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8.2: Managing Benzodiazepine, Cannabis, Nicotine and other Withdrawal Prepared by J. Mabbutt & C. Maynard NaMO September 2008 8.2: Managing other drug withdrawal: Objectives 1. During the session nurses & midwives will learn how to identify, assess & manage a patient in benzodiazepine, cannabis, nicotine & other drug withdrawal 2. At the end the session, nurses will have a basic understanding & knowledge to safely & effectively identify, monitor & manage benzodiazepine, cannabis, nicotine & other drug withdrawal 8.2: Managing drug withdrawal This presentation gives general guidelines for managing withdrawal. Refer to Section 9 for specific details of withdrawal symptoms and management for the most commonly used substances For further information, refer to the New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) http://www.health.nsw.gov.au/policies/gl/2008/GL2008_011.html 8:2 Indications and guidelines Benzodiazepine Withdrawal – Option – Case Study Present the post natal case study for benzodiazepine and other drug withdrawal from Guidelines CD Rom Section 01 Discuss each section in small groups or as a large group and feedback 8:2 Indications and guidelines – Benzodiazepine withdrawal – Onset & duration of benzodiazepine withdrawal Onset of withdrawal depends on the half-life of the particular benzodiazepine used by the person Withdrawal from short-acting benzodiazepines generally occurs earlier & is more severe Withdrawal symptoms do not necessarily decrease steadily from a peak, but can follow a fluctuating course with good & bad periods Eventually the good periods will last longer & become more frequent Generic name Trade name Time to peak concentration Elimination half life † Equivalent dose ‡ Diazepam Antenex Ducene Valium Valpam 30-90 min Biphasic: rapid phase half-life, 3 hours; elimination half-life, 20-48 hours 5 mg Alprazolam Alprax Xanax Kalma 1 hour 6-25 hours 0.5-1.0 mg Bromazepam Lexotan 0.5-4 hours 20 hours 3-6 mg Clobazam Frisium 1-4 hours 17-49 hours 10 mg Clonazepam Paxam Rivotril 2-3 hours 22-54 hours 0.5 mg Flunitrazepam Hypnodorm 1-2 hours 20-30 hours 1-2 mg Table 9.9: Absorption rates, half-life, & equivalent daily doses of common benzodiazepines** * Based on manufacturer’s product information. †Elimination half-life: time for the plasma drug concentration to decrease by 50%. ‡ Equivalent dose: approximate dose equivalent to diazepam 5 mg. Generic name Trade name Time to peak concentration Elimination half life † Equivalent dose ‡ Lorazepam Ativan 2 hours 12–16 hours 1 mg Nitrazepam Alodorm Mogadon 2 hours 16–48 hours 2.5–5 mg Oxazepam Alepam Murelax Serepax 2–3 hours 4–15 hours 15–30 mg Temazepam Euhypnos Normison Temaze Temtabs 30–60 min after tablets, 2 hours after capsules 5–15 hours 10–20 mg Triazolam Halcion 1–3 hours Biphasic: rapid phase half-life, 2.5–3.5 hours; elimination half-life, 6– 9 hours 0.25 mg Zolpidem Stilnox 0.5–3 hours 2.5 hours Not known Table 9.9: Absorption rates, half-life, & equivalent daily doses of common benzodiazepines** * Based on manufacturer’s product information. †Elimination half-life: time for the plasma drug concentration to decrease by 50%. ‡Equivalent dose: approximate dose equivalent to diazepam 5 mg. 8:2 Indications and guidelines – Benzodiazepine withdrawal – Signs & symptoms of benzodiazepines withdrawal Subjective symptoms with few observable signs of withdrawal are a feature, particularly of low dose withdrawal Individuals may report feeling extremely mentally distressed (as though they are “going mad”), although they may not have any obvious signs of physical discomfort This may result in the person not receiving the care that would be appropriate during this time Common symptoms Less common symptoms Uncommon symptoms Anxiety Nightmares, agoraphobia Delusions Insomnia Feelings of unreality Paranoia Restlessness Depersonalisation Hallucinations Agitation Panic attacks Seizures Irritability Nausea, dry retching, decreased Persistent tinnitus Poor concentration Increased sensory perception, Confusion Poor memory Increased temperature, ataxia Depression Gastrointestinal unrest Muscle tension, aches and twitching Menstrual changes Table 9.10: Symptoms of benzodiazepine withdrawal NSW Health (2007) 8:2 Indications and guidelines – Benzodiazepine withdrawal – Major complications of withdrawal The major complications of withdrawal are: Progression to severe withdrawal Delirium with risk of injury (to self or others) Risk of dehydration or electrolyte imbalance Potential for seizures Presence of concurrent illness, which masks or mimics withdrawal Orthostatic hypotension 8:2 Indications and guidelines – Benzodiazepine withdrawal – Course of withdrawal Withdrawal from short-acting benzodiazepines (e.g. oxazepam, temazepam, alprazolam, & lorazepam) typically produces a faster and more severe onset of symptoms Withdrawal from long-acting benzodiazepines (e.g. diazepam, nitrazepam) may be more difficult to undergo and complete Figure 9.3: Withdrawal from short and long-acting benzodiazepines Adapted from Frank L, Pead J. New concepts in drug withdrawal: a resource handbook © 1995 State of Victoria. Reproduced with permission. 8:2 Indications and guidelines Managing benzodiazepine withdrawal Undertake nursing observations to identify & manage withdrawal symptoms & prevent the progression to severe withdrawal In particular, offer: Reassurance regarding distorted sensory stimuli Heat & massage for muscle aches Symptomatic management to reduce the severity of symptoms 8:2 Indications and guidelines – Managing benzodiazepine withdrawal – Monitoring There is no validated tool for recording benzodiazepine withdrawal symptoms in an inpatient setting The symptoms previously listed in Table 9.10 need to be monitored 8:2 Indications and guidelines – Managing benzodiazepine withdrawal – Pharmacological treatment (1) Initial stabilisation of dose (preferably with a long-acting benzodiazepine) – a gradual dose reduction preferably as an outpatient In hospital: patients taking high doses, or polydrug users, should be stabilised on a long-acting benzodiazepine (preferably, diazepam), at a dose about 40% of their regular intake prior to admission (or 80 mg/day, whichever is lower) Reduction & withdrawal should follow once their other medical condition has been dealt with From the New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) 8:2 Indications and guidelines – Managing benzodiazepine withdrawal – Pharmacological treatment (2) Referral to Drug & Alcohol outpatient services or supportive GPs needs to be arranged well in advance of discharge to organise a continued outpatient reduction regime Please contact a specialist Drug & Alcohol medical officer/nurse practitioner/ senior clinical nurse for advice & support If patients stabilise on a dose in the range 40–80 mg of diazepam daily, withdrawal should be at the rate of at least 5 mg per week until the dose reaches 40 mg, then 2.5 mg/week A maximal rate of withdrawal would be to reduce the dose by 10 mg at weekly intervals until 40 mg, then by 5mg at weekly intervals this will take 12 weeks as an outpatient New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) 8:2 Indications and guidelines – Managing cannabis withdrawal – Onset & duration of cannabis withdrawal (1) Most symptoms commence on day 1, peaking at day 2-3, returning to baseline after a week or two Can be an onset of aggression (day 4) often peaking after 2 weeks of abstinence and anger (day 6) also being particularly significant There is a National Cannabis Prevention and Information Centre (NCPIC) with has a range of resources and information regarding cannabis withdrawal, for the workforce, users & families, http://ncpic.org.au/ – 1800 30 40 50 8:2 Indications and guidelines – Managing cannabis withdrawal – Onset & duration of cannabis withdrawal (2) Special considerations include: Patients with a comorbid mental health condition as there may be unmasking of the mental illness during withdrawal Appropriate assessment & management is required Patients who use cannabis for chronic pain may require assessment for adequate pain management & referral to specialist pain services Patients with a history of aggression may require closer monitoring and a higher dose of benzodiazepine Common symptoms Less common symptoms/equivocal symptoms Anger or aggression Chills Decreased appetite or weight loss Depressed mood Irritability Stomach pain Nervousness/anxiety Shakiness Restlessness Sweating Sleep difficulties, including strange dreams Table 9.13 Cannabis withdrawal symptoms (Budney et al., 2004:1975) 8:2 Indications and guidelines – Managing cannabis withdrawal – Monitoring Cannabis withdrawal can be monitored by using a withdrawal assessment scale such as the Cannabis Withdrawal Assessment Scale (see Appendix 5) Not all patients will require medication for withdrawal The following table lists medications for symptomatic relief of cannabis withdrawal Symptom Medication Sleep problems benzodiazepines, zolpidem zopiclone, promethazine Restlessness, anxiety, diazepam irritability Stomach pains buscopan, atrobel Physical pain, headaches paracetamol, non-steroidal antiinflammatory agents Nausea promethazine, metoclopramide Table 9.14 Medications for relief of cannabis withdrawal (NSW Health 2007) 8:2 Indications and guidelines – Managing cannabis withdrawal – Pharmacological Treatment Given the wide interpersonal variability, dosages and prescribing schedules will most effectively be decided upon only after a thorough exploration of the individual patient’s symptom profile and circumstances. Outpatient regimens might be: 7 days of diazepam 5 mg four times daily, zopiclone 7.5 mg at night, NSAIDs / buscopan as needed, or 7 days of zolpidem 7.5 mg at night From the New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) 8:2 Indications and Guidelines Nicotine withdrawal signs & symptoms (1) Onset of withdrawal is usually within a few hours of the last cigarette & withdrawal symptoms peak at 24-72 hours Withdrawal symptoms vary, but can include the following: Irritability Cravings Increased nervousness and tension Sleep disturbance Stomach upsets 8:2 Indications and Guidelines Nicotine withdrawal signs & symptoms (2) Bowel disturbance Loss of concentration Muscle spasm Changes in taste Headaches Cough Increased appetite 8:2 Pharmacological treatment Treatment: Indication for in patient nicotine withdrawal There is generally no indication for admission into a Drug & Alcohol inpatient facility but may be admitted into hospital & experience withdrawal from nicotine consequently Patients should be informed of the NSW Health Smoke Free Workplace Policy (1999) & offered support to stop NRT should be used when not contraindicated Refer to NSW Health Guidelines GL2005_036: Nicotine Dependent Inpatients http://www.health.nsw.gov.au/policies/GL/2005/pdf/GL2005_036.pdf 8:2 Nicotine withdrawal Pharmacological treatment – Pharmacotherapiesc A holistic approach to smoking cessation is important and a pharmacotherapy should be seen as one part of this approach Pharmacotherapy options are: Nicotine Replacement Therapy (NRT) Bupropion Other options such as clonidine, & nortriptyline Type Dose and Duration Side Effects Contraindications Relative: • Ischaemic heart disease Absolute: • Recent MI • Serious arrhythmias • Unstable angina • Pregnancy Less than 10 cigs per day 10-20 cigs per day More than 20 cigs per day Patches None Nicobate® 14 mg Nicorette® 10 mg Nicobate® 21 mg Nicorette® 15 mg Transient skin irritation, itching, dreams, sleep disturbance, indigestion, diarrhoea Gum None 2 mg, 8-12 per day 4 mg, 8-12 per day Jaw discomfort, nausea, indigestion, hiccups, excess saliva, sore throat Inhaler None Nicorette® 6-12 cartridges per day Not recommended Mouth and throat irritation, cough, nausea and indigestion Table 9.16 Pharmacotherapy of nicotine replacement therapies Type Dose and Duration Less than 10 cigs per day Bupropion 10–20 cigs per day Side Effects Contraindications Headaches, dry mouth, impaired sleep, seizures, nausea, anxiety, constipation and dizziness 1. seizure disorders or significant risk of seizure 2. bulimia 3. anorexia nervosa 4. bipolar disorders More than 20 cigs per day 150 mg for 3 days, then 150 mg b.d. for 7 weeks Table 9.17 Pharmacotherapy of bupropion (Zyban®) From New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) 8:2 Hallucinogen Dependence and withdrawal These drugs are not usually associated with dependence arising from long term, high-level use There is no evidence of a withdrawal syndrome from hallucinogens even after abrupt cessation or substantial reduction in their use 8:2 Solvents Withdrawal (1) Withdrawal syndrome can occur in some cases, but it is generally mild Symptoms include: Anxiety Depression Headache Nausea Dizziness 8:2 Solvents Withdrawal (2) Drowsiness Chills Abdominal pains Muscular cramps Sometimes, confusion & hallucinations can occur after chronic solvent use 8:2 Indications and guidelines – Ketamine withdrawal Abrupt withdrawal can occur after cessation of long-term daily use (White et al 2002) There is no validated tool for recording ketamine withdrawal symptoms Symptoms of withdrawal are: Fear Tremors; facial twitches Craving Animal studies show seizures, irritability & weight loss during ketamine withdrawal 8:2 Indications and guidelines Gamma Hydroxybutyrate (GHB) Withdrawal (1) GHB use should be suspected in particular groups such as clubbers & body builders who present with signs compatible with alcohol intoxication but record a breath alcohol level of zero – E.g. nystagmus, ataxia, nausea, vomiting, bradycardia & hypotension) Withdrawal presents as rapid onset, prolonged alcohol withdrawal picture, with less autonomic arousal and risk of seizures, but marked confusion, delirium & hallucinations, waxing & waning over a two week period 8:2 Indications and guidelines GHB withdrawal (2) Management may require the use of both short & long acting benzodiazepines Additional sedation with propofol may be required in some patients There is no validated tool for recording GHB withdrawal symptoms 8:2 Steroids Withdrawal Generally, physical dependence does not appear to occur with steroid use