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Detoxification can be defined as the means by which the drug-dependent person may
withdraw from the effects of that drug in a supervised way in order that withdrawal
symptoms and the risks relating to withdrawal are minimised.
Should detoxification occur at home or in the hosptipal?
In many instances effective detoxification can be performed in the home supported by
the local doctor and other health workers. This should be considered when:
These criteria mainly relate to detoxification from alcohol.
That is, assisted by the use of controlled sedatives, or non-medicated in which no
sedation is required.
This process should be carried out in a safe environment, ideally in a quiet and
comfortable home environment.
In the more severe cases medication is important and sedative treatment should be titrated against the severity of the patients withdrawal symptoms and signs. At no time should drug therapy be given to those patients who are still intoxicated.
There are two main approaches:
Tapering withdrawal regimen
Loading dose
Vitamin therapy
All patients treated for withdrawal from alcohol should receive thiamin to prevent the onset of Wernicke's Encephalopathy. An intravenous or intramuscular dose of 100 mg of thiamin immediately should be given and then orally 100 mg two to three times a day for two weeks.
Electrolyte and fluid balance
The fluid state of patients should be carefully assessed and a watchful eye kept for fluid depletion or fluid overload.
Withdrawal of benzodiazepines can be performed on an outpatient basis. This would need
to occur over six weeks but in some cases this may be increased to 10-15 weeks.
Withdrawal is managed by using a long-acting benzodiazepine such as diazepam in a dose
relevant to that of the drug in question. The following guidelines should be followed:
The doctor's role in the community is firstly to prevent dependence by judicious and
limited prescribing of sedatives and hypnotics for specific clinical situations on a
short-term basis, and to manage the detoxification of those who have established
dependence on these drugs.
Such a withdrawal state may occur in those who are taking short-acting barbiturates, but often may be delayed several days in those who are taking longer-acting preparations such as phenobarbitone. Other symptoms and signs that may occur are hypertension, abdominal cramps, and anorexia.
It is necessary to withdraw such patients on long-term sedation. At the outset a decision should be made whether formal detoxification is required.
Such detoxification can be achieved in the home, but in patients with more severe dependence hospitalisation in a detoxification unit is advised.
The most common opiate in use today is heroin.
Symptoms include nasal stuffiness and rhinorrhoea, sweating and lacrimation. Anxiety, restlessness and irritability follow, and over the next 36 hours chills and muscle cramps, particularly intestinal cramps, may occur. Vomiting and diarrhoea are also common at this stage.
In general the withdrawal syndrome from opiates is much less severe than withdrawal from sedative drugs or alcohol.
A combination of clonidine and diazepam is recommended.
Because of the complexities of the pharmacology involved in polydrug use and abuse it is unwise to contemplate withdrawal except in an inpatient environment.
There is not a lot of evidence to support the idea that there is a cannabis withdrawal syndrome. This does not mean that it is easy for some people to stop using cannabis.
Cessation of use may be situationally determined to a large degree. The presence of particular cues may lead to cannabis use. Cues may be internal or external. External cues may include mixing with a cannabis using group, a joint being shared or cannabis smoke at a party. Feeling bored, despondent or unhappy are all examples of internal cues which may lead to cannabis use.
Management should follow the general principles of detoxification:
Nicotine is one of the most addictive substances known (see Chapter 5, Tobacco). Any person smoking 20 or more cigarettes per day will experience nicotine withdrawal. This physical withdrawal is one aspect of relapse in smoking cessation.
The recommendations of Richmond and Webster (1988) present a very useful approach to
assisting patients to quit. There are a number of important principles:
The 'happy user'
These people should be informed about the risks to which they expose themselves and others. Provide written material to reinforce the information you have told them.
Those thinking about quitting
These people can be assisted by encouraging them to:
Those who have decided to quit
These people can be helped to do so by:
Delay: a tactic to reduce feelings of panic or anxiety, by continually delaying having a cigarette. After a few days craving will lessen and a sense of achievement and confidence will emerge.
Distract: make a conscious effort to do something when a craving emerges. This may include counting, exercise, working, eating, drinking etc.
Avoid: for the first two weeks try to avoid those high risk situations, triggers or cues which may produce craving for a cigarette. These may include coffee, alcohol, the pub/club, smoking friends etc. Over time these situations will be able to be faced with confidence.
Escape: from situations that produce cravings when the tactics above fail. Leave the room, go outside or make a phone call. Such action will lower the urge to smoke and previous activities can be continued.
These people can be assisted by:
Detoxification from psychostimulants is generally effective using non-pharmacological management techniques. While abstinence is the preferred treatment goal, there is no evidence to suggest that tapered withdrawal is any less effective in the cessation of psychostimulant use. All patients undertaking detoxification should be encouraged to abstain from the use of other mind-altering drugs, such as alcohol or marijuana, which may act as triggers or conditioned cues for the use of psychostimulant drugs or reduce the ability of the individual to cope with cravings experienced during withdrawal.
While most patients can undertake detoxification in an outpatient program, inpatient
treatment may be more appropriate in the following circumstances:
Where inpatient treatment is necessary, programs should be tailored to the specific needs of the patient. While the goals of individuals will differ, all patients should remain in inpatient care until withdrawal symptoms subside.
There are a number of options available, all of which will not be appropriate for all
patients.
Pharmacologic interventions are used to achieve and sustain abstinence through the reduction of withdrawal symptoms. While most cases do not require drug treatment, where necessary, pharmacological interventions should be tailored to the needs of the individual and used in addition to a comprehensive treatment program.
Note: The treatments outlined below have been extrapolated from cocaine management data and therefore it is not known how effective they will be in the management of amphetamine detoxification.
Desipramine is the drug of choice. When used in conjunction with bromocriptine or
amantadine (both dopamine agonists), reduced craving and dysphoria are reported during
cocaine withdrawal.
Pharmacological treatment can continue if cravings recur.
Methylphenidate, which has amphetamine-like properties, has been shown to be an effective treatment in individuals with pre-existing adult attention deficit. Likewise, lithium has been an effective treatment among individuals with bipolar or cyclothymic disorders.
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