Download Basic Principles of Detoxification

Basic Principles of Detoxification
Mark Menestrina, MD, FASAM
Medical Director, SEMCA
National Field Medical Advisor, Reckitt
Benckiser Pharmaceuticals
April 30, 2012
Credit where credit due…
•  Detoxification and Substance Abuse
Treatment Training Manual: Based on a
Treatment Improvement Protocol (TIP#45)
SAMHSA, 2008
•  Priniciples of Addiction Medicine, R Ries et.
al., 4e, Lippincott Williams and Wilkins, 2009
•  Addiction Medicine: An Evidence-Based
Handbook, Rastegar and Fingerhood,
Lippincott Williams and Wilkins, 2005
•  Principles of Addiction Medicine: The
Essentials, C Cavacuiti, Lippincott Williams
and Wilkins, 2011
Integration of Detoxification and
Substance Abuse Treatment
•  Detox patients are in a crisis, providing
a window of opportunity to
acknowledge substance abuse problem
and seek treatment
•  Research shows that detox is often
followed by a reduction in drug use and
a desire to seek treatment
•  Detox staff can facilitate patient’s entry
into treatment
Addiction is a Brain
Chemistry Disease
•  Involves the Meso-Limbic System
(Primitive and not conscious)
•  Neurotransmitter Mediated
•  Denial is a Hallmark Feature
•  Emotional, Physical, Psychological
•  Chronic, Progressive, potentially Fatal
•  Affects Family, Community, Society
•  Different than Abuse, anyone can Abuse
Drugs or Alcohol.…A Preventable
Behavior
6
7
Chemical Dependence
8
Behavioral Dependence
9
Detox DOES NOT equal
Treatment…
But it is often the first step in
the Recovery Process
Withdrawal Syndrome and
Detoxification
•  WITHDRAWAL SYNDROME is the
predictable constellation of signs and
symptoms following abrupt
discontinuation of, or rapid decrease
in, intake of a substance that has been
used consistently for a period of time.
•  DETOXIFICATION is the management
of the Withdrawal Syndrome
“First, do no harm”
Hippocrates
Loeb’s Laws of Medicine
•  1) If what you are doing for the patient
is helping the patient, keep doing it.
•  2) If what you are doing for the patient
is not helping the patient, stop doing it.
•  3) Never ever let your patient see a
surgeon.
Goals of Detoxification
CSAT 1995a
•  Provide a safe withdrawal and enable
the patient to become free of nonprescribed medications
•  Provide a withdrawal that is humane
and protects the patient’s dignity
•  Prepare the patient for ongoing
treatment of his or her dependence
Module 1 Objectives
•  Define detox as distinct from substance
abuse treatment
•  Describe the three essential components of
detox: evaluation, stabilization, and
fostering entry to treatment
•  Distinguish the six different DSM-IV-TR
definition of terms relating to detox and
treatment
•  Identify at least two challenges to providing
effective detox
History of Detoxification
Services
•  AMA declares alcoholism a disease in
1958
•  The Uniform Alcoholism and
Intoxication Treatment Act (1971)
•  Emergence of humanitarian views of
those who are substance use
dependent
•  Emergence of new treatment models
Three Components of
Detoxification Process
•  Evaluation: screening and assessment
•  Stabilization: assisting the patient
through detox and withdrawal
•  Fostering readiness and entry into
treatment
Review of Terms
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Substance
Substance-related disorders
Substance dependence
Substance abuse
Substance intoxication
Substance withdrawal
Fostering and Maintaining
Abstinence
•  Fostering abstinence includes:
- Ongoing assessment of physical,
psychological and social status
- Identification of relapse triggers
- Primary medical and psychological care as
needed
•  Maintaining abstinence includes:
- Continuation of counseling and support
- Refinement and strengthening of strategies
for relapse prevention
7 Key Assumptions and Guiding
Principles for Detox and
Substance Abuse Treatment
1)  Detox is not complete treatment
2)  Detox process includes evaluation,
stabilization and fostering treatment
readiness
3)  Detox takes place in a wide variety of
setting
4)  All treatment must be of the same
quality and thoroughness
7 Key Assumptions and Guiding
Principles for Detox and
Substance Abuse Treatment
5)  Insurance coverage for complete
detox is cost-effective
6)  Detox programs must be culturally
competent in order to address the
unique needs of all patients
7)  Success depends on continuation of
treatment after detox
Linkages to Treatment Services
•  Linkages from detox to treatment leads to an
increase in recovery and a decrease in
repeated detox and treatment services
•  Recovery leads to reductions in crime and
reductions in expensive medical and surgical
treatments
•  Effective linkage to treatment services
remains a signficant challenge to detox
providers
Module 2 Objectives
•  Define the types of settings for detox
and treatment services
•  Describe the role of the settings in the
delivery of services
•  Identify at least five issues to consider
in determining whether inpatient or
outpatient detox is preferred setting
Five Settings for Detoxification
Services
1)  Physician’s office
2)  Freestanding urgent care center or
emergency department
3)  Freestanding substance abuse
treatment or mental health facility
4)  Intensive outpatient and partial
hospitalization programs
5)  Acute care inpatient services
Six ASAM Assessment Criteria
for Patient Placement
1)  Acute intoxication and/or withdrawal
potential
2)  Biomedical conditions and complications
3)  Emotional, behavioral or cogntive
conditions and complications
4)  Readiness to change
5)  Relapse, continued use or continued
problem potential
6)  Recovery/living environment
Setting #1: Physician’s Office
•  Ambulatory Detox Without Extended Onsite
Monitoring
- Trained clinicians
- Medically supervised evaluation, detox and
referrals
- Patients regularly monitored
- Patients must have positive social support
- Services delivered in office, treatment
facility or patient’s home
Setting #1: Physician’s Office
•  Ambulatory Detox With Extended Onsite
Monitoring
- Services provided by RNs or LPNs
- Include medically supervised evaluation,
detox and referrals
- Patients monitored for several hours each
day
- Patients must have positive social support
network
- Services provided in treatment setting such
as a day hospital
Setting #2: Freestanding Urgent
Care Center or Emergency Dept
•  Patients who require primary medical and/or
nursing care services
•  Include physician managed procedures and
protocols
•  Medically directed assessments and acute
care include initiation of detox
•  Not likely to include biomedical stabilization
or 24 hour observation
•  Triage to inpatient can be facilitated
•  Staffing is typically physicians and nurses
Setting #3: Freestanding
Substance Abuse Treatment or
Mental Health Facility…Inpatient
•  Medically managed intensive patient
detoxification
•  24 hour supervision, observation and
support for intoxicated or withdrawing
patients
•  Stabilization and facilitation of linkages to
other services
•  Multidisciplinary staff: physicians, nurses,
counselors, social workers, psychologists
Setting #3: Freestanding
Substance Abuse Treatment or
Mental Health Facility..Residential
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Medically managed or social detox
24 hour supervision and support
Emphasize peer and social support
Staffing: credentialed personnel using
physician-approved protocols for
observation, monitoring and supervision
•  Medical consultation available 24/7
•  Some provide supervision of selfadministered medication
Setting #4: IOP and Partial
Hospitalization Programs
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Regularly scheduled detox sessions
Follows established protocols
Onsite patient monitoring
Linkages to treatment services
Staffing includes interdisciplinary team
of physicians, RNs, LPNs, counselors,
social workers and psychologists
Setting #5: Acute Care Inpatient
Settings
•  Medically monitored inpatient detox
•  24 hour medically supervised eval and
monitoring
•  Follows established protocols
•  Staffing includes interdisciplinary team
of physicians, RNs, LPNs, counselors,
social workers, psychologists
•  Counselors available 8 hours a day for
planned interventions
Module 3 Objectives
•  Identify overarching principles for patient
care during detox
•  Describe strategies for evaluating/addressing
psychosocial/medical issues for detoxing
patients
•  Address issues with special populations
•  Describe strategies for engaging/retaining
detox patients
•  Identify effective referral techniques
promoting initiation of substance abuse
treatment
Biomedical Evaluation Domains
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General health history
Mental status
Physical assessment
Use and patterns of substance abuse
Past treatments for substance abuse
Psychosocial Evaluation Domains
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Demographics
Living conditions
Violence/suicide risk
Transportation availability
Financial situation
Dependent children
Legal status
Physical, sensory or cognitive abilities
Conditions Requiring Immediate
Medical Attention
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Change in mental status
Increase in anxiety or panic
Hallucinations
High body temperature
Increase/decrease in blood pressure
Insomnia
Abdominal pain
Gastrointestinal bleeding
Changes in responsiveness of pupils
Conditions Requiring Immediate
Psychiatric Attention
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Suicide risk
Anger
De-escalating aggressive behaviors
Co-occurring mental disorders
Nutritional Considerations
During Detoxification
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Malnutrition can interfere with detox process
Stress of detox requires additional nutrients
Nutritional evaluation is necessary for detox
New routines for mealtime and diet are
crucial
•  Important to manage gastrointestinal
symptoms during detox
•  Nutritional therapy may be required
Detoxification Considerations for
Adolescents
•  Binge drinking is common and can
cause escalating alcohol levels
•  Some drugs taken are not identifiable,
routinely screen for illicit drugs
•  Nondisclosure of drug use: (multiple
substances with alcohol) establish
rapport and obtain thorough history
•  Screen for suicide potential
Detox Consideration for Parents
with Dependent Children
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•  Barriers to Treatment:
Parents, especially mothers, fear for
the safety of their children
Some children experience distress
while parent is in treatment
Ensure children have a safe place to
stay
Social services may need to be
involved
Detox Considerations for
Domestic Violence Victims
•  Both men and women may be vicitims
•  Increased risk for female drug abusers to be
victims
•  Develop safety plan when violence is
disclosed
•  Avoid communications between abused and
abuser during detox
•  Vicitms may need help with parenting skills
•  Know local childcare resources
Detox Consideration for
Culturally Diverse Patients
•  Patient’s detox expectations may vary
•  Patient’s experience in health care
system may vary
•  Patient’s cannot be defined by their
culture/ethnicity
•  Use open-ended questions to gain
understanding
•  Important to have bilinual staff if
possible to avoid language barriers
Detox Consideration for Chronic
Relapsers
•  Relapser may feel hopeless and
vulnerable
•  Acknowledge progress made before
relapse
•  Reassure that gains from prior
progress have not been lost
•  Reinforce the importance of recovery
Strategies to Engage and Retain
Patients in Detoxification
•  Offer hope
•  Provide atmosphere with comfort, relaxation,
cleanliness and security
•  Educate patients on withdrawal process
•  Utilize support systems
•  Maintain a drug-free enviornment
•  Consider alternative approaches
•  Enhance patient motivation
•  Foster a therapeutic alliance
Enhancing Patient Motivation
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Focus on strengths
Show respect for autonomy
Avoid confrontation
Provide individualized treatment
Avoid using labels
Use empathy
Recognize small steps toward achieving
goals
•  Raise awareness of discrepancies
•  Use reflective listening
Stages of Change
•  Precontemplation: no consideration for
change, unaware of problem
•  Contemplation: some awareness of problem,
willing to consider change but ambivalent
•  Preparation: aware of problem, decision
made to change, goal setting
•  Action: takes steps to achieve goals to
change
•  Maintenance: works to maintain changes
made
Fostering a Therapeutic Alliance
•  Be supportive and empathetic
•  Refer when patient cannot be engaged
•  Establish rapport, discuss confidentiality
issues, be cognizant of challenges for patient
•  Be consistent, trustworthy, reliable, calm and
cool, confident and humble
•  Be able to set limits without power struggle
•  Be cognizant of patient’s progress
•  Encourage patient’s self-expression
Common Barriers to Referral
After Detox
•  Patient’s may believe they are “cured” once
eliminating substance
•  Patient’s may feel they no longer need help
after detox
•  Insurance may only provided partial or
limited coverage
•  Paperwork for insurance may be
overwhelming
•  Patients may struggle with insurance system
Evaluating Rehab Needs
•  Psychosocial needs
•  Special needs may limit access to rehab
•  Limitations or conditions may limit
suitable treatment settings
•  Support system may influence referral
•  Dependent children may impact needs
•  May be need for gender-specific
treatment
Areas for Assessment
•  Medical
•  Motivation
•  Physical, sensory or
mobile limitations
•  Relapse history and
potential
•  Substance abuse/
dependence
•  Developmental or
cognitive issues
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Family/social support
Co-occurring issues
Dependent children
Trauma/violence
Treatment history
Cultural background
Strengths and
resources
•  Language
Treatment Settings
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Inpatient programs
Residential treatment programs
Therapeutic communities
Transitional/halfway houses
PHP and day programs
Intensive outpatient programs
Traditional outpatient services
Recovery maintenance activities
Following Through with
Treatment Referral
•  Patients are more likely to initiate
treatment if they:
- Believe they will be helped
- Are employed
- Motivated beyond precontemplation
- Have family and social support
- Have co-occurring psychiatric
conditions
Strategies to Promote Initiation
of Treatment After Detox
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Assess degree of urgency
Reduce appointment wait times
Call to reschedule missed appointments
Provide information to show expectations
Offer tangible incentives
Engage support of family members
Introduce patient to counselor
Offer referral/services to address other needs
Minimize accesss to treatment barriers
Maintain motivation during waitng list period
Facilitate coordination of co-occurring treatment
Ensure medical appointments are being made
Some patients may require non-traditional treatment
Module 4 Objectives
•  Identify biochemical markers and their use
for screening and assessment
•  Describe key concepts for treatment
regimens for detox from specific substances
•  Explain why management of polydrug abuse
and use of alternative approaches to detox
are important
•  Identify special considerations for special
populations in the detox process
Biochemical Markers
•  Lab tests that detect the presence of alcohol
or other drugs
•  Used to support a diagnosis
•  Used for forensic purposes
•  Used to detect the use of alcohol or other
drugs during treatment
•  Can serve as motivational enhancement
•  Can help in moving patient from
contemplation to action
Most Common Types of
Biochemical Markers
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Blood alcohol levels
Breath alcohol levels
Urine drug screens
Gamma-glutamyltransferase GGT
Carbohydrate-deficient transferrin CDT
Mean corpuscular volume MCV
Ethylglucoronide EtG
Alcohol Intoxication
•  20-100mg%: Mood, behavior changes,
reduced coordination, impaired driving
•  101-200mg%: Reduced coordination,
speech, gait, judgment impaired
•  201-300mg%: Marked impairment of thing,
memory, alertness. Blackouts
•  301-400mg%: Reduction of BP and temp.
Sleepiness, amnesia, N&V
•  401-800mg%: Coma, incontinence, death
Alcohol Withdrawal
•  Restless, irritable,
anxiety, agitation
•  Anorexia, N&V
•  Tremors, increased
HR and BP
•  Insomnia, intense
dreams/nightmares
•  Poor concentration,
impaired memory
and judgment
•  Increased sensitivity
to sound, light,
tactile sensations
•  Hallucinations—
auditory, visual or
tactile
•  Delusions
•  Seizures
•  Hyperthermia
•  Delirium
Alcohol and other Sedatives
•  Alcohol and other Sedatives exert their
effects by directly or indirectly enhancing
GABA (inhibitory)
•  With abstinence there is a relative deficiency
of GABA
•  Alcohol also inhibits the sensitivity of
autonomic adrenergic systems with resulting
upregulation with chronic alcohol intake
•  Discontinuation leads to rebound
overactivity of brain and peripheral
noradrenergic systems
Alcohol/Sedative Withdrawal
Signs and Sx
•  Begin 6-24 hours after alcohol cessation,
variable for other sedatives, depending on
half-life
•  Early s/s include anxiety, sleep disturbances,
vivid dreams, anorexia, nausea and
headache
•  Tachycardia, hypertension, hyperactive
reflexes, diaphoresis, hyperthermia
•  Seizures most often occur within 48 hours
•  Delirium Tremens (DTs) typically begins
48-72 hours after last drink, preceded by
typical signs and symptoms of early
withdrawal
CIWA-Ar
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Nausea and Vomiting
Tremor
Paroxysmal Sweats
Anxiety
Agitation
Tactile Disturbances
Auditory Disturbances
Visual Disturbances
Headache
Orientation/Sensorium
•  Scored from 0-7 (0-4
for Orientation
•  Maximum Score 67
•  <10 generally don’t
require meds, >20
do
•  Between 10-20,
follow closely for
worsening
withdrawal
Pharmacological Management
•  Suppression of Withdrawal through use
of a cross-tolerant medication, usually
with a longer duration of action
•  Reduction of signs and symptoms of
withdrawal through alteration of
another neuropharmacological process
•  May use one or the other or both
Benzodiazepines for Detox
•  Safer Therapeutic
Index
•  Anxiolytic
•  Better with hepatic
dysfunction
(lorazepam and
oxazepam)
•  Euphorogenic
•  Abuse Potential and
Cross Addiction
•  Many Alcoholics are
also using/
dependant on
Benzos
Phenobarbital for Detox
•  Not very
euphorogenic
•  Long half-life
•  Lower abuse
potential
•  Therapeutic Index
not as favorable as
benzos
•  Not as anxiolytic
•  Caution with
hepatic disease,
porphyria
Benzodiazepines and Other
Sedative Hypnotics
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•  Important Factors for Success:
Start detox during period of low
external stressors
Patient must be committed to taper off
substance
Develop plan for managing underlying
anxiety disorders
Frequent patient contact
A Protocol for
Benzodiazepine Withdrawal
(+/- Alcohol)
•  Phenobarb Protocol, with phenobarb taper
after detox (3-6 days?)
•  Begin valproic acid 1000 mg +/- daily unless
contraindication, in which case consider
gabapentin or other anticonvulsant mood
stabilizer…continue 6 weeks or more, taper?
•  Significant withdrawal symptoms may be
treated with propanolol, quetiapine, etc
•  Insomnia usually treated with trazodone,
occasionally atypical antipsychotics
Seizures and Alcohol /
Benzodiazepine Withdrawal
•  The number one predictor of w/d seizures is
a previous history of w/d seizures…get a
good history!
•  For alcohol w/d only (no hx of benzos)
consider adding valproic acid to phenobarb
•  Brighton Hospital: ~2-3 seizures per year
(~2500 admissions), usually non-disclosed
significant benzo dependence and occur
after detox and transfer to rehab
Opioid Intoxication
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Lowered HR, BP, body temperature
Sedation
Pinpoint pupils (miosis)
Slowed movement
Slurred speech
Head nodding
Euphoria, calmness, imperviousness to
pain
Opioid Withdrawal Syndrome
•  Usually begin within 12 hours after
cessation of short acting opiates
(heroin, hydrocodone, immediate
release or crushed oxycodone), later
with longer acting drugs (methadone,
oxycodone)
•  Rarely life-threatening…the “Safest
Withdrawal”, or is it?
Opioid Withdrawal
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Increase HR, BP, body temperature
Insomnia, increased reflexes
Enlarged pupils
Sweating, increased respirations
Tearing, runny nose, muscle spasms
Abdominal cramps, N&V, diarrhea
Bone and muscle pain
Anxiety
Clinical Opioid Withdrawal
Scale (COWS) Wesson & Ling 2003
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Resting Pulse
Sweating
Restlessness
Pupil Size
Bone/Joint Aches
GI symptoms
Tearing/Rhinorrhea
Tremor
Yawning
Anxiety
Gooseflesh
•  Like CIWA,
numerical values
given and score
totaled
•  Various Scales
exist, all serve to
measure withdrawal
and guide need for
treatment
Common Medications Used to
Manage Opioid Withdrawal
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Methadone
Clonidine (Catapress®)
Buprenorphine (Suboxone®)
Rapid and Ultra-rapid opioid
detoxification
Stimulant Withdrawal
(Cocaine, Crack, Amphetamines)
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Depression, fatigue, anxiety, irritability
Hypersomnia or insomnia
Poor concentration
Psychomotor retardation
Increased appetite
Paranoia
Drug craving
Cocaine and other Stimulants
•  Regular users seem to experience
withdrawal, but not as clear cut as sedatives
or opioids
•  Symptoms include dysphoria, fatigue,
insomnia or hypersomnia and psychomotor
agitation or retardation, cravings, increased
appetite and vivid unpleasant dreams (“using
dreams”)
•  Peak at 2-4 days, longer for amphetamines
•  Treatment generally supportive
(amantadine?)
Symptoms of Inhalants and
Solvents
•  Delirium, tremors, weakness, weight
loss, inattentive behavior, depression
•  Impaired cognitive, motor and sensory
functioning
•  Internal organ damage, including heart,
lungs, kidneys and liver
Medical Management of Inhalant
Abuse and Dependence
•  Provide safe environment that is free of
inhalants
•  Supportive care, including ample sleep
and well-balanced diet
•  Determine if patient is abusing other
substances
•  Access mental status
•  Provide appropriate therapy and
interventions
Nicotine Withdrawal Symptoms
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Depressed mood, anxiety
Insomnia, irritability, frustration, anger
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Medical Management of Nicotine
Withdrawal
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Self-help interventions
Behavioral interventions
Nicotine replacement therapy
Bupropion (Wellburtin®)
Combination therapy
Varenicline (Chantix®)
USPHS Nicotine Intervention:
The 5 A’s
•  ASK about tobacco use
•  ADVISE to quit
•  ASSESS willingness to make a quit
attempt
•  ASSIST in the quit attempt
•  ARRANGE a follow up
Marijuana
•  THC abstinence syndrome
•  Symptoms include:
- Anxiety
- Restlessness, irritability
- Sleep disturbance
- Change in appetite
No medical complications of withdrawal
Anabolic Steroids
•  Subject to abuse
•  Aggressive, manic-like behavior
•  W/D includes fatigue, depression,
restlessness, insomnia, anorexia,
reduced sex drive, headache, nausea
•  Side Effects can be reversed and may
include: UTIs, skin redness and
blistering, edema, behavior changes
•  No detox protocol for steroids
Club Drugs
•  A diverse class including GHB,
Ecstasy, Rohypnol
•  Used in nightclubs and “raves”
•  Withdrawal symptoms may include
intoxication and overdose
•  Destructive effects on nervous system
and mental health
Best Practices for Management
of Polydrug Abuse
•  Prioritize substances according to
withdrawal severity
•  Alcohol and sedative hypnotics
(benzos) have the most severe w/d
•  Opioid detox is the next priority
•  Some substances will not require
treatment during detox, including
stimulants, marijuana, hallucinogens
and inhalants
Considerations for Pregnancy
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Detox on demand, women-centered
Transportation, child care issues
Counseling and case management
Access to safe housing
Legal, nutritional, social needs
Ensure health and safety of both infant and
mother
•  Clarify risk/benefit of any medications
•  Protocol for w/d may vary with each
pregnancy
Considerations for Elderly
•  Supportive, nonconfrontational agespecific group
•  Screen for depression, grief, loss
•  Linkages to specialized services
•  Alcohol and drug issues more severe
with elderly
•  At risk for co-occurring disorders
•  Ongoing assessments and monitoring
for medical problems common in aged
Considerations for Disabled
•  Eliminate barriers: attitudinal,
discriminatory, communication and
architectural
•  Impairment categories include physical,
sensory, cognitive, affective
•  Detox programs must screen for disabilities,
be compliant with federal laws, provide
access to services, coordinate treatment and
know local and national disability resources
Considerations for Minorities
•  African Americans are at greater risk for DM
and HTN, may display distrust with
counselors of different culture and may be at
greater risk of toxic side effects with
antidepressants
•  Hispanic/Latinos are largest minority in US.
Access level of acculturation, language
competency helpful, family is important,
substance use often viewed as moral
weakness
Considerations for Minorities
•  Native Americans, great diversity, highest
rate of alcohol and drug use. Fables and
Healing Circles may be helpful. Frame 12
steps in terms of circle, not a ladder
•  Avoiding eye contact is traditional
•  Tend to seek treatment later with more
medical complications
•  Fetal Alcohol Syndrome 33x US average
Considerations for Minorities
•  Asians and Pacific Islanders, also a very
diverse group
•  May show concern for counselor credibility,
trustworthiness
•  Higher sensitivity to alcohol
•  Smoking rates tend to be high
•  Some detox meds may be metabolized more
slowly
•  Important to use traditional healing methods
and ask attitude toward Western medicine
Considerations for Other
Populations
•  Gay, Lesbian, Bisexual and Transgender
- Monitor staff attitude
- Help patients with previous negative experiences and
accept personal power
•  Adolescents
- Physical dependence not as severe, more rapid
response to detox
- Retention is a problem
- Higher club drugs and steroids
- Peer relationships play a large role in treatment
Considerations for Incarcerated
or Detained Individuals
•  Substance use common, 70-80% of
inmates have used or committed drug
offenses
•  Abrupt w/d from alcohol or sedatives
can be life-threatening
•  W/D from opioids can cause great stress
•  Substance abuse can continue during
incarceration
•  Access to detox can be major problem
Summary
•  Detoxification is not treatment, but it
often may be the first phase of
engaging a person, and can serve as an
entry point to facilitate ongoing change
and entry into the recovery process
•  “A teachable moment”
Selected Cases…
•  Male alcoholic, with severe cirrhosis,
who states his doctor told him to
stay away from liquor, just drink beer
or wine
•  Alcoholic, relapsed after chemo
nurse told him to have a glass of
wine after txs
•  Alcoholic, on alprazolam for 3
months after doctor told him to take
a pill each time he wanted to drink
•  Gentleman who said his doctor of 17
years didn’t know he drank
Warren L.
•  51 yo wm, presents intoxicated but
walking and talking, BAT of 0.43
•  Except for hx of HTN, no other
problems
•  What would you be concerned about
in addressing and treating his
withdrawal?
Shirley B.
•  63 yo wf, hx of multiple admissions
for alcoholism w/o sustained
recovery
•  Denies any other drug use, but UDS
on admission is positive for
benzos…which, when questioned,
she says she “got something in the
ER” 2 days previously
Lawrence T.
•  44 yo AA male, presents with hx of
heroin, hydrocodone and oxycodone
•  20 hours after admission, he c/o of
being “dope sick”, and buprenorphine
is started
•  He becomes violently ill, with sweats,
vomiting, diarrhea, refuses to take any
further Rx and leaves AMA
ADDICTION TREATMENT MADE
EASY…. “A” to “B”
M Menestrina
NEGATIVE
Consequences:
The job, liver,
judge, wife, boss,
friend get the
individual’s
attention!
POSITIVE
Reinforcement:
The individual
actually begins to
like and enjoy
“recovery”
While this process is achievable, it is not likely to all make sense
to the patient. It may involve 12 step, counseling, treatment of
co-morbid conditions, Medication Assisted Treatments and
other modalities.
“NEVER DOUBT THAT A
SMALL GROUP OF
DEDICATED CITIZENS CAN
CHANGE THE WORLD…
INDEED IT IS THE ONLY
THING THAT EVER HAS”
Margaret Meade