detoxification
DESCRIPTION
Detoxification. Dr Gholam Reza Kheirabadi Assistant Professor of Psychiatry Behavioral Sciences Resaerch Center Isfahan University of Medical Sciences [email protected]. Detoxification ( Medically supervised withdrawal). - opioid Agents for treating opioid withdrawal. - PowerPoint PPT PresentationTRANSCRIPT
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DetoxificationDetoxification
Dr Gholam Reza Kheirabadi
Assistant Professor of Psychiatry
Behavioral Sciences Resaerch Center
Isfahan University of Medical [email protected]
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DetoxificationDetoxification( Medically supervised ( Medically supervised
withdrawal) withdrawal)
-opioid Agents for treating opioid withdrawal.-opioid Agents for treating opioid withdrawal.(Methadone, buprenorphine , LAAM & (Methadone, buprenorphine , LAAM & Tramadol)Tramadol)-Non opioid Approach for Detoxification.Non opioid Approach for Detoxification.(clonidine & lofexidine)(clonidine & lofexidine)
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وزن – دولتي شركت يك كارمند سال ميان 76مرديكرده- مراجعه پزشك روان همسرشبه با كيلو
. است . ترياك به مرد اعتياد خانواده مشكل استكه است داروهائي تجويز خواهان ريزان اشك جوان زن
مي . مرد كند اعتياد ترك آنها كمك با بتواند همسرش . تواند مي بخواهد هروقت ندارد چنداني مشكل گويد
. ريز و انكار مكانيسم از افراط حد به نكند مصرف ماده. كند مي استفاده مشكل نمائي
چيست؟ شما توصيه
- معتاد كه زماني به درمان شروع كردن موكول الف. پيداكند كافي انگيزه
انگيزشي – مصاحبه انجام بخانواده – به كمك باهدف زدائي مسموميت شروع ج
انها اگر كه واقعيت واين - نگردند بر هرگز است ممكن بروند
كند – اعتماد شوهرش به گوئيم مي بيمار همسر به داعتياد حد در ومشكل
. نيست
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است؟ پذير درمان واقعا اعتياد آيااست؟ آسان و سريع درمان اين آيا
در اعتياد آسان ساعت 48درمانبيزاري؟؟ ايجاد با درد بدون
= ؟؟ درمان زدائي مسموميتدرمان؟؟ = پرهيز
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: مراحل مواد وابستگي درمانپرهيز- – 1 آغاز انگيزه ايجادزدائي- 2 مسموميتو- 3 پرهيز ا ادامه درمان آغازدر : صلي شركت درماني روان شروع
( گمنام ( معتادين خودياري هاي گروهتغيراتشخصيتي – زندگي سبك تغيير
زندگي– ونگرشبه عادات تغيير
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اول كردن : اصل انفرادي مواد وابستگي درمان در
دوم .اصل نكنيد : استفاده آور اعتياد مواد ازها ديازپين وبنزو افيوني مواد از استفاده اين بر بنا
قاعده ونه است استثنا بيمار؟ كدام روشبراي كدام
روشسنگاپور- 1روشها
تيلن- + 2 تريپ آمي كلونيدينمواد- 3 هاي آگونيست ديگر و متادونافيوني
Individualization
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Outpatient Treatment ProgramOutpatient Treatment Program
• Initial stabilization up to cessation of illicit opioids( initial period of abstinence).
• Gradual dose reduction(3%/week is
Superior to 10%/week reduction).• Timetable is superior to free reduction.• More gradual reduction= more successfulness )
• More supervision after 20-30mg/day of methadon
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Inpatient Treatment ProgramInpatient Treatment Program
• Initial stabilization fore 24-48 hours( up to 60 mg).
• 10-20% reduction of methadone/day(or 5mg/day)
• Close supervision & supportive resources
• Termination with in 7-10 days
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MEHTADONEMEHTADONE
• Stabilization on Methadone:-Initial dose:A:10-20mg→ if withdrawal persist → Repeat the
dose( 2 hours later ) [ no more than 40mg during first day].
B: Calculation of equivalent withdrawal suppressing dose of methadone?
(Methadone is 3time potent than morphine).C: Add 10mg/2-3day or week( different for
outpatient V.S inpatient detoxification?) up to final stabilization(more gradual and upper final
dose in outpatient setting).
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Buprenorphine:Buprenorphine:
• Introduction:• developed in 1970• Agonist-antagonist( or partial agonist)?
analgesic.• Low dependency• Substitution of heroin and morphine with lower
withdrawal symptoms• Significant drug of abuse (IV injection form)• Favorable for detoxification and maintenance
therapy
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Pharmacology and Pharmacology and pharmacokinetics pharmacokinetics
• HL: 48-72 hours.• Partial µ agonist (pure agonist in lower doses)• Weak Ќ antagonist (agonist-antagonist in higher doses)• Safe and little chance of lethal doses• Ceiling effect and safety:=8-12 mg →maximum clinical effect=↑8-12mg(16-32mg) →:-no increase of clinical effect and side effect-increase duration of clinical effect (suitable for
maintenance therapy)
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Drug formsDrug forms
• Solution: buprenorphine + alcohol• Tablet:(0.2,0.4, 2 & 8mg) buprenorphine only
(subutex)• Tablet:(2 & 8mg) buprenorphine + naloxone
(4/1) (subuxone)…superiority?• Injection form?• 4 mg of sublingual tablet=40 mg methadone• 8 mg of sublingual tablet=50-60 mg methadone
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Protocol: outpatient Setting Protocol: outpatient Setting ProtocolProtocol
• Initial dose:2-8 mg( first dose withdrawal)
• Stabilization of patient next days(2-4mg/day up to 8-32mg)
• Stabilization for 24-48 hours( or more)
• Decreasing 2mg of drug/ days- week.
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Protocol: Inpatient Setting Protocol: Inpatient Setting
8mg of Buprenorphine on the first 8mg of Buprenorphine on the first day and 2mg/day reduction on the day and 2mg/day reduction on the
next days. next days.
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TramadolTramadol
• Mechanism: serotonin & nor-epinphrin reuptake inhibitor(Parent compound) + µ agonist(metabolize compound-desmethyltramadol).
• Withdrawal control with200-400mg for modest and 600 mg for sever withdrawal)
• Seizure in high doses CNS suppressant Using with B.Z & seretonergic syndrome with SSRI.
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αα2 Agonists2 Agonists
2
- Clonidine
-Lofexidine (Less Hypotensive)
2
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Mechanism & SideffectsMechanism & Sideffects
• It has specificity towards the presynaptic alpha-2 receptors in the vasomotor center in the brainstem. This binding decreases presynaptic calcium levels, and inhibits the release of norepinephrine (NE). The net effect is a decrease in sympathetic tone
• This drug may cause drowsiness, lightheadedness, dry mouth, dizziness, or constipation. Clonidine may also cause hypotension. It can also cause inhibition of orgasm in women
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ClonidineClonidine
• Patient stabilized on low dose of opioids (30 – 40 Methadone/ day).
• starting dose 0/1 – 0/3.
*Maximum dose (1/mg/day) In outpatient & 1.5-2.0mg/day In hospitalized patients.
*Adjusting Dose based On Hypotension & sedation.
Contraindication: acute or chronic cardiac disease, Renal & metabolic disease, Hypotension).
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Clonidine Clonidine • More effective in: =stabilization on Methadone. =good Relationship with therapist.• Effective in suppressing of : Sweating, cramps,
nusea, vomiting and diarrhea• Ineffective In suppressing of (Muscle aches –
Lethargy – Insomnia – restlessness and Craving).• Non – effective on relapse after complete
detoxification.• Facilitation of detoxification of Methadone
Maintained patients & subsequent stabilization on naltrexone.
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• Escitalopram is associated with reductions in pain severity and pain interference in opioid dependent patients with depressive symptoms
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Rapid & Ultrarapid detoxification Rapid & Ultrarapid detoxification
• Naloxone + clonidine
• Naloxone + clonidine + sedatives
• Naltrexon + clonidine and/ or sedatives
• Full Anesthesia For 3-4 hours.
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other techniquesother techniques
* Symptomatic treatments (Healthy & Motivated).
• Abrupt withdrawal withought Intervention.
* Abrupt withdrawal with Emotional support
• Acupuncture
• Herbal Medication
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Opioid Dependence Treatment in Opioid Dependence Treatment in Special PopulationsSpecial Populations
• Criminal Justice Patients
• Pregnant Women
• Health professionals • Psychiatric Patients
• HIV-positives & hepatitis-c positives
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Opioid Dependence Treatment in Opioid Dependence Treatment in Special PopulationsSpecial Populations
=Criminal Justice Patients
*Opium use and criminal activity:
-This relation is complex and reciprocal.
-There is no direct relation between opioid use and criminal behavior( except in withdrawal periods for ……... ) .
*Opium dependents in justice system:
-Direct coercion to treatment
-Incarceration and opium dependence
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Opioid Dependence Treatment in Opioid Dependence Treatment in Special PopulationsSpecial Populations
=Pregnant Women:• Poor prenatal care• Low birth weight • Elevated risk of morbidity & mortality• No teratogenicity reported • Cautious detoxification( before 14 & after 32 weeks)• Methadone in pregnancy( dose adjustment).• Buprenorphine in pregnancy.
• Health professionals:
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Opioid Dependence Treatment in Opioid Dependence Treatment in Psychiatric PatientsPsychiatric Patients
=Mood Disorders: -Mood disorders as most prevalent disorders among opium
dependence. -Routine Vs selected antidepressant administration. -Opium treatment program and control of depressive symptoms.
= Bipolar Disorder and opium dependence: -Management principles………………….. - Drug interactions( carbamazepine & methadone). -MMT & Bipolar Disorder.
=Anxiety Disorders: comorbidity and principles of drug treatments.
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Opioid Dependence Treatment in Opioid Dependence Treatment in Psychiatric PatientsPsychiatric Patients
=Psychotic Disorders:-comorbidity of psychotic disorders and opium dependence- Antimanic & antipsychotic effects of opioids (Methadone)
=Alcohol Abuse:-Comorbidity of Opioid and alcohol abuse( up to 50%)-Balance of Alcohol & Opioid use-Disulfiram & Methadone-naltreoxone with dual benefits.=Nicotine dependence in opium users
=Polysubstance abuse:-more psycopathology than single users and poor outcme-more suitable for maintenance program-more suitable for TC or NA groups
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Hiv positvesHiv positves
• Only 33% of study participants received concurrent treatment for MI and SA,
• CONCLUSION: Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.
• The available evidence strongly suggests the need for the large-scale implementation of comprehensive treatment and care strategies for IDUs that include both treatment of drug dependence and HAART.
• highly active antiretroviral treatment (HAART).• injecting drug users (IDUs)• Improving treatment adherence in drug abusers who are
HIV-positive.