hrs; or 1-2 mg IM q 2 hrs. prn; taper x 3 days

C. Treatment of severe withdrawal.

1. Diazepam is best for severe DTs, because it is effective IV and its rapid action: Diazepam 10 mg IV; then repeat 5 mg IV every 5 minutes until calm but still awake.

2. Lorazepam for patients with moderate-to-severe liver disease, or taking Cimetidine or Ranitidine (H2 receptor antagonists), or elderly, confused, or seriously ill medical patients. A short-acting benzodiazepine gives physician more immediate control over the patient's medication status. Use Lorazepam 4 mg po q l hr, up to 10 to 12 mg or 1-2 mg IM q 4hr, taper over 3 days.

For DTs plus hepatic dysfunction: Lorazepam 1-2 mg IV q 5 min until calm but awake.

D. Avoid These Medications for Detoxification:

- Thorazine: can lower the seizure threshold.

- Beta-blockers (propranolol, atenolol): may mask DTs.

- Alpha-adrenergic agonists (clonidine, lofexidine): may mask delirium tremens.

Pharmacotherapy of Alcohol Withdrawal
Three Components of Withdrawal Benzodiazepines

(all work)

Beta-blockers (Inderal) Alpha-2-adrenergic agonists (Clonidine)
Autonomic Nervous System Hyperactivity Yes Yes Yes
Neuronal Excitation (seizures) Yes No ?
Distorted Perceptions (hallucinations, delirium) Yes No ?

E. Valproic acid and newer anticonvulsants: Experimental detox protocols need more careful study to establish patient criteria, dose ranges, appropriate length of treatment and

F. Patients addicted to both alcohol & benzodiazepines: seizures are more likely; CBZ is an option for detoxification, IF liver function is adequate. However, protocols need

G. Supplemental Medication

1. Phenytoin (Dilantin)

- Needed only in patients with a history of grand real seizures unrelated to alcohol withdrawal.

- Give a loading dose (400 mg po q 4h x 3) followed by their routine daily dose (if off of reeds).

2. Haloperidol Marked agitation or belligerence: 3 to 5 mg IM; rarely need more than one dose.

3. Magnesium Sulfate - do not use unless magnesium levels are low and the patient develops cardiac arrhythmias or neurologic complications (seizures).

4. Treatment of Vitamin Deficiency (See Appendix I)