Tara M. Wright, MD, Jeffrey S. Cluver, MD, and Hugh Myrick, MD
CHAPTER OUTLINE
■ INTOXICATION STATES
■ RISE IN DESIGNER DRUGS NOT READILY DETECTED THROUGH ROUTINE TOXICOLOGY SCREENING
■ WITHDRAWAL STATES
■ SPECIAL POPULATIONS
■ CONCLUSIONS
Recognition of intoxication and withdrawal states is critical for the appropriate management of individuals with substance use disorders. In addition to being able to recognize the unique intoxication and withdrawal states of particular substances of abuse, the treatment of patients who are under the influence of, or experiencing withdrawal from, substances of abuse requires an understanding of many variables. These variables include an appreciation of the natural history and variants of such syndromes, a complete assessment of the patient’s individual medical, psychiatric, and social issues, and knowledge of the uses and limitations of a variety of behavioral and pharmacologic interventions. All therapies must be individualized to each patient’s needs and adjusted to reflect the patient’s response to treatment.
The number of referrals due to complications from acute intoxication or withdrawal from substances to emergency departments (EDs) are at all-time highs. Data from the Drug Abuse Warning Network revealed that the total number of drug-related ED visits increased 81% from 2004 (2.5 million) to 2009 (4.6 million). ED visits involving nonmedical use of pharmaceuticals increased 98.4% over the same period, from 627,291 visits to 1,244,679 (1). The largest pharmaceutical increases were observed for oxy-codone products (242.2% increase), alprazolam (148.3% increase), and hydrocodone products (124.5%). Among ED visits involving illicit drugs, only those involving ecstasy increased more than 100% from 2004 to 2009 (123.2% increase) (1). For patients aged 20 or younger, ED visits resulting from nonmedical use of pharmaceuticals increased 45.4% between 2004 and 2009 (116,644 and 169,589 visits, respectively). Among patients aged 21 or older, there was an increase of 111.0% (1).
This chapter serves as an introduction to the identification and management of intoxication and withdrawal states, with the management of specific substances to be reviewed in subsequent chapters in this section.
INTOXICATION STATES
Intoxication is the result of being under the influence of, and responding to, the acute effects of alcohol or another drug of abuse. It typically includes feelings of pleasure, altered emotional responsiveness, altered perception, and impaired judgment and performance. The recognition of intoxication states is of paramount importance in the appropriate treatment of substance-abusing patients. Intoxication states can range from euphoria or sedation to life-threatening emergencies when overdose occurs. Typically, each substance of abuse has a set of signs and symptoms that are seen during intoxication. Identification and treatment of intoxication can lead to appropriate management of the withdrawal phenomenon and provide an avenue for entry into treatment. The initial challenge to the clinician, however, is diagnosis, because intoxication can mimic many psychiatric and medical conditions.
Identification and Management of Intoxication
The identification of intoxication begins with the collection of patient data through a patient history, physical examination, and laboratory screening. Of immediate concern is life-threatening intoxication or overdose. Thus, the first priority is general supportive care and resuscitative actions. It is important to determine not only the severity of the substance ingestion but also the patient’s level of consciousness, the substances involved, and any complicating medical disorders. Often, more than one substance of abuse is involved, and it is critical to know what substances have been ingested, as well as how much of each substance.
Historical information regarding substance use usually can be obtained from the patient. Questions regarding the quantity and frequency of substance use provide valuable information to the clinician. Discovering chronic patterns of substance use may aid in subsequent referral to addiction treatment. Acute intoxication may impede an individual’s ability to provide such information. In these cases, the patient’s companions or family may be able to provide important information.
Standardized questionnaires for self-administration by the patient or for use by the physician are designed to elicit answers related to alcohol use. Toxicology screens provide valuable information regarding the type or types of substances used. As discussed below, the rise in the use of “designer drugs” can make identification of the causative substance(s) more difficult by routine toxicology screening. When screening for substances of abuse, urine is the most widely used specimen because of the ease with which a sample is obtained, the relatively high concentrations of drugs and metabolites present in urine, and the stability of metabolites when frozen (2). Drug screens can aid in the differential diagnosis when atypical symptoms are present. Such screening can be particularly helpful in cases where little clinical history is available. Having knowledge of the particular sensitivities, specificities, and cross-reactivities of the particular urine drug screen being used is of vital importance to the appropriate interpretation of the urine drug screen. In addition, one must have an understanding of the usual duration of detectability of particular substances. However, the duration of detectability can be significantly impacted by the amount of substance ingested, individual rates of metabolism and excretion, as well as fluid ingestion of the individual.
Screening for alcohol is most frequently accomplished by breathalyzer or blood alcohol levels; however, urine tests are also available that detect metabolites of alcohol. Laboratory assays that measure increases in liver enzymes—such as gamma-glutamyl transpeptidase, aspartate aminotransfer-ase, and alanine aminotransferase—can be helpful in identifying alcohol use. Although alcohol is not the only cause of an increase in gamma-glutamyl transpeptidase (GGT), and GGT frequently does not increase in younger drinkers, this assay is a reliable predictor of drinking behavior. A biologic assay to monitor alcohol intake involves percent carbohydrate-deficient transferrin (%CDT), which is a more sensitive and specific indicator of heavy alcohol consumption (3,4). The conjugated ethanol metabolites ethyl gluc-uronide (EtG) and ethyl sulfate (EtS) are other measures used to confirm or rule out recent drinking. Although EtG and EtS account for only less than 0.1% of the ingested ethanol dose, they remain detectable in urine for several hours up to some days longer than ethanol, the time lag largely depending on the amount consumed (5).
RISE IN DESIGNER DRUGS NOT READILY DETECTED THROUGH ROUTINE TOXICOLOGY SCREENING
The rise in the use of “designer drugs” or “synthetic legal intoxicating drugs” is contributing to escalation of ED visits because of the severity of physical and behavioral hazards associated with acute intoxication. This is especially dangerous as these substances are not detected in routine drug screen, and overdose can be lethal. The psychoactive “designer drug” methylenedioxypyrovalerone, the primary ingredient in “bath salts,” is a synthetic, cathinone-derivative, central nervous system stimulant that is taken to produce a cocaine-or methamphetamine-like high. The intoxication lasts 6 to 8 hours and has high addictive potential. Overdoses are characterized by profound toxicities, with physical manifestations ranging from tachycardia, hypertension, arrhyth-mias, hyperthermia, sweating, rhabdomyolysis, and seizures to those as severe as stroke, cerebral edema, cardiorespiratory collapse, myocardial infarction, and death. Behavioral effects include panic attacks, anxiety, agitation, severe paranoia, hallucinations, psychosis, suicidal ideation, self-mutilation, and behavior that is aggressive, violent, and self-destructive. Treatment is principally supportive and focuses on counteracting the sympathetic overstimulation, including sedation with intravenous benzodiazepines, seizure prevention measures, intravenous fluids, close monitoring, and restraints to prevent harm to self or others. The clinical presentation is often complicated by coingestion of other psychoactive substances that may alter the treatment approach (6).
“Spice” refers to a wide variety of herbal mixtures that produce experiences similar to marijuana and that are marketed as “safe,” legal alternatives to that drug. They are sold under names such as K2, fake weed, Yucatan Fire, Skunk, and Moon Rocks, and others. They are labeled “not for human consumption.” While they do contain plant material, synthetic cannabinoid compounds are responsible for their psychoactive effects. These products are popular among young people; of the illicit drugs most used by high school seniors, they are second only to marijuana. Contributing to their popularity is the misperception that they are “natural” and therefore safe, and they are not detected in routine urine drug screening. Spice users report experiences similar to those produced by marijuana (elevated mood, relaxation, and altered perception); however, the effects can be even stronger than those of marijuana. Some users report psychotic effects like extreme anxiety, paranoia, and hallucinations. Physical and neuro-logic manifestations of acute intoxication can include tachycardia, vomiting, agitation, and confusion. It has also been associated with myocardial ischemia, and in a few cases, it has been associated with myocardial infarction (7).
Salvia (Salvia divinorum) is an herb common to southern Mexico and Central and South America. The main active ingredient in Salvia, salvinorin A, is a potent activator of kappa opioid receptors in the brain. Traditionally, S. divino-rum has been ingested by chewing fresh leaves or by drinking their extracted juices. Its dried leaves can also be smoked as a joint, consumed in water pipes, or vaporized and inhaled. Users typically experience hallucinations or transient psychotic episodes. Subjective effects have been described as intense but short lived, appearing in less than 1 minute and lasting less than 30 minutes. They include psychedelic-like changes in visual perception, mood and body sensations, emotional swings, feelings of detachment, and a highly modified perception of external reality and the self, leading to a decreased ability to interact with one’s surroundings (8).
WITHDRAWAL STATES
Substance withdrawal has been defined by the American Psychiatric Association as “the development of a substance-specific maladaptive behavioral change, usually with uncomfortable physiological and cognitive consequences, that is the result of a cessation of, or reduction in, heavy and prolonged substance use.” (9) The signs and symptoms of withdrawal usually are the opposite of a substance’s direct pharmacologic effects. Substances in a given pharmacologic class produce similar withdrawal syndromes; however, the onset, duration, and intensity are variable, depending on the particular agent used, the duration of use, and the degree of neuroadaptation.
Evidence for the cessation of or reduction in use of a substance may be obtained by history or toxicology. Additionally, the clinical picture should not correspond to any of the organic mental syndromes, such as organic hallu-cinosis (9). Withdrawal may, however, be superimposed on any organic mental syndrome. Therefore, a thorough physical examination is necessary, including appropriate laboratory analysis of basic organ functions.
The term detoxification implies a clearing of toxins. However, for individuals with physiologic substance dependence, detoxification is defined as the management of the withdrawal syndrome.
Goals of Detoxification
Detoxification includes a set of interventions by which a substance an individual is physically dependent on is eliminated from the body. Detoxification seeks to minimize the physical harm caused by the abuse of substances. The American Society of Addiction Medicine (ASAM) lists three immediate goals for detoxification of alcohol and other substances: (a) “to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug-free”; (b) “to provide a withdrawal that is humane and thus protects the patient’s dignity”; and (c) “to prepare the patient for ongoing treatment of his or her dependence on alcohol or other drugs” (10). Furthermore, it comprises three essential and sequential steps: evaluation, stabilization, and fostering patient readiness for and entry into treatment (11). It is important to distinguish detoxification from substance use disorder treatment. Substance use disorder treatment/rehabilitation involves a constellation of ongoing therapeutic services ultimately intended to promote recovery for substance use disorder patients (11). Detoxification may be the first step in this process.
Many risks are associated with withdrawal, some of which are influenced by the setting in which detoxification occurs. For example, in persons who are severely dependent on alcohol, an abrupt, untreated cessation of drinking may result in marked hyperautonomic signs, seizures (which may be recurrent), withdrawal delirium, or even death. Other sedative–hypnotics also can produce life-threatening withdrawal syndromes. Withdrawal from opioids and stimulants produces severe discomfort, but generally is not life threatening. It may, however, present a danger to those who are debilitated by advanced HIV disease, medical sequelae of addiction, advanced age, coronary artery disease, and other medical problems. Moreover, risks to the patient and society are not limited to the severity of the patient’s physical disturbance, particularly when the detoxification is conducted in an outpatient setting. Outpatients experiencing withdrawal symptoms may self-medicate with alcohol or other drugs that can interact with withdrawal medications in an additive fashion or precipitate overdose.
A caring staff, a supportive environment, sensitivity to cultural issues, confidentiality, and the selection of appropriate detoxification medications (as needed) are important components of a humane withdrawal. However, staff must be clear in their treatment goals and set firm boundaries, as well as be sympathetic and have experience in dealing with difficult behaviors that often accompany detoxification. Supportive others (family members, friends, or employers) should be enlisted whenever possible to assist in the care of the patient during outpatient detoxification.
During detoxification, patients may form therapeutic relationships with treatment staff and other patients, providing an opportunity to explore alternatives to an alcohol-or drug-using lifestyle. Detoxification is therefore an opportunity to offer patients information and to motivate them for longer-term treatment. Unfortunately, managed care organizations and other third-party payers often regard detoxification as separate from other phases of alcohol and other drug treatment, as though detoxification occurs in isolation from such treatment. In clinical practice, this separation cannot exist; detoxification is but one component of a comprehensive treatment strategy.
General Principles of Management
Some detoxification procedures are specific to particular drugs, whereas others are based on general principles of treatment and are not drug specific. The general principles are presented here; subsequent chapters address specific treatment protocols for each class of drugs.
There is a risk of serious adverse consequences for some patients who undergo withdrawal. As such, an initial medical assessment is important to determine the need for medication and medical management. Such an assessment should include evaluation of predicted withdrawal severity and medical or psychiatric comorbidity. Although the severity of a given patient’s withdrawal cannot always be predicted with accuracy, helpful information includes the amount and duration of alcohol or other drug use, the severity of the patient’s prior withdrawal experiences (if any), and the patient’s medical and psychiatric history. Past complicated withdrawal should alert the practitioner to the likely possibility of future complicated withdrawals. The kindling hypothesis has been well supported in alcohol research, such that past alcohol withdrawal seizures are a strong indicator of future alcohol withdrawal seizures (12). A widely used instrument in clinical and research settings for the initial assessment and ongoing monitoring of alcohol withdrawal is the Clinical Institute Withdrawal Assessment of Alcohol–revised. The Clinical Institute Withdrawal Assessment of Alcohol–revised is a short test that rates the severity of withdrawal, as observed by the clinician. In general, low scores (<8) suggest that pharmacotherapy may not be required, whereas high scores (>10) indicate a greater risk of seizures and delirium tremens.
Every means possible should be used to ameliorate the patient’s withdrawal signs and symptoms. Medication should not be the only component of treatment, because psychological support is extremely important in reducing the patient’s distress during detoxification.
The duration of detoxification is not a clearly defined, discrete period. Because detoxification often requires a greater intensity of services than other types of treatment, there is a practical value in defining a period during which a person is “in detoxification.” The detoxification period usually is defined as the time during which the patient receives detoxification medications, even though some signs and symptoms may persist for a much longer period. Another way of defining the detoxification period is by measuring the duration of withdrawal signs or symptoms. However, the duration of these symptoms may be difficult to determine in a correctly medicated patient, because symptoms of withdrawal are largely suppressed by the medication.
Another problem in defining the duration of detoxification is the fact that many patients may have prolonged withdrawal signs or symptoms, or “protracted withdrawal syndrome.” Symptoms of the syndrome include disturbances of sleep, anxiety, irritability, mood instability, and craving. The very existence of the protracted abstinence syndrome has been the subject of considerable controversy; however, there is increasing evidence in the literature supporting its existence. The protracted withdrawal syndrome is hypothesized to be a period when individuals are at a heightened risk of relapse (13,14).
Physicians often find it difficult to distinguish symptoms caused by drug withdrawal from those caused by a patient’s underlying mental disorder, if one is present. The signs and symptoms of protracted withdrawal thus are not as predictable as those of acute withdrawal, which produces measurable signs that researchers can study in animals under controlled laboratory conditions; protracted withdrawal, on the other hand, often is confined to distress symptoms for which there are no animal models. The plan of care for detoxification should be individualized to account for the considerable variation among patients in terms of signs and symptoms of withdrawal. The best outcomes are obtained by tailoring the detoxification regimen to meet the needs of individual patients. The initial plan of care for detoxification should be adjusted to reflect the patient’s response to the treatment provided.
Pharmacologic Management
There are two general strategies for pharmacologic management of withdrawal: suppressing withdrawal through use of a cross-tolerant medication and reducing signs and symptoms of withdrawal through alteration of another neuropharmacologic process. Either or both may be used to manage withdrawal syndromes effectively. To suppress withdrawal with cross-tolerant medication, a longer-acting medication typically is used to provide a milder, controlled withdrawal. Examples include use of methadone for opioid detoxification and diazepam for alcohol detoxification. Medications that are not cross-tolerant are used to treat specific signs and symptoms of withdrawal. Examples include use of clonidine for opioid or alcohol withdrawal.
Detoxification alone rarely constitutes adequate treatment. The provision of detoxification services without continuing treatment at an appropriate level of care constitutes less than optimal use of limited resources. The maintenance of abstinence can be a very difficult goal to achieve: It has been estimated that approximately 50% of alcohol-dependent patients relapse within 3 months of detoxification. The appropriate level of care and content of treatment following detoxification must be clinically determined, based on the patient’s individual needs. Biopsychosocial factors to be considered in determining the continuing treatment plan include medical and psychiatric conditions, motivation, relapse potential, and available support systems. These factors correspond to the dimensions of illness described in the American Society of Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders, second edition–revised (ASAM PPC-2R) (15).
Detoxification Settings
The initial assessment should facilitate the selection of the appropriate level of care for detoxification. In determining the most appropriate setting, the practitioner should match the patient’s clinical needs with the least restrictive and most cost-effective setting (11). Detoxification may take place in a variety of inpatient and outpatient settings. Multiple instruments have been designed to facilitate selection of an appropriate level of care. The ASAM PPC-2R contains detailed guidelines for matching patients to an appropriate intensity of services for detoxification. Detoxification is conducted in both inpatient and outpatient settings. Both types of settings initiate recovery programs that may include referrals for problems such as medical, legal, psychiatric, and family issues.
Inpatient Detoxification
Inpatient detoxification is offered in medical hospitals, psychiatric hospitals, and medically managed residential treatment programs. It allows 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. The primary emphasis in this setting should be placed on ensuring that the patient is medically stable (including the initiation and tapering of medications used for the treatment of substance use withdrawal), assessing for adequate biopsychosocial stability (and quickly intervening if this is lacking), and linking the patient to appropriate inpatient and outpatient services once it is medically safe to do so (11). Inpatient detoxification provides the safest setting for the treatment of substance withdrawal, because it ensures that patients will be carefully monitored and appropriately supported. Such monitoring is especially important if the patient is dependent on high doses of alcohol or other sedative–hypnotic drugs. Compared with outpatient detoxification, inpatient detoxification may provide better continuity of care for patients who begin treatment while in the hospital. In addition, inpatient detoxification separates the patient from substance-related social and environmental stimuli that might increase the risk of relapse (16).
In the case of detoxification from alcohol, about 20% of those undergoing treatment for alcohol withdrawal must be treated as inpatients. Relative indications for inpatient treatment include past alcohol withdrawal seizures or delirium, pregnancy, medical or psychiatric illness, or lack of a reliable support system (17,18). Abnormalities of electrolytes or blood counts, infection, trauma, and the presence of structural brain lesions can be predictors of the most severe cases of withdrawal (19). Inpatient care of alcohol withdrawal can be 10 to 20 times as expensive as outpatient care. Generally, therefore, it is reserved for those expected to have severe withdrawal symptoms and to require a more intensive level of care (such as patients with past severe withdrawal symptoms).
Outpatient Detoxification
Outpatient detoxification usually is offered in community mental health centers, methadone maintenance programs, addiction treatment programs, and private clinics. Essential components to a successful outpatient detoxification include a positive and helpful social support network and regular accessibility to the treatment provider (11). Medical and nursing personnel involved must be readily available to evaluate and confirm that detoxification in the less supervised setting is safe. They must be able to interpret the signs and symptoms of alcohol and other drug intoxication and withdrawal, have knowledge of the appropriate treatment and monitoring of these conditions, and have the ability to facilitate the individual’s entry into treatment (11). Advantages of outpatient detoxification include the fact that it is much less expensive than inpatient treatment, the patient’s life is not disrupted to the degree that it is during inpatient treatment, and the patient does not undergo the abrupt transition from a protected inpatient setting to the everyday home and work settings.
EDs are important components of outpatient detoxification as they often serve as a gateway to detoxification services. Detoxification programs may rely on ED staff to assess and initiate treatment for patients with medical conditions or medical complications that occur during detoxification. For social model programs, EDs often serve as a safety net for patients who need medical treatment. For the substance-abusing individual who has overdosed or who is experiencing a medical complication of abuse, the ED may be the initial point of contact with the health care system and serve as a source of case identification and referral to detoxification. Many patients experiencing alcohol withdrawal seizures present initially to an ED where they are taken after a seminal episode.
Considerations in Selecting a Setting
The best detoxification setting for a given patient may be defined as the least restrictive, least expensive setting in which the goals of detoxification can be met. The ability to meet this standard assumes that treatment choices always are based primarily on a patient’s clinical needs. A comprehensive evaluation of the patient often indicates what therapeutic goals might be achieved realistically during the time allotted for the detoxification process.
Treatment providers should consider detoxification settings and patient matching within the context of a fundamental principle of high-quality patient care. This principle is that the patient’s needs should drive the selection of the most appropriate setting. The severity of the patient’s withdrawal symptoms and the intensity of care required to ensure appropriate management of these symptoms are of primary importance. Pressures to achieve cost savings are having a significant effect on the selection of treatment settings for detoxification. Many insurance companies, managed care organizations, and other payers have adopted stringent policies concerning reimbursement for alcohol and other drug detoxification services. These policies govern not only the setting in which the services are provided but also the maximum number and duration of detoxification episodes that are covered benefits. Such policies give insufficient weight to the variety of factors that affect the selection of a setting in which the patient has the greatest likelihood of achieving satisfactory detoxification. Some persons in need of detoxification, for example, may not be appropriate candidates for outpatient detoxification because of environmental impediments such as a spouse who is using alcohol or other drugs. Such a patient may be more appropriately detoxified in a residential setting such as a recovery house or other residential environment that is free of alcohol and other drug use. Panelists convened by the federal Center for Substance Abuse Treatment expressed concern that important clinical decisions often are driven by economic rather than clinical considerations (10,11). They affirmed that the dominant principle in patient placement is that detoxification is cost-effective only if it is appropriate to the needs of the individual patient.
Use of the ASAM Patient Placement Criteria
The ASAM PPC-2R is intended for use as a clinical tool for matching patients to appropriate levels of care. The criteria reflect a clinical consensus of adult and adolescent treatment specialists and incorporate the results of a comprehensive peer review by professionals in addiction treatment. The ASAM criteria describe levels of treatment that are differentiated by the following characteristics: (i) degree of direct medical management provided; (ii) degree of structure, safety, and security provided; and (iii) degree of treatment intensity provided.
The ASAM criteria offer a variety of options on the premise that each patient should be placed in a level of care that has the appropriate resources (staff, facilities, and services) to assess and treat that patient’s substance use disorder. The ASAM patient placement criteria are routinely under review to maximize their utility. As such, a supplement to the ASAM Patient Placement Criteria on Pharmacotherapies for Alcohol Use Disorders, specifically for detoxification and relapse, was published in 2010.
Relapse
Many individuals undergo detoxification more than once, and some do so many times. When recently dependent persons return for repeat detoxification, it generally is with a more realistic expectation of what is needed to remain free from alcohol and other drugs. O’Brien et al. (20) point out that compliance and relapse in addictive disease are comparable to rates of relapse in other illnesses, such as diabetes and hypertension. Therefore, they recommend comparable long-term treatment. Although addicted persons are at increased risk of relapse at certain points in their recovery, relapse can occur at any time. The relapsed patient is an appropriate candidate for detoxification and continuing treatment, including relapse prevention education.
SPECIAL POPULATIONS
Although researchers have not yet thoroughly evaluated withdrawal strategies for certain populations, patients in several groups clearly require special consideration.
Pregnant and Nursing Women
Special concerns attend detoxification during pregnancy. For example, withdrawal from opioids can result in fetal distress, which can lead to premature labor or miscarriage. On the other hand, opioid agonist treatment, coupled with good prenatal care, is generally associated with good maternal and fetal outcomes. Methadone maintenance has historically been accepted as the standard approach to the opioid-dependent pregnant woman; however, recent research also supports the efficacy of buprenorphine, particularly as it may be less likely to cause neonatal abstinence syndrome (21”23). It should be noted, however, that both of these medications are classified as pregnancy category C. Although offspring of women on opioid maintenance therapy tend to have a lower birth weight and smaller head circumference than drug-free newborns, no developmental differences at 6 months of age have been documented. Clonidine (frequently used in opioid detoxification) also is a pregnancy category C medication.
Federal panels recommend that all pregnant and nursing women be advised of the potential risks of drugs that are excreted in breast milk (10,24). Nevertheless, they advise that detoxification protocols should not be modified for nursing women unless there is specific evidence that the detoxification medication enters the breast milk in amounts that could be harmful to the nursing infant (10,24). These decisions often must include weighing the risks and benefits to both the mother and infant. For instance, the American Academy of Pediatrics (25) categorizes benzodiazepines as “drugs for which the effect on nursing infants is unknown, but may be of concern.” The addiction provider should coordinate treatment decisions with an obstetrician or pedi-atrician in these cases.
Persons Who Are HIV Positive
Substance use disorders increase the risk of contracting HIV through the use of contaminated needles and risky sexual behavior. In addition, substance use disorder treatment can help reduce the transmission of HIV by reducing these behaviors (26). Substance use disorders and HIV/AIDS interact with one another in a complex manner. The presence of an alcohol or drug addiction can certainly impede compliance with an individual’s medication regimen for the treatment of HIV (26). A diagnosis of HIV infection does not change the indications for detoxification medications, which can be used in HIV-positive persons in the same way they are used in uninfected patients. A federal panel advises that, if deemed appropriate, the detoxification process need not be altered by the presence of HIV infection (10,27,28). However, the treatment provider does need to be aware of the possible drug interactions between antiretroviral agents used to treat HIV and medications used in detoxification and adjust dosages accordingly (26). For instance, methadone and buprenorphine are two agents widely used in the management of opioid withdrawal, both of which can have interactions with HIV medications, although methadone to a more significant degree than buprenorphine (29).
Patients with Other Medical Conditions
Neurologic Disorders
Brain-injured patients are at risk for seizures (10). If an alcohol-or other drug-abusing patient who has sustained trauma to the head becomes delirious, the cause of the delirium should be investigated. Slower medication tapers should be used in patients with seizure disorders (10). Doses of anticonvulsant medications should be stabilized before sedative–hypnotic withdrawal begins. The treatment of individuals with past alcohol or sedative–hypnotic withdrawal seizures is controversial. In such a situation, the use of anticonvulsant agents (carbamazepine, valproate) should be considered, either alone or in combination with benzodiazepines.
Cardiovascular Disorders
Patients with cardiac disease require continued clinical assessment. Underlying cardiac disease may be worsened by the symptoms of autonomic arousal (elevated blood pressure, increased pulse, and sweating) as seen in alcohol, sedative, and opioid withdrawal (11). Because of this, it may be necessary to withdraw the medication at a slower than normal rate. Treatment providers also should be alert to the possibility of interactions between cardiac medications and the agents used to manage detoxification.
Hepatic or Renal Disorders
Severe liver or renal disease can slow the metabolism of both the drug of abuse and the detoxification medication. Use of shorter-acting detoxification drugs and a slower taper is appropriate for such patients but requires precautions against drug accumulation and oversedation (11).
Chronic Pain
Patients who experience pain and receive opioids may not require detoxification from prescribed medications unless they meet the criteria for opioid abuse or dependence (10). However, treatment providers should exercise caution when prescribing medications for chronic pain in patients who have current or past addictive disorders. In a large secondary data analysis of chronic users of opioids for chronic noncancer pain, a diagnosis of non–opioid substance abuse was the strongest predictor of opioid abuse/dependence (30). Mental health disorders were also moderately strong predictors of opioid abuse/dependence in this group (30). Furthermore, the use of Schedule II opioids, headache, back pain, and substance use disorders have been associated with increased ED visits and alcohol-or drug-related encounters among adults prescribed opioids for 90 days or more. It may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher-risk recipients (31).
General principles when using opioids in the treatment of chronic pain include comprehensive follow-up, using adjunctive interventions where necessary, regular prescription pickup, appropriate screening for use and abuse, and a limitation on the number of physicians and pharmacists providing treatment (32). Also, when indicated, any patient who has taken opioids or sedative–hypnotics for a prolonged period should be weaned from them gradually.
Patients with Psychiatric Comorbidities
It is difficult to accurately assess underlying psychopathology in a patient who is undergoing detoxification (10). Drug toxicity or organic psychiatric symptoms (particularly with amphetamines, cocaine, hallucinogens, or phencycli-dine [PCP]) can mimic psychiatric disorders. For this reason, thorough psychiatric evaluation should be conducted after 2 to 3 weeks of abstinence. At the time patients are evaluated for detoxification, some with underlying psychiatric disorders already may be prescribed antidepressants, neuroleptics, anxiolytics, or lithium. Although staff at some treatment programs may believe that such patients should discontinue all psychoactive medications, a federal panel has advised that this course of action may not be in the best interest of the patient (10). Abrupt cessation of psycho-therapeutic medications may cause withdrawal symptoms or reemergence of symptoms of the underlying psychopathology. Thus, decisions about discontinuing the medication should be deferred temporarily. If, however, the patient has been abusing the prescribed medication or the psychiatric condition clearly was caused by the patient’s alcohol or other drug abuse, the rationale for discontinuing the medication is more compelling. Individuals who use both sedative–hypnotics and alcohol pose a real challenge for detoxification, which generally should be conducted in an inpatient setting and over a prolonged period.
During detoxification, some patients decompensate into psychosis, depression, or severe anxiety. In such cases, careful evaluation of the withdrawal medication regimen is of paramount importance. Anxiety symptoms can cause an overestimation of withdrawal severity on the Clinical Institute Withdrawal Assessment of Alcohol–revised and therefore result in overuse of medication for withdrawal. If the decompensation is the result of inadequate dosing with the withdrawal medication, the appropriate response is to increase that medication. If the dose of the withdrawal medication appears to be adequate, other medications may need to be added. Before selecting the alternative, however, it is important to consider the potential side effects of the additional medication and the possibility of interaction with the withdrawal medication. If withdrawal medications are adequate and appropriate but the patient continues to decom-pensate, nonaddicting psychotropic medications (such as antipsychotics, anticonvulsants, or antidepressants) may be indicated for the treatment of psychoses, depression, or anxiety emerging during withdrawal. After detoxification is completed, the patient’s need for medications should be reassessed. A trial period with no medications may be indicated.
Adolescents
Results from the Monitoring the Future survey found that overall, in 2012, 8th, 10th, and 12th graders showed non-significant declines in the use of any illicit drug (33). The percentage using any illicit drug other than marijuana has been declining gradually since about 2001. Marijuana use has been rising among teens for the past 4 years; however, the increases appeared to have halted in 2012. Contributing to this is the perception that marijuana is not harmful and increasing social acceptance stemming from the legalization of marijuana in an increasing number of states. Roughly 1 in 15 high school seniors today is a current daily, or near-daily, marijuana user (33).
The psychotherapeutic drugs (i.e., amphetamines, sedatives, tranquilizers, or narcotics other than heroin) now make up a larger part of the overall US drug problem in adolescents than was true 10 to 15 years ago (33). The reason for this is multifactorial; including increased prescribing of these drugs for legitimate purposes, increased advertising of these drugs directly to consumers, and the use of a number of street drugs has declined substantially since the mid-1990s. It seems likely that young people are less concerned about the dangers of using these prescription drugs outside of a medical regimen.
Alcohol remains the substance most widely used by today’s teenagers. Despite recent declining rates, seven out of every ten students (69%) have consumed alcohol (more than just a few sips) by the end of high school, and three out of ten (30%) have done so by 8th grade. In fact, over half (54%) of 12th graders and more than one-seventh (13%) of 8th graders in 2012 report having been drunk at least once in their life (33).
Adolescents in detoxification pose somewhat different clinical issues than do adults. Patterns of use, negative consequences, context, and control of use may all be unique in adolescents in comparison to adults. Physical dependence is often not as severe in the adolescent compared with the adult, and the adolescent patient’s response to detoxification usually is more rapid than that of the adult (10,34). Inquiring about academic performance, school attendance, and disciplinary problems can be particularly important to help the practitioner ascertain the adolescent’s risk of a substance use disorder. Behavioral problems may be more indirect, and the potential for suicide needs to be evaluated carefully. Substance abuse, particularly when comorbid with depression, contributes to an increased rate of suicide in this age group. Adolescents who are undergoing detoxification need a structured environment that is nurturing and supportive. This is especially important because adolescents are notorious for leaving treatment against medical advice. Also, adolescents should be housed separately from adults. Decisions about involving the family in treatment should be made on a case-by-case basis and should reflect an assessment of family functioning. Note that federal regulations allow methadone detoxification of adolescents, but state regulations vary. Both methadone and buprenor-phine have documented efficacy for opioid detoxification in the adolescent population; however, similar to adults, maintenance therapy compared to detoxification appears to lead to improved treatment retention and treatment outcomes (35).
Older Adults
Possible factors that may impact the treatment of intoxication and withdrawal in older adults include the increased likelihood of medical comorbidities with multiple prescribed medications and prescribing physicians, greater access to prescription medications (which may be abused), and possible impaired mobility from either social isolation or general medical conditions resulting in difficulty accessing clinic-or office-based treatment. It is essential to conduct a complete assessment and careful monitoring of the patient for comorbid conditions, such as respiratory or cardiac disease or diabetes (36). Because the aging patient may be taking a number of prescription and over-the-counter drugs, the possibility of drug interactions cannot be ignored. For these reasons, detoxification in a medically monitored or medically managed setting often is required (10). The cumulative effects of years of drinking may lead to more severe withdrawal symptoms in elderly persons (37). The shorter-acting benzodiazepines may be of more clinical utility in this population given their lower risk of oversedation. It may be necessary to reduce the doses of detoxification medications because of older patients’ slowed metabolism or coexisting medical disorders.
Persons in Criminal Justice Settings
Persons who are incarcerated or in detention in holding cells or elsewhere should be assessed for dependence on alcohol or other drugs because untreated withdrawal from alcohol and sedative–hypnotics can be life threatening. Prevalence of dependence in these settings is higher than in the general population because an estimated 70% of people arrested for violent offenses test positive for substances. According to data from the Arrestee Drug Abuse Monitoring program in 2000, 64% of male arrestees tested positive for at least one of five illicit drugs (cocaine, opioids, marijuana, meth-amphetamines, and PCP), and 36% reported heavy drinking in the 30 days before arrest (38). It is therefore critical that criminal justice and treatment staff be trained to detect signs and symptoms of substance abuse and to refer clients for appropriate medical treatment in cases of acute intoxication or withdrawal (39).
Although heroin withdrawal is not life threatening to a healthy individual, it can be very difficult for the individual and should be treated appropriately. Patients who have been on opioid agonist treatment before being incarcerated should continue to receive their usual dose of medication. Opioid agonist treatment should be discontinued as gradually as possible if the jurisdiction or setting does not allow patients to receive these medications while incarcerated. Individuals who are on methadone maintenance may experience severe withdrawal symptoms if the medication is stopped abruptly. Indeed, methadone abstinence symptoms may persist for weeks or months and include severe vomiting and diarrhea, which can lead to complications. Pain may be severe and intractable. Detoxification protocols need not be modified for incarcerated persons, except to the extent that state laws restrict the use of methadone or buprenor-phine in criminal justice settings. In such cases, linkages with local methadone detoxification programs are advised.
In caring for incarcerated patients, the physician needs to be aware that in some settings, there is an underground market for psychoactive medications. Patients may try to deceive caregivers about their dependence to obtain drugs for sale to others. For this reason, prison medical staff need special training in patient assessment and detoxification (40).
CONCLUSIONS
The recognition and treatment of intoxication and withdrawal states represent important initial steps in the treatment of alcohol or other drug addiction. The primary goal of managing intoxication and withdrawal states is the prevention of morbidity and mortality. Whereas the treatment of intoxication often takes place in a medical setting, the treatment of withdrawal can occur in either an inpatient or an outpatient setting. Many variables must be taken into consideration in providing optimum care to patients who are undergoing treatment of withdrawal states. The ASAM PPC-2R can aid the clinician in matching patients to the appropriate levels of care for ongoing treatment of their addictive disorders.
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