Addiction Medicine (ADM) Steven C. Boles, D.O., FASAM Steven C. Boles, D.O., FASAM Board Certified -...

Addiction Medicine (ADM)

Steven C. Boles, D.O., FASAM Board Certified - FP ASAM Certified – ADM Board = American Osteopathic Board of Family Physicians ASAM = American Society of Addiction Medicine Adjunct Clinical Faculty - Midwestern

University Arizona College of Osteopathic Medicine

Case #1: “Don’t drink before surgery….” 45 y/o M, post-op ORIF femur fx Becomes agitated, slightly febrile Remains tachycardic, on POD#2 His last drink was 3 DAYS AGO He was given 4mg lorazepam initially in

the ER, and some BZD’s during surgery 12 hrs later

He is given 80mgs Valium PO that day But still pulls out his IV, wants to walk,

and Hears noises that aren’t there, per the

RN.

Case #1: “Don’t drink before surgery….” The pt at this point has not had his risk for alcohol

withdrawal syndrome (AWS) recognized

except possibly by the ER. But that concern, Dx, and Rx has not been followed-up on during all the attention given his surgical problem.

Case #1: “Don’t drink before surgery….” The pt at this point has had partial Rx for AWS, blunting its development, but NOT preventing the progression into the

emergence of early delirium tremens.

Case #1: “Don’t drink before surgery….” He hears noises that aren’t there,

per RN. He is given IV Haldol 5mgs q 4hrs x

2 And calms down. He receives Ativan & Haldol Over the next 48 hrs, in decreasing

taper Goes home POD #5

Case #1: “….., but if you do, always tell your doctor” REMEMBER : Always give BZD’s BEFORE HALDOL To avoid SZ’s And if Haldol is given IV, Extrapyramidal side effects (EPS’s) Rarely, if ever, occur. And what is the top dose of IV Haldol

(haloperidol) that may be given to a human being???????

Case #1: Alcohol Withdrawal Syndrome (AWS) & Thiamine Give thiamine 100mgs PO/IM/IV BEFORE ANY GLUCOSE IV To prevent precipitating : - Wernicke’s encephalopathy - Korsakoff’s confabulatory

amnestic psychosis

Case #1: AWS & Thiamine Give ALL pts at least 100 mg/day

PO. However, If alcoholic encephalopathy is

present : - give 200 mg TID, either PO or IV - for 4 WEEKS And how would one quickly test for

this type of encephalopathy?

CLINICALLY:Alcoholic Frontoparietal Hippocampal Encephalopathy

Detection : simply add a small test to

the neuro exam Give them a pen and paper, and

ask them to, “Draw me a clock that says 10 after 11, please.”

Takes 2 minutes or less You may be VERY surprised at the

response from someone so talkative

Case #1: AWS & Thiamine

IF EITHER: Wernicke’s encephalopathy, or Korsakoff’s amnestic psychosis are present: give 1000mg/day of thiamine x 4

wks (that’s not a misprint)

Case #2: “Lying to your doctor can be fatal”

39 y/o F, (+)chronic pain, Rx’d MTD (methadone) 40 mg/day, X

6 yrs, presents for detox from BZD’s &

cocaine (family angry w/her) Wants to stay on her methadone

(MTD) States, “I was in jail for 3 days, and all they gave me was Risperdal, and now I’m starting to have WD”.

Case #2: “Lying to your doctor can be fatal” So, pt started on detox for cocaine/BZD And, she is given her usual 40 mg MTD/day on day #1 of detox (20

mg BID) On day #2, pt mildly sedated, 3 hrs post 20mg AM MTD dose. Total MTD = 60mg thus far Prior to PM dose, pt is barely arousable

(intoxicated), RR=6/min Passed out, lying sideways, across her

bed.


What is the dose of methadone that can fatal, if given to an opioid naïve pt? According to Goodman & Gilman’s “The Pharmacological Basis of

Therapeutics”, (the King James’ version of

pharmacology) it’s only 60mg.

Case #2: “Lying to your doctor can be fatal” Brother verifies she was in jail for 6

wks. Given 12.5 mg naltrexone PO, not naloxone (active by IV route). Pt simply wakes up, has some

coffee, writes a letter (RR=22) and stays up

all night. Additional 62.5 mg naltrexone given

over next 3 days (MTD obviously DC’d).


Acutely precipitation of opioid withdrawal

DID NOT OCCUR, after an opioid antagonist was given in this case,

As it would have, if her initial HX was true.

And, by the way what did her MTD dosing curve look like???

After all, she was only given 3 identical 20mg doses.

TIME hrs/DAY

M

T

D

10

20

30

40

50

60

70

80

90

100

0 12 1 12 2 12 3 12 4 12 5 12 6 12 7

110 3 identical 20mg doses of MTD:- Given 24 hrs apart - To a pt who is NOT NEUROADAPTED (i.e. naïve) to the dose.Assume 100% absorption & average metabolism(i.e. pt is not a rapid nor slow metabolizer, & there are no drug interactions)

TIME hrs/DAY

M

T

D

10

20

30

40

50

60

70

80

90

100

0 12 1 12 2 12 3 12 4 12 5 12 6 12 7

110

INTOXICATED AND ALMOST DEAD FROM VENTILATORY FAILURE

NALTREXONE 12.5mg given

NALTREXONE 25mg given

Acute Alcohol Withdrawal Syndrome (AWS) :

Signs & Symptoms : Tachycardia HT Diaphoresis Insomnia Anxiety N/V

Acute AWS : symptoms & signs Tremor Generalized SZ’s Psychomotor agitation Hallucinosis/delusions (+/-

insight) DT’s

AWS : Hallucinosis

Visual : - lights too bright - animal life: dogs, rodents, bugs in

room

AWS : Hallucinosis

Auditory : - sounds too loud/startling - start out as unformed sounds clicking buzzing thumping from other room - may progress to formed voices

AWS : Hallucinosis

Auditory : Formed voices - friends/relatives - accusatory in nature In contrast to those of

schizophrenia : - religious - political

AWS : Delusions

“I need to get dressed.” “I need go to work.” “I’ve got bills to pay.” “I gotta get outa here.”

Acute AWS begins when Etoh levels start to fall, if the pt is neuroadapted to ETOH Driven by : Downregulation of inhibitory

systems Upregulation of excitatory

systems Dysregulating LC : NE output Resultant hypernoradrenergic

activity From the brainstem.

AWS : withdrawal seizures (WD SZ’s) Begin: 8 – 24 hrs AFTER LAST DRINK May occur BEFORE a pt’s BAL=0 Peak: 24 hrs after last drink Type: grand mal (generalized) singly, or in bursts over a period of 1 – 6 hrs Dilantin (phenytoin) is not effective

Rx.

AWS : WD SZ’s

Risk of occurrence in pt’s with :

genetic predisposition (+)Hx of prior WD SZ’s

(“kindling”) undergoing concurrent WD from : - BZD’s - BARB’s - nonBARB sedatives (Soma /

GHB)

DT’s

Generally appear 72 – 96 hrs After last drink That’s 3 – 4 DAYS AFTER LAST

DRINK lasting for an ADDITIONAL 2 – 3 DAYS (rare > 50

d) If someone starts into AWS + DT’s, You’re looking at ONE WEEK.

CLASSIC DT’s

(+) all S&S’s of mild AWS, only now

SEVERE : - tachycardia - HT - diaphoresis - tremor - fever

CLASSIC DT’s(cont.d) - global confusion - absorbed in a separate psychic

reality - believes him/her self to be in a location other than hospital - may misidentify staff as personal acquaintances - hallucinations without insight

CLASSIC DT’s(cont.d) - marked psychomotor agitation - efforts to get out of bed LASTING FOR HOURS - absence of clear sleep LASTING FOR DAYS Always monitor & Rx these pt’s IN AN ICU

RISK OF DT’s :

(+) BAL > 300 mg/dl at presentation

(+) AWS seizure (SZ) at presentation

AWS Rx :

KEY : EARLY RX with BZD’s To PREVENT potentially FATAL DT’s To shorten Rx time Increase pt safety & comfort Prevent intercurrent medical

complications

BZD of choice :

Use : DIAZEPAM (Valium), PO/IV NEVER : IM - variable absorbtion with - slow/undependable onset - delayed respiratory depression If IM BZD needed : LORAZEPAM

(Ativan) (Lorazepam may also be given IV)

Exception to Valium Rx : Two groups of pts : #1 = Elderly #2 = Significant liver disease - (GGT > 600) - underlying active viral hepatits

(HCV) - hepatic cirrhosis

Exception to Valium Rx : BOTH groups of pts have reduced BZD elimination, but CYP oxidative pathways are reduced FAR MORE, than the glucuronide conjugation

pathways.

Exception to Valium Rx : In these pts, use Lorazepam (Ativan) Oxazepam (Serax) Because both drugs are ALREADY 3-OH BZD’s and therefore

Exception to Valium Rx : only require glucuronidation for elimination; and this avoids ACCUMULATION of toxic/sedating prodrug, or intermediate active metabolites, resulting from 2-keto BZD

metabolism (Valium/Librium are 2-keto BZD’s)

2-KETO BZD’s N-DESALKYLATEDCOMPOUNDS 3-OH BZD’s

CHLORDIAZEPOXIDE(LIBRIUM) (Intermediate)

DIAZEPAM(VALIUM) (Long)

TRIAZOLO BZD’s

TRIAZOLAM(HALCION) (Short)

ALPRAZOLAM(XANAX) (Short)

7-NITRO BZD’s

CLONAZEPAM(KLONOPIN) (Long)

DEMOXEPAM(Long)

NORDIAZEPAM(Long)

TEMAZEPAM(RESTORIL) (Int)

OXAZEPAM(SERAX) (Int)

LORAZEPAM(ATIVAN) (Int)

ALPHA –OH’svia oxidation

(Short)

Nitroreduction & acetylation (NO ACTIVE METABOLITE)

GLUCURONIDATION

REMEMBER :

All BZD’s reduce AWS symptoms, but

Diazepam, lorazepam, and clonazepam

Are better ANTICONVULSANTS (because they have larger

volumes of distribution, and are more lipophilic)

than either chlordiazepoxide (Librium), or oxazepam (Serax)

REMEMBER :

ALWAYS give Valium/Ativan BEFORE the Haldol, to eliminate/reduce risk of SZ’s from

haloperidol

AWS Rx : Structured BZDDosing on med/surg floor DIAZEPAM : - 20mg PO q 6 hrs x 4 doses, then - 10mg PO q 6 hrs x 4 doses, then - 5mg PO q 6 hrs x 4 doses, then

DC Closely monitor pt Give additional doses, or hold

doses, prn

AWS Rx : Structured BZDDosing on med/surg floor LORAZEPAM : - 2mg PO or IV q 6 hrs x 4 doses,

then - 1mg PO or IV q 6 hrs x 4 doses,

then - 0.5mg PO or IV q 6 hrs x 4 doses,

then DC Same precautions

AWS Rx : Symptom- Triggered BZD Protocol on a Chemical Dependency

(CD) Unit VALIUM : 5-20 mg PO q 1-2 hrs, prn CIWA-r

scale Usually results in : - 140mg Day #1 - 70mg Day #2 - 30mg Day #3 None, or 5mg last day

AWS Rx : Symptom- Triggered BZD Protocol on a Chemical Dependency

(CD) Unit

AWS Rx : Symptom- Triggered BZD Protocol If agitation : - Ativan 2-4mg PO/IM q 6 hrs If psychotic symptoms : - Ativan 2-4mg PO/IM q 6 hrs, then - Haldol 2-5mg PO/IM q 6 hrs with - Benadryl 50mg PO/IM q 6 hrs If more than 1 dose Haldol given, then

begin - Cogentin 1mg PO q 12 hrs

AWS Rx : DT’s ** Ativan 1mg IV + Haldol 2mg IV,

then Ativan 2mg IV + Haldol 3mg IV,

then Ativan 3mg IV + Haldol 5mg IV Q 20 MIN, going up scale, IF NO RESPONSE to prior dose. May repeat scale q 2-3 hrs, prn Pt must be monitored in ICU

AWS Rx : DT’s

If not controlled with above, then Paralyze Completely sedate Intubate & ventilate Provide supportive ICU care Hope pt does not die

Etoh Pharmacology :Elimination

Elimination Rate = 20 mg/dl, per hr,

in the serum, based on the BAL lab test.

The absolute amount of alcohol eliminated

from the body is 10 grams per hour, or about the amount of alcohol in a

“standard drink”

Etoh Pharmacology :Elimination

(BAL) + (20)(hrs since last drink) = Calculated BAL @ time of the last

drink Used to predict the SEVERITY of : - impending AWS - risk of DT’s, or SZ’s during AWS.

Is the Breathalyzer in agreement with BAL ? Breathalyzer result of 0.100 means: = 0.100 grams Etoh / 210 L of

expired deep lung air = (0.476 mg / L) = (0.05% of the

BAL) BAL = 950 mg / L BAL = 95 mg / dl BAL ~ 100 mg/dl, i.e., legally drunk

Case #3: What’s the Dx? In the mid 1980’s, The supertanker, “Exxon Valdez” ran aground in Alaska. Captain Hazelwood’s BAL was reported to be = 61 mg/dl (Breathalyzer = 0.061)

Case #3: What’s the Dx? But it was drawn 11 hrs AFTER the grounding. Retrograde extrapolation, determined his BAL = 226mg/dl, (Breathalyzer = 0.226) at the time of the accident, by Dr. David Smith, during his trial testimony.

Case #3: What’s the Dx?

I would have calculated it as : (11 hrs) x (20 mg/dl per hr) + ( 61

mg/dl ) = 281 mg/dl BAL, ( Breathalyzer = 0.281 ), AT THE TIME OF THE OF THE

ACCIDENT, At the time of his last drink. But they didn’t call me.

Case #3: What’s the Dx? Either way, he was really drunk. But the ever vigilant Coast Guard Never detected any signs of

insobriety Other than the smell of alcohol.

Case #3: What’s the Dx? ANYONE who can operate a supertanker, with a BAL = 281 mg/dl, and not APPEAR DRUNK

Case #3: What’s the Dx? to the cop who arrested him, is neuroadapted to Etoh; and, therefore his Dx is ALCOHOLISM. And he is also at a very high risk for alcohol withdrawal seizures & subsequent DT’s.

HALFTIME BREAK

2 4 6 8 10 12 14 16 18 20 22 24 26 28 2 4 6 8 10 12 DAYS MONTHS

DURATION OF SEDATIVE – HYPNOTIC / BZD WDS

WITHDRAWAL INTENSITY

ACUTE WDS HIGH DOSE, ANYLOW DOSESHORT ACTING

LOW DOSE LONG ACTING

PROLONGED POST ACUTE WDS (PAWS)

Case #4: Subpoenaedto provide testimony 47 y/o M crashes into parked cars

in his neighborhood one afternoon An 8-page report is generated by

the arresting officer & DRE on the scene

DRE = Drug Recognition Expert The report details the driver’s (your

pt’s) condition at the time :

Case #4: Subpoenaedto provide testimony - dilated pupils, bloodshot eyes - persistently elevated BP & pulse - diaphoresis - shaking, twitching, tremor - rapid speech, - at times not making sense - high anxiety level

Case #4: Subpoenaedto provide testimony He is arrested for driving

impaired, Under the influence OF A

STIMULANT subsequent UDS/serum drug

screen: - acetylsalicylic acid - cotinine - caffeine - nordiazepam

Case #4: Subpoenaedto provide testimony You prescribed Librium (chlordiazepoxide) 2 months previously, to help him stop drinking after he was

released from jail for a DUI. His defense attorney would like

you to explain ANY of this at trial, if you can.

Case #4: At trial, on the witness stand You look at the forensic lab tech, and

note her fine & accurate work. You tell the judge & jury that the

drugs represent : Cigarettes (cotinine metabolite); Aspirin (acetylsalicylic acid); Coffee (caffeine); and Librium (nordiazepam metabolite).

Case #4: On the stand

You explain to them that nordiazepam is psychoactive by-product of Librium

and that both are sedatives/tranquilizers.

You look at the DRE, and commend him on his very accurate & detailed 8 page report (with small, neat, block-printing).

He proudly returns your gaze.


You also agree, in your expert opinion, that the pt was indeed

under the influence of a stimulant, at the time of the accident.

But, that the stimulant was the natural norepinephrine IN HIS BRAIN,

and not any illicit substance, since none was detected upon forensic testing.


You look at the at everyone in the courtroom, and explain the

ONLY POSSIBLE EXPLANATION FOR THESE FACTS

are that the alcoholic defendant was in early DT’s from AWS, and even though this is very

dangerous, it is not against the law.


You look back to the DRE, and he looks down at all his hard work, and almost starts to cry. You also explain that the pt was

clearly not under the influence of a tranquilizer, and in fact, if he had

taken MORE Librium, he wouldn’t have had the accident in the first place.


You further comment that the T1/2 of

Librium = 100 hrs (4 days) Nordiazepam = 200 hrs (8 days) especially in someone with early

cirrhosis. And that it takes ~ 10-12 T1/2’s to clear any drug from the body, explaining the (+) UDS, 60 days

later.


Also note: There was NO PARENT COMPOUND

found on the UDS There was no chlordiazepoxide Only its metabolite, nordiazepam Indicating this WAS NOT an acute

intoxication reaction from the Librium




TRIAZOLO BZD’s



7-NITRO BZD’s


DEMOXEPAM(Long)

NORDIAZEPAM(Long)





(Short)


GLUCURONIDATION

2 4 6 8 10 12 14 16 18 20 22 24 26 28 2 4 6 8 10 12 DAYS MONTHS

DURATION OF SEDATIVE – HYPNOTIC / BZD WDS

WITHDRAWAL INTENSITY

ACUTE WDS HIGH DOSE, ANYLOW DOSESHORT ACTING

LOW DOSE LONG ACTING

PROLONGED POST ACUTE WDS (PAWS)

Mild-Moderate BZD WDS : Adrenergic / Autonomic Anxiety Restlessness / agitation N/V, yawning Insomnia HT Tachycardia Mydriasis (dilated pupils)

Severe BZD WDS : Adrenergic /Autonomic Autonomic hyperactivity Unstable vital signs Hyperpyrexia (fever)

BZD WDS : Musculoskeletal Tremor Weakness Fasciculations Spasms Cramps Hyperreflexia

BZD WDS : Mild-Moderate Neuropsychiatric Sensory Hypersensitivity to - light, sound, touch, smell Light headedness / dizziness Depression Depersonalization Confusion Difficulty expressing thoughts

BZD WDS : Severe Neuropsychiatric S&S’s Psychosis Delusions Hallucinations Mania Catatonia Delirium SZ’s

BZD WDS : Sort of sounds like AWS, doesn’t it? Both Etoh & BZD’s Are GABA-receptor agonists Whose WDS’s are really unopposed Down-regulated GABA withdrawal

syndrome (WDS)

Sedative-Hypnotic WDS :

Will occur after prolonged, high-dose exposure, & neuroadaptation, to any of the following:

Non-BARB / Non-BZD meds : e.g. - Chloral hydrate (Noctec) - Meprobamate (Equanil, Miltown) - Carisopradol (Soma) Or any similarly dosed BARBITURATE

Sedative-Hypnotic WDS : Severe Neuropsychiatric S&S’s Delirium Psychosis Hallucinations Hyperthermia Cardiac arrest & death


Is essentially IDENTICAL to AWS (Alcohol Withdrawal Syndrome) Because BOTH Etoh & BARB’s pharmacologically

are GABA receptor agonists & NMDA-Glutamate receptor

antagonists


Is essentially IDENTICAL to AWS Because after neuroadaptation, Both syndromes represent the newly

unopposed pathologic effect of Down-regulated GABA receptors Combined with Up-regulated NMDA-Glu receptors

BZD WDS will exacerbate these comorbid conditions : CAD / cardiac dysrhythmias / CV

disease Asthma SLE Inflammatory bowel disease Severe NIDDM/IDDM Severe arthritis Severe thyroid disease

BZD & Sedative-Hypnotic WDS Rx : INPT use ONLY

Phenobarb substitution method : - compute PB equivalent dose/day - note: this is NOT same as

therapeutic dose equivalency, - but it will prevent severe WDS

BZD & Sedative-Hypnotic WDS Rx : - DRUG : PHENOBARBITAL

EQUIVALENT - Xanax 1mg : PB 30mg - Klonopin 2mg : PB 30mg - Valium 10mg : PB 30mg - Fiorinal 2 tabs : PB 30mg - Soma 2 tabs : PB 30mg - Ativan 2mg : PB 30mg

BZD & Sedative-Hypnotic WDS Rx : The MAXIMUM STARTING DOSE of PB Is 500mg/day The computed PB equivalent Is given in divided doses TID / QID And reduced by about 30mg per

day, With dose titration up, or down, PRN

BZD & Sedative-Hypnotic WDS Rx : A pt taking Xanax 6mg/day, plus Soma 8/day, plus 6 pack of beer/day Gets : 6 + 4 + 3 = 13 PBE’s = 13 x 30mg PB = 390mg PB day #1

BZD & Sedative-Hypnotic WDS Rx : Phenobarb 120mg x 1, then 90mg q 6hr x 3 doses, then 75mg q 6hr x 4 doses, then 60mg q 6hr x 4 doses, then 60mg q 8hr x 3 doses, then 45mg q 8hr x 3 doses, then 30mg q 8hr x 3 doses, then 15mg q 12hr x 2 doses, then DC

1st 24 hrs=390mg

BZD & Sedative-Hypnotic WDS Rx : Observe pt for any of the 3 signs

of toxicity before each dose of PB :

- nystagmus - ataxia - dysarthria If any 1 present, skip 1 dose If any 2 present, skip 2 doses

Case #5: Consult in ICU“The confused pt” They want to know if there are

any drug WDS that produce obtundation, or

coma, on the 3rd-4th day after doing well the first 2 days? 42 y/o M, came in agitated,

paranoid, hallucinating. (+) known “heavy drinker/IVDU” UDS = (+) AMPHET only

Case #5: Consult in ICU“The confused pt” BAL = 0 (+) elevated vital signs (+) ALT= 112, AST= 84, GGT=213 Alb=3.4, Bili=2.1 (other labs WNL) “We followed the CD protocol, to

prevent suspected AWS & DT’s. Now it’s the 4th day he’s been in ICU;

his vitals are OK, but we can’t wake him up.”

Case #5: Consult in ICU“The confused pt” “Really. “Exactly what did you give him?” “He had 4mg Ativan & 3mg Haldol in

ER. We gave him, let’s see, a total of

70mg Valium over the first 36 hrs.” “I see. Well, it does look like you

followed the protocol, ……sort of. You just forgot one very important

thing.”

Case #5: Consult in ICU“The confused staff” There are no WDS’s that progress to

coma/obtundation (severe BZD WDS may include

catatonia, but not coma) Pt had: Stimulant Intoxication

Psychosis, evidenced by UDS (+) for

AMPHETAMINE WHEN HAVING PSYCHOTIC

SYMPTOMS . Additionally,

Case #5: the ICU pt &“The confused staff” He ALSO was at risk for, or

simultaneously in, DT’s. (a very bad combination). He had hepatic insufficiency, per

labs, with ALD (alcoholic liver disease), superimposed on chronic active HCV hepatitis. (another VERY bad combination).

Case #5: the ICU pt(the problem with the case) Suspected by ALT > AST (confirmed

later by additional Hx, & (+) HCV Ab)

The problem was not recognizing the severity of his liver disease / oxidative deficiency,

compounded by giving him a 2-keto BZD (Valium),

instead of a 3-OH BZD (Ativan / Serax).

Case #5: the ICU pt(the problem with the case)

Leading to accumulation of : - unmetabolized diazepam, and it’s

active metabolite, - desmethyldiazepam (nordiazepam). Both of which have T1/2’s of about 100

hrs (4 days), and both are psychoactive CNS

depressants. I told them to DC the Valium, and he’d wake up in 2 weeks.




TRIAZOLO BZD’s



7-NITRO BZD’s


DEMOXEPAM(Long)

NORDIAZEPAM(Long)





(Short)


GLUCURONIDATION

Cocaine :

Pharmacokinetics : T1/2 cocaine = 40-60 min Metabolized by - plasma cholinesterase to - benzoylecgonine, found in urine - up to 48 hrs, on UDS

Cocaine Intoxication :

Psychiatric effects : (+) mimics naturally occurring

mania Cocaine induced paranoia is usually

distinguished by drug content on UDS

May precipitate, or exacerbate - major psychiatric Dx’s

Cocaine Intoxication : Medical aspects Cardioventricular tachydysrythmias Acute MI / Aortic dissection Vasospasm, thrombosis, ischemia,

necrosis (any organ, e.g. retinal artery)

Asthma / pulmonary dysfunction with melanoptysis (“crack lung”)

Pneumomediastinum / pneumothorax

Intrauterine / placenta abruptio

Cocaine Intoxication :

Psychiatric effects : (+) mimics naturally occurring

mania Cocaine induced paranoia is usually

distinguished by drug content on UDS

May precipitate, or exacerbate Almost any major psychiatric

Diagnosis

Amphetamine & Methamphetamine (MA) :Intoxication Repeated administration may

cause : - paranoid psychosis - stereotypical behaviors with

repeated touching / picking / bruxism during the intoxication phase, but not the withdrawal phase.

Amphetamines / MA Intoxication : Medical effects : - HT, tachydysrythmias - hyperthermia - SZ’s - malnutrition - cerebral vasculitis - orofacial dyskinesias (remember the “binky” with

MDMA)

Psychomotor StimulantIntoxication : (+) Aminergic

Restlessness, irritability, tremor Talkativeness Anxiety Labile mood (esp. violence with MA) HA Chills, vomiting, diaphoresis Delirium

Psychomotor StimulantIntoxication : Psychiatric - Hypervigilance - Panic reactions - Compulsive stereotypical

behavior - Paranoia All of which is often referred to as, “Tweaking”

Psychomotor StimulantIntoxication : Rx (+) Agitation / anxiety : - Ativan 1-2 mg IV/IM/PO q 30-60

min - Valium 10-30 mg PO q 30-60

min

Psychomotor Stimulant Intoxication Psychosis Rx :

Ativan 1mg IV + Haldol 2mg IV, then

Ativan 2mg IV + Haldol 3mg IV, then

Ativan 3mg IV + Haldol 5mg IV Q 20 MIN, going up scale, if no response to prior dose. May repeat scale q 2-3 hrs, prn Pt must be monitored in ICU (Just like treating DT’s, isn’t it?)

Cocaine, MA, or other stimulant WDS : (+) “craving” (+) depressed mood (+) anhedonia (+) pleasure deficiency syndrome (+) fatigue (+) hypersomnolence

Cocaine, MA, or other stimulant WDS (cont.d) : THERE IS NO SPECIFIC DRUG Rx

REQUIRED, BUT IF PSYCHOTIC SYMPTOMS

PERSIST BEYOND 4 DAYS, THEN ANTIDEPRESANTS OR

ANTIPSYCHOTICS MAY BE INDICATED

OWS “The flu” : Serotonergic/ Adrenergic signs & symptoms

Myalgias & arthralgias Dysphoria / Depressed mood ANXIETY Perspiration / diaphoresis Fever Exacerbation of ANY comorbid

painful medical or orthopedic condition

OWS “The flu” : Cholinergic signs & symptoms Lacrimation Rhinorrhea Yawning N/V Diarrhea / intestinal CRAMPS

OWS “The flu” : Dopaminergic signs & symptoms

Anhedonia Opioid craving Opioid seeking behavior

Case #6: “The DEA”(Don’t Ever Attempt)

27 y/o F, (+)ODS, presents to the office,

Desiring detox from smoking heroin. Percocet & Ativan are prescribed for

detox, and she is told to continue attending

AA. Anything wrong with this treatment? 2 weeks later, she presents for inpt

detox What went wrong?

Case #6:ADM point of view: Never give prn mood altering meds

to an addict, and expect him/her to control them. After all, their disease is

characterized by LOSS OF CONTROL OVER USE. The treatment can, therefore, be reasonably expected to fail.

Case #6: Administering or Dispensing Narcotic Drugs 21 CFR (1306.07) : To AMINISTER, or DISPENSE (BUT NOT PRESCRIBE), narcotic drugs to a narcotic dependent

person for “detoxification treatment”, or “maintenance treatment”, a physician

MUST HAVE A SEPARATE REGISTRATION with the attorney general. [Sec. 303 (g) of the Act (21 U.S.C. 823

(g)]

Case #6:DEA point of view: Traditionally, treating addiction to

opiates with opioids (methadone) without a separate DEA registration as a Narcotic Treatment Program, (that means being a methadone

clinic)

Case #6:DEA point of view:

Or without having a waiver from SAMHSA to prescribe buprenorphine

(Suboxone or Subutex) is not included in the CSA, and therefore, such activity is OUTSIDE THE SCOPE OF MEDICAL PRACTICE, AND THEREFORE, IS ILLEGAL.

Case #7: “What shall I name my new hospital?”

A 29 y/o pt (+)ODS, In methadone (MTD) clinic, presents on a weekend, to ER, claiming her MTD take-home dose is lost, stolen, wasn’t picked up,

etc….. The pt has no other medical

problems. “I’m afraid of having MTD

withdrawal.”

Case #7: “What shall I name my new hospital?”

(+) anxiety, elevated vitals are noted.

The pt was given Ativan & clonidine, and then DC’d to home by POV. Was this a good idea? No. The pt promptly took all of their

meds at one time; and then promptly, “Fell asleep at the wheel”, and rolled their vehicle several times.

Case #7: What else could have been done?

First off, the ER should DOCUMENT THAT THE PT WAS IN OWS, IF ANY FORM OF TREATMENT WAS TO BE OFFERED.

Absent signs & symptoms of OWS, NO Dx could have been made, other

than ODS, and NO Rx would be indicated.

Additionally, in this pt’s case, a UDS should confirm the presence of

MTD, if MTD was taken within 2-3 days.

Case #7: What else could have been done? Note: the UDS employed must be

able to detect MTD, as MTD does NOT GIVE A (+) RESULT

AS AN “OPIATE” ON A SCREENING TEST.

MTD is reported as “MTD”. Remember MTD is structurally

different from MS/codeine (opiates), and other synthetic opioids.

Remember the signs & symptoms of OWS

Case #7: What else could have been done?

ADMINISTER 15mg MTD PO / IM x 1 dose Observe for relief of OWS at 3 hrs post dose, and document findings. Arrange for referral to treatment center. Instruct pt to return the following day To determine if another MTD dose should be

administered (but not prescribed). DO NOT PRESCRIBE OR DISPENSE ANY

OPIODS Under what authority can this be done?

Case #7: Controlled Substances Act Same law: 21 CFR 1306.07 (b) “Nothing in this section of the law shall

prohibit a practitioner who is not specifically registered to conduct a NTP

From ADMINISTERING (BUT NOT PRESCRIBING) narcotic drugs To a narcotic dependant person for the purposes of relieving acute withdrawal symptoms when

necessary

Case #7: 21 CFR 1306.07 (b) (cont’d.) while arrangements are being made for referral for treatment. Not more than one day’s medication may be ADMINISTERED to the person AT ONE TIME. Such emergency treatment may be

carried out for NOT MORE THAN 3 DAYS, and MAY NOT BE RENEWED or extended”.

And in closing,

I’m pleased we could spend this time together today.

Good luck on your Boards. I’m grateful you were so

attentive. Thank you.

Addiction Medicine (ADM) Steven C. Boles, D.O., FASAM Steven C. Boles, D.O., FASAM Board Certified -...

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