Detoxification/Withdrawal

Goals

Differences between adolescent and adult patterns of use, effects on brain, concerns with detoxification/withdrawal.

Understand top concerns with particular substances Alcohol Opiates/opioids Cannabinoids Methamphetamine/cocaine/stimulants

Adolescent Brain

Continues to develop until 20s Back to front

Main Points

Different patterns of use Alcohol: binge vs. daily Polypharmacy as a general rule

Substances effect adolescent differently

The younger age at initiation the more risk for abuse/dependence

Alcohol

Pattern of Use Binge type Less likely to be daily drinkers

Less sensitive to the sedating effects of alcohol Higher BAC More blackouts More damage

What does this mean in corrections?

More likely to overdose than go through medically significant withdrawal

What happens with alcohol overdose? Increasing BAC leads to increasing

sedating effects Loss of muscle control, stupor, coma,

death Death from aspiration, choking,

respiratory depression

What happens with Alcohol Withdrawal

Requires significant duration of daily drinking with tolerance 60% who meet criteria for dependence will

experience some symptoms of withdrawal (>90% mild to moderate)

6-24 hours from last drink Changes to major neurotransmitters in brain

Enchances GABA-major inhibitory neurotransmitter

Homeostatic changes Increase in blood pressure, heart rate,

anxiety, n/v, seizure, death

CIW-A

Clinical Institute Withdrawal Assessment

Questionnaire /Assessment done by clinician/nurse

Score 10 or more needs medical treatment/evaluation

What to do if limited nursing?

J Clin Psychopharmacol 1991; 11:291-295

CIWA-Ar Scale

Nausea and Vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances

Auditory disturbances Visual disturbances Headache, fullness in head Disorientation

Opioids/opiates

Heroin Prescription Drugs

Hydrocodone (vicodin, norco) Oxycodone Morphine Methadone

CDC- National Epidemic of Overdose Deaths

Rates of Opioid Pain Reliever (OPR) overdose deaths, OPR treatment Admissions and Kilograms of OPR sold

Drug overdose death rate and rate of opioid pain relievers sold in the US- 2008

Effects of Opioids Sedation Pupil Constriction Slurred speech Impaired attention/memory Constipation/ urinary retention Nausea Confusion/delirium Seizures Slowed heart rate Respiratory depression

What does this mean for corrections? Overdose potential

Depends on which opiate: ▪ Onset of action.▪ Hydrocodone (peak .5hr, duration 3-4 hours)▪ Methadone (peak: 2-4 hours, duration 24 hours)

▪ Tolerance of individual▪ Tolerance to respiratory depression may be slower than tolerance to

euphoric effects

Symptoms of overdose:▪ Triad: ▪ Altered LOC▪ Respiratory Depression (RR<12)▪ Miotic Pupils

Withdrawal Cows

Management of Opioid Overdose

Basic life support Assess Ventilation▪ Support ventilation

Naloxone hydrochloride – opioid antagonist▪ .4mg to .8mg, may have to be repeated▪ May need higher doses and multiple repeated

doses over time

Opioid Withdrawal

Not life-threatening but so uncomfortable prompts relapse.

Onset of symptoms depends on the duration of use and ½ life of drug used Heroin: onset 4-6 hours Methadone: onset: 36 hours

Neurophysiologic rebound in target organs

The generalized CNS suppression during use is replaced by CNS hyperactivity.

Clinical Opiate Withdrawal Scale- COWS

Treatment

Supportive measures Medication assisted

clonidine

Psychostimulants

Medical Morbidity-Acute Intoxication

CVS Ventricular

irritability Hypertension Tachycardia Myocardial

Infarction Neurologic

Seizure Stroke Hyperthermia

Rhabdomyolysis Acute Renal Failure Insomnia

Chronic Methamphetamine Use CVS

Cardiomyopathy Myocardial

Infarction Strokes

Pulmonary Pulmonary

Hypertension COPD

Neurologic Memory Impairment Deficits in judgment Poor impulse control

Infectious HIV/Hepatitis C Skin infections Complications IVDA

MA Psychiatric Morbidity

Psychosis Acute:▪ Classically paranoid▪ Persecutory delusions▪ Ideas of Reference▪ Heightened

awareness Chronic:▪ Psychosis can persist

after acute episode or recur with little or no further MA use.

▪ Sensitization

Mood Disorder Mania during

intoxication Depression during

withdrawal Anxiety

Management of Intoxication

Confirm diagnosis by urine toxicology screen

Gastric lavage or activated charcoal for ingestion

Seizures: Diazepam Psychosis /Agitation: Diazepam +/-

antipsychotic Hyperthermia: external cooling

Withdrawal from Methamphetamine Hyperarousal

Agitation, severe craving, nightmares Vegetative Symptoms

Decreased energy, craving sleep, increased appetite

Anxiety-related symptoms Anxiety, loss of interest, anhedonia,

psychomotor retardation Severe dysphoria, mood volatility,

irritability and sleep pattern disruption

Cannibinoids

Drug of choice- most daily marijuana use

Intake: Adverse events: paranoia, increased

blood pressure/HR

Withdrawal Symptoms similar to nicotine withdrawal No real treatment for withdrawal

Synthetic Cannibinoids

Synthetic Cannibinoids- spice, KQ

Mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC

Street names: Spice, K2, Black Mamba, Blaze, JWH-018, 073, Kronic(added BZ), krypton (added opioid)

Typically smoked Sold in Europe since 2002-2004.

Widely available for purchase on Internet in 2006

2010: states began banning product 2011: schedule 1 drug First cannibinoid identified was JWH-018

and CP47,497. Now there are well over 20 new synthetic cannabinoids.

10 -100 more potent than THC Strong affinity to CB1 receptors

Responsible for psychoactive effects Central and peripheral nervous sx, Cardiovascular system

Some of herbal ingredients added may have psycho-active potential (opioid-like, Bz,etc)

Onset 3-5 minutes Duration of action: 1-8 hours

Physiologic Response- CB1 Activation

Depends on dose Mood effects

Euphoria and dysphoria Hyperactivity, anxiolysis and anxiety

Perceptual effects Change in time perception Hallucinations/psychotic states Paranoia Depersonalization/dissociation

Cognition effects: Fragmented thinking Short term memory impairment

Motor effects Ataxia, loss of coordination, slurred

speech Immunosuppressive Cardiovascular effects

Increased heart rate, orthostatic hypotension

Toxicology effects

Unpredictable toxicology Adverse effects are dose dependent Emerging evidence that adverse

effects are more severe Especially in teens (as is Marijuana)

Seizures Psychosis

Growing acceptance that cannabis use may increase the risk of psychosis and/or psychosis like conditions. Cannabis risk is mild.▪ 41% increased risk in developing psychosis for

cannabis users v. non-cannabis users▪ 109% increase for heavy cannabis users

Commonly reported in SC users▪ Clearly associated with both the onset and

exacerbation of recurrent psychotic episodes

Mood and Anxiety Anxiety Catatonia

Cardiovascular effects Increased heart rate Pediatrics: Adolescents presenting with

chest pain, confirmed myocardial infarction.