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Drug and Alcohol Detoxification.
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Showing posts with label
Drug and Alcohol Detoxification.
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If an individual is using drugs and he or she decides to stop using, they can... right? Not really. Why, you ask. Quite simple. It can be summed up all in one word: withdrawal. Drug use is more than just a bad habit. Drug use is addictive not only because psychologically an individual feels compelled to use, but also because his or her body develops a physical dependence. When this dependence develops and drug use is abruptly discontinued, symptoms of withdrawal can and usually do arise. Basically, the body goes into shock. The exact symptoms of withdrawal will change depending on the drug the individual is dependent upon. Here we will discuss some of the different withdrawal states that can occur.
What are examples of withdrawal?
* Benzodiazepines
* SSRI discontinuation syndrome
* Methadone withdrawal symptoms
* Alcohol withdrawal syndrome
* Delirium tremens
* Neonatal abstinence syndrome
Why Does Physical Dependence Occur?
As one uses more and more of a drug, or any kind of substance, the body develops a drug tolerance. This does not just refer to illegal substances, it can also happen when one drinks coffee on a daily basis. After a while, just one cup may not be enough to get that kick which is neccesary to get going in the morning, or to stay up all night. Thus, a second or third cup may be needed. In the case of drug users, one pill or one puff on x substance may not be enough. The body adapts to the substance that has been introduced. When the drug is no longer available withdrawal symptoms that are the opposite of the direct effects of the drug appear- and this is when the withdrawal occurs. Depending on the elimination half life of the drug, symptoms can arise a few hours afer the drug is stopped or may even begin several days after discontinuation of the substance.
So, Withdrawal just Applies to Heavy Drugs Users...Right?
There are many legal drugs used all over the world which are generally not associated with having a withdrawal effect. These are medications which are not generally used to generate a feeling of pleasure, however, the body can still develop a dependence. Some of these substances include:
* Beta blockers (used for management of cardiac arrythmias)
* Corticosteroids – cortisone (an anti-inflammatory)
* Antidepressants/Antianxiety
* Anticonvulsants (used to prevent seizures)
For this reason, one must not abruptly discontinue any medication without consulting with his or her medical provider.
Its all about the dopamine
The euphoria that drugs produce is usually what causes addiction. This is produced by the nucleus accumbens which is considered the pleasure center of the brain. Dopamine is used by this center to cause the euphoria drug users enjoy. The particulars of dopamine use by the body, varies depending on the drug utilized. Constant use of the drug means that the body requires, more and more stimulation, this leads to dependence. In order to produce feelings of euphoria, one needs more and more of the drug. Withdrawal syndrome is characterized by dysphoria which is the opposite of euphoria- sadness. Symptoms of withdrawal include: Depression, anxiety, and craving.
Why Can Some People Just Stop and Others Cant?
Ever heard someone say: “I stopped smoking cold turkey.” This type of easy withdrawal doesn’t happen for everyone. How someone withdraws from a drug depends on many factors. For instance, how long have they been using? What kind of medication/drug is it? At what rate have they been using? All of these questions need to be answered in order to properly assess how someone is going to withdraw. Depending on the medication, an individual may need supervision while withdrawing from a substance. This applies to both benzodiazepines and alcohol withdrawal, which if not carefully handled can lead to seizures. If alcohol is stopped abruptly, delirium tremens can occur, and this can be deadly.
Rebound Withdrawal
This often occurs with depression medications. When a medication is stopped, withdrawal from the drug results in a return to the original symptom, often in a much worse state. Meaning, a depressed person may become more depressed than they originally were. Depression also occurs for individuals using amphetamines, stimulants and ecstasy. After being in a state of euphoria, the individual may crash and become depressed. Other medications that may result in rebound include:
* Analgesics include: Advil, Ibuprofen, Aspirin, Tylenol and some prescription medications can cause headaches for long periods of time.
* Nasal decongestants: including Afrin and Otrivin, can cause rebound congestion if used for more than a few days.
* Sedatives and benzodiazepines can cause rebound insomnia when used regularly to aid sleep.
The only way to combat rebound of these symptoms is to deal with the symptoms for a few days and allow the body to go back to its normal state.
What if Someone Wants to Stop Using?
The best thing to do when attempting to withdraw from drugs is to consult the medical professionals who can properly outline a course of action which will be effective. Never attempt to withdraw from any medication, legal or otherwise, on one’s own as the effects of such a venture could be potentially deadly.
Drug dependence is a universal public health problem of which opioid dependence, notably involving heroin and morphine are a major component. In Europe alone, there are an estimated 1.1 million intravenous drug users and the number is estimated to be at least 3 times that many in North America. The majority of these individuals remain untreated. Opioid dependence is a chronic relapsing medical condition that requires long-term treatment and patient support. In addition, many of these intravenous drug users share syringes and needles, a practice that can lead to the transmission of serious blood-borne infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C.
Currently opiate dependence treatments like methadone can be dispensed only in a few centers that focus in addiction treatment. There are not enough addiction treatment clinics to assist all patients seeking treatment. Suboxone is the first narcotic drug available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed by a physician. Hopefully, this advance in therapeutics will provide more patients the opportunity to access treatment.
Suboxone (buprenorphine with naloxone) is currently available for the maintenance treatment of opioid addiction. The intention of adding naloxone to the formulation is to deter intravenous misuse and reduce the symptoms of opiate dependence. Suboxone treatment is intended for use in adults and adolescents more than 16 years of age who have agreed to be treated for addiction.
Once detoxification of the individual is completed, Suboxone is used during the maintenance phase of treatment. Suboxone has recently become the drug of choice instead of methadone in the treatment of opiate addiction. Suboxone use is less rigidly controlled than methadone because it has a lower potential for abuse and is less dangerous in an overdose. As patients progress on therapy, the physician may write a prescription for a take-home supply of the medication.
Suboxone Prescription
Only those physicians who have approval from the Drug Enforcement Agency (DEA) are able to start in-office treatment and provide prescriptions for ongoing medication. The Center for Substance Abuse Treatment (CSAT) maintains an active database to help patients locate qualified doctors.
Route of Administration
Suboxone is available as a tablet which is always administered sublingually. The pill is placed underneath the tongue until it is fully dissolved. Swallowing or sucking on the pill does not offer any therapeutic benefit. When placed underneath the tongue, the pill dissolves and is absorbed in 10 -20 minutes.
Suboxone treatment is generally done under medical supervision. During the induction phase, one is taught how to properly take the medications and dose adjustments are done during the phase. One is usually started on the smallest dose until the best therapeutic effect is obtained. Once the ideal dose is obtained, the individual is seen once in a while and prescriptions can generally be available from the same physician.
Suboxone is available as 2 and 8 mg tablets. Most anecdotal reports indicate that the response to the 2 mg dose is suboptimal. The majority of individuals report benefit at higher doses of 8-16 mg. The aim of the maintenance treatment is to rid the drug craving and decrease the anxiety. The dose is usually adjusted until the drug craving features are diminished.
Since Buprenorphine is a Schedule III drug, the physician is only allowed to prescribe 5 refills in 6 months.
Maintenance therapy
Although Suboxone can be used for detoxification, its intended use is for maintenance. The ideal candidate for maintenance therapy with Suboxone is an older individual who has previously been on drugs but now has a job and wants a stable lifestyle. The individual previously has failed detoxification and wants to live a simple life without the daily cravings of his previous addiction. The majority of past drug users immediately adjust to Suboxone as the cravings disappear immediately and a smoother life style are accessible.
Suboxone Control
Because of the great potential for abuse, FDA works closely with the drug manufacturer, Reckitt-Benckiser, and other agencies to develop an in-depth risk-management plan. The FDA receives quarterly reports from the manufacturer and pharmacies and maintains a comprehensive surveillance program. This monitoring allows for early detection of abuse of the drug. The major components of the risk-management program are preventive measures and surveillance. Preventive measures instituted include drug education, tailored distribution, Schedule III control under the Controlled Substances Act (CSA), child resistant packaging and supervised dose induction. The program regularly monitors local pharmacies and web sites. Numerous other agencies also monitor the abuse of Suboxone and these include:
-Drug Abuse Warning Network (DAWN). This agency run by the Substance Abuse and Mental Health Services Administration (SAMHSA) gathers data from emergency rooms related to the illicit use of drugs or non-medical use of a legal drug.
-Community Epidemiology Working Group (CEWG). This agency monitors the use of buprenorphine.
-National Institute of Drug Abuse (NIDA). NIDA frequently sends newsletters to physicians about the addictive drugs and to report it if necessary.
Side Effects
The most common reported side effect of Suboxone includes:
- Cold or flu-like symptoms
- Headaches
- sweating
- insomnia
- Nausea
- Mood swings
- Pain
- restlessness
Like other opioids, Suboxone have been associated with respiratory depression (difficulty breathing) especially when combined with other depressants.
Cautions
Intravenous use of Suboxone usually in combination with benzodiazepines or other CNS depressants has been associated with significant respiratory depression and death. Suboxone has the potential for abuse and produces dependence of the opioid type with a milder withdrawal syndrome than full agonists. There are no adequate and well-controlled studies of Suboxone use in pregnancy. Due caution should be exercised when driving cars or operating machinery.
One of the defining characteristics of an addictive personality is the inability to practice delayed gratification. Whatever the individual wants, he or she wants now, not later, not in five minutes. Having said this, one of the main components present in substance abuse treatment is a behavioral change in order to procure long lasting abstinence from drug use. Enter rapid drug detox- is it an option from hard core drug users? The ads offer quick, efficient and painless detoxification from opiod drug use. In a few hours, the drug user has totally bypassed the often, long and torturous road to recovery.
But the question comes….is it effective? An even more pressing question- is it safe? The physicians that run these operations will say, yes, absolutely, there is no danger in rapid detox. However, seven patients from 1999-2003 died under the care of Dr. Lance Gooberman at the U.S. Detox Intensive Treatment Center which is based in New Jersey. This physician had his license taken away from him. Why did these patients die? Well, the procedure puts a lot of stress on the drug user’s body, which is already not in full working order. Over the course of the last few years however, there has been much advancement in the rapid detoxification process.
How Does Rapid Opiod Detoxification Work?
In order to speak about the rapid detoxification process, one must speak of Andre Waismann. Dr. Waismann is an Israeli physician, specifically an anesthesiologist, who started practicing the rapid detoxification method in 1994. Dr. Waismann and his team screen patients for their levels of dependence to their drug of choice, in most cases, opiates. Opiates are artificial endorphins. Meaning, one naturally produces endorphins which make one feel happy, and are the physiological components behind someone experiencing a natural high. Continued use of opiates causes the body to stop producing endorphins and the opiate receptors present need more and more stimulation in order to procure a reaction. The brain may also develop more receptors to take in the opiates that are being introduced to the system.
The Waismann team administers drugs that anesthesiologists use to block the opiod receptors and then a drug is introduced that blocks opiods. The entire process takes about 36 hours and according to Dr. Waismann, the patients don’t feel any of the symptoms associated with withdrawal:
• Abdominal pain
• Agitation
• Diarrhea
• Dilated pupils
• Goose bumps
• Nausea
• Runny nose
• Sweating
• Vomiting
Patients are screened prior to treatment to find out what level of dependence they are displaying. The physician sedates the patient and medications are introduced to block the opiod receptors from further reaction to opiod. The patient’s are monitored as the medications are being administered. According to Dr. Waismann the patient is unaware this process is taking place. For a year after treatment, the patients take Naltrexone, which is a tablet taken once a day by mouth. The purpose of naltrexone is to block opiod receptors which should stop the patient from getting a high should they attempt to use.
Can This Really Work?
According to the organizations that perform rapid opiod detoxification, there are no issues with the treatment. For instance, according to a study from Mount Sinai Medical Center, University of Miami School of Medicine, the process is one hundred percent successful. According to this institution, relapse is only reported fifty five percent of the time, during the six month follow up period. These numbers do not include use of alcohol and other drugs however. Furthermore, there are physiological risks for the addict going through a rapid detoxification program as demonstrated by Dr. Gooberman’s practice.
Is It a Magic Cure?
The answer to this is no. Though these practices will have one believe that the detoxification process will result in unsolicited recovery from substance abuse, what this does not take into account is the fact that one is dealing with an addict. It is not just the fact that the individual is using substances; it is the behaviors and lifestyle that accompanies drug use which need to be remedied. This includes unlearning behaviors that have been with the individual for most of his or her life. Unlearning them takes time and a lot of work on the part of the addict. Rapid detoxification is just the first step in a lifetime of work the addict has to commit to.
Dr. Waismann’s method is a helpful push in the direction of recovery from opiod use, however, unless there is a bridge to behavioral changes, it is likely that the addict will relapse. The use of naltrexone, as Dr. Waismann suggests can help to fight cravings while the patient continues to work on the reasons why he or she is looking for a chemical high. It is the nature of the addict to look for the easier way to do things. In terms of detoxification, there is nothing wrong with that, but for lasting abstinence one must change his or her behaviors in addition to physically ridding the body of these substances. So, final verdict, Waismann’s method can work but its not the end of the treatment- its only the beginning.
There have been substantial advances when it comes to understanding the biochemical and genetic basis for substance abuse and addiction over the past ten years. In spite of this knowledge very little information is disseminated in regards to alternative forms of detox treatment. One form of alternative treatment is rapid detox and is a viable alternative for certain patients.1 Rapid detoxification and rapid opiate detox can be beneficial if you are suffering from an addiction to heroin, prescription painkillers, Oxycontin, Methadone, Suboxone, Vicodin, Darvocet, Percocet, Hydrocodone or any other opioid. 2
Traditional treatment entails a detoxification period that is often debilitating and has horrendous withdrawal symptoms that are both painful and often dangerous for the patient. Not only is there intense physical pain there is often psychological cravings for months beyond treatment. 3 Statistics show that with regular detox methods within a year 85 to 90 percent of all patients have suffered a relapse and are using again. 4
The most visible and widely talked about rapid detox method is the Waismann Method. 5 The Waismann Method also known as Neuro-Regulation is performed in a hospital intensive care unit. It involves cleansing the opiate receptors in the patient’s brain of the narcotics while the patient is under anesthesia. During the procedure, the patient will experience no conscious withdrawal, and will be able to return home within days. Over 65 percent of the patients who are treated with the Waismann Method remain drug free after one year.
In April 2000, the American Society of Addiction Medicine (ASAM) released a public policy statement on rapid and ultra rapid opioid detoxification.6 Based on their policy and further studies, ASAM updated April 2005, to include their policy recommendations which are listed below and should be considered when considering detox.
Policy Recommendations
1. Opioid detoxification alone is not a treatment of opioid addiction. ASAM does not support the initiation of acute opioid detoxification interventions unless they are part of an integrated continuum of services that promote ongoing recovery from addiction.
2. Ultra-Rapid Opioid Detoxification (UROD) is a procedure with uncertain risks and benefits, and its use in clinical settings is not supportable until a clearly positive risk-benefit relationship can be demonstrated. Further research on UROD should be conducted.
3. Although there is medical literature describing various techniques of Rapid Opioid Detoxification (ROD), further research into the physiology and consequences of ROD should be supported so that patients may be directed to the most effective treatment methods and practices.
4. Prior to participation in any particular modality of opioid detoxification, a patient should be provided with sufficient information by which to provide informed consent, including information about the risks of termination of a treatment plan of prescribed agonist medications such as methadone or Buprenorphine, as well as the need to comply with medical monitoring of their clinical status for a defined period of time following the procedure to ensure a safe outcome. Patients should also be informed of the risks, benefits and costs of alternative methods of treatment available.
In rebuttal to ASAM’s policy Clifford Bernstein, M.D., medical director of AAMOD, the leading practitioners of the Waismann Method treatment for opiate dependency, stated that the study offered misleading results and failed to recognize those who have had success with rapid detox.7 He states that anesthesia-based detox is a humane and effective medical treatment that allows patients to avoid most of the unnecessary withdrawal symptoms. Furthermore, he points out that the study misleads the reader into believing that anesthesia-based detox is not a successful method for opiate treatment by stating that 80% of participants dropped out of follow-up treatment. This statistic does not say anything about the success of the detox treatment or whether or not patients were able to stay off of the drugs. Since the opiates have been blocked from their brains and they no longer feel cravings following the anesthesia-based detox, many of these patients do not need an aftercare program. He stated that the study did not accurately represent the procedure, the merits of the doctors performing it nor the benefits of this treatment. He states that the procedure is safe, however one should use the same precautions as any other procedure under anesthesia as well as verify the qualifications of the doctor performing and to be sure to do it at an hospital with appropriate emergency resources if they are necessary.
Rapid detox is a relatively painless way for people suffering from addiction to opiates. While rapid detoxification can be effective, it is should be undertaken only after discussing the pro’s and con’s as well as follow- up treatment.
Opiate addiction is recognized as a central nervous system disorder, caused by continuous opiate intake.1 Extended opiate use leads to the nerve cells in the brain to stop functioning as they normally would and stop producing natural endorphins. Because the body is getting opiates and no longer is producing endorphins the nerve cells start to degenerate and cause a physical dependency on opiates. Sudden withdrawal (quitting cold turkey) leads to a syndrome called withdrawal syndrome. Withdrawal syndrome is a long and painful process and can result in permanent damage to the cardiopulmonary system and the central nervous system. Untreated and unmonitored, it can result in death for unhealthy patients. For these reasons, opiate dependency treatment requires appropriate and responsible medical care.2 These symptoms have led to the growth of ultra-rapid, anesthesia-assisted opioid withdrawal procedures. Proponents state that rapid detox as a painless way to withdraw from opioid. However, studies show that the procedure can lead to risk of death, psychosis, increased stress, delirium, attempted suicide, abnormal heart rhythm and acute renal failure and are very expensive.3
There other tradional forms of opate detoxification including opioid agonist drugs. These include drugs like methadone, levo-alpha-acetylmethadol (LAAM), or Buprenorphine; Clonidine, which blocks some withdrawal symptoms; ultra-rapid opioid detox under anesthesia; and an experimental method using the drug lofexidine. Opioid agonist drugs act like opiates but do not produce the same high and are administered in doses that are gradually reduced. Since these medications act like opiates there appear to be no noticeable or significantly reduced withdrawal symptoms.4
Clonidine can be administered by a transdermal patch, which dispenses the drug gradually and consistently over a seven- day period. Patients who choose to use the patch should also take Clonidine orally for the first two days since medications taken through the skin takes two days to reach a steady effectiveness. Monitoring of blood pressure is essential since Clonidine causes hypotension and sedation.
Rapid detox is done under general anesthesia with intubations for six to eight hours. During this time a combination of drugs, usually naltrexone and Clonidine are administered to the patient.4 Lofexidine, a non-addictive drug brought to the market in 1992, is a centrally acting alpha-2 adrenergic agonist targeted for relief of opiate withdrawal symptoms.
Withdrawal symptoms continue to be the greatest obstacle in heroin detoxification treatment. Studies concur that there is no proof that one detoxification treatment is better than another. Relapses continue to occur in numerous cases around the world therefore making opiate addiction very difficult to treat successfully long term. Studies show that on average addicts will stop and start detox 10-25 times in their lifetime relapsing back to opiate use each and every time5
Opiate detoxification involves admitting there is a problem, seeking medical help, staying focused on the goal and rehabilitation and treatment through a continuing program. Statistics and studies how that there is no easy cure all nor is there a guarantee that a relapse will not happen. Support from family, friends and physicians along with the will to succeed are all necessary factors in successful detox regardless of the method chosen. While there are many methods to use for opiate detox, one must choose the method that looks at their general health condition, psychological state, external support and length of time addicted and making an informed decision that best meets the needs of the individual.
Addiction to drugs and alcohol encompasses more than a behavioral intervention. The reason for this is drug addiction is a complex disease, however, it is treatable. Like chronic illnesses such as hypertension and asthma, relapse can occur with drug addiction even after extended periods of continued abstinence. For this reason, repeated treatments may be necessary. Treatments should be tailored to the individual in order to be more effective and long lasting, therefore allowing people to live long and productive lives.
In a study conducted in 2004, 22.5 million American needed treatment for substance abuse. Out of this large number, only 3.8 million received help (NSDUH2004).Leaving substance abuse and addiction cases untreated, though in the short-term can save money, in the long-term can lead to many extraneous costs to society. Some of these things include: court and criminal costs, emergency room visits, prison costs, child abuse and neglect, foster care, welfare costs, healthcare utilization, reduced productivity and unemployment.
For every dollar spent on addiction treatment, there is a four to seven dollar reduction in the cost of crimes related to drugs. In 2002, it was estimated that $181 billion dollars was the cost to society for drug use. Over $500 billion was spent when including tobacco and alcohol costs. This includes lost productivity, healthcare and criminal justice costs. Substance abuse programs that are run successfully and efficiently can help society in more than one way. Not only can they assist the person in need, they can also help reduce the amount of sexually transmitted disease that are spread such as HIV/AIDS and Hepatitis. In addition, crime and costs to society can also be reduced. So, the question comes, how can one develop an effective treatment program?
Effective Treatment Guidelines
Research has been conducted since the 1970s shows that treatment can help people avoid relapse, change destructive behaviors, and take them out of a life of substance abuse and addiction. Treatment tends to be a long term process and can require several episodes of treatment. This research has helped lay down the structure on which effective treatment programs should be based.
• Treatment does not need to be voluntary to be effective.
• For certain types of disorders, medications are an important element of treatment, especially when combined with counseling and other behavioral therapies.
• No single treatment is appropriate for all individuals.
• Treatment needs to be readily available.
• Effective treatment attends to multiple needs of the individual, not just his or her drug addiction.
• Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
• Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
• An individual’s treatment and services plan must be assessed often and modified to meet the person’s changing needs.
• Medical management of withdrawal syndrome is only the first stage of addiction treatment and by itself does little to change long-term drug use.
• Possible drug use during treatment must be monitored continuously.
• Counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction.
• Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, and should provide counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
• As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a long-term process and typically requires multiple episodes of treatment, including "booster" sessions and other forms of continuing care.
An All Encompassing Treatment
When treating an individual for addiction treatment, it is important for the individual as a whole to be looked at. Usually, treatment begins with detoxification which is followed by treatment and relapse prevention. Initially, in order to ease the individual into treatment, medications may be needed in order to control symptoms of withdrawal. All encompassing care includes mental health services, medical care and of course aftercare. In order to make sure that someone in recovery continues to stay there is to make sure all bases have been covered. Follow up options such as community or family based recovery support systems can be essential to acquiring and maintaining a life that is free of drug use and abuse.
Medications
Medications can help in various different fashions. In some cases, coming off of a substance can be life threatening and medication is necessary. Often times, the symptoms of withdrawal can be so severe that medication is necessary. This is not considered treatment; it is however, the first step in the process of recovery. Going through withdrawal treatment is not sufficient. If one does not receive further treatment, it is like not receiving treatment at all.
Using chemical substances can help to establish brain functioning that may have gone awry. At present medications are available to help reestablish pathways for addiction related to heroin, morphine (opioid) and nicotine (tobacco). Other medications are currently being developed for treatment of cocaine and methampetamines (stimulants) and marijuana (cannabis) addictions.
Methadone and buprenorphine act as antagonists on brain receptors which means that they block the pathways which opiates like heroin take. This helps to block the drugs effects, suppresses symptoms of withdrawal and can even reduce the incidence of cravings. Ideally, this helps patients to stop drug seeking behaviors and activities that may be criminally related. Thereby, patients should be more focused on treatment having reduced many outside stimuli.
Behavioral Treatments
This is a very important part of effective therapeutic treatment. Stopping substance abuse habits is only effective if behaviors change, therefore, attitudes have to be changed so that a healthy lifestyle is maintained. Life skills need to be altered, unhealthy patterns need to be changed. In addition, medication effectiveness is usually better, and this can help people stay in treatment longer which will hopefully improve the likelihood of the individual staying clean.
Outpatient behavioral treatment can include a wide variety of programs. Most include group or individual counseling. Some of the more popular forms of treatment include the following behavioral treatment programs:
• Motivational Incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.
• Cognitive Behavioral Therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
• Motivational Interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.
• Multidimensional Family Therapy, which addresses a range of influences on the drug abuse patterns of adolescents and is designed for them and their families.
Residential treatment can be very helpful, even more so for individuals with severe problems. Therapeutic communities are structured programs in which patients remain for half a year to twelve months. Those in treatment usually have long histories of drug addiction, have often been involved in criminal activity and may have reduced social functioning. Treatment communities have become so evolved that they may also be structured to accommodate women who are pregnant or have children. The purpose of treatment communities is to help the individual learn how to behave in society without drugs.
In conclusion, with the proper mix of effort on the part of the individual, the proper care by practitioners, medications and community, a formula for success on the part of the substance user can be acquired. With that formula put in motion, an addict can become a former one and go on to live a happy and fulfilling life.
Since the 1960s, many addicts have reported that even a single dose of ibogaine, a hallucinogenic alkaloid extracted from the root of an African shrub, helps them kick their habit by reducing their cravings for drugs. And there is hard evidence to back these claims, as well.1 Ibogaine was first introduced as a potential treatment for opiate addiction by Howard Lotsof, who took the drug in 1962 looking for a psychedelic experience, and awoke 30 hours later with no cravings and no withdrawal symptoms, despite being a heavy heroin user at the time.2 Lotsof was able to develop and follow an ibogaine maintenance program, which he then followed for three years while remaining opiate free. In 1986, Lotsof opened a company by the name of NDA International to advocate for the use and research of ibogaine and its active constituents as anti-addictive compounds.
Since ibogaine aides in the cessation of addiction, it started to be used to deal with opiates and other substance addictions. Ibogaine has only been introduced to Western scientific medicine but has documented use by the Bwiti tribe in Central Africa for centuries. At lower doses ibogaine has the ability to increase energy and mental alertness and appears to decrease the desire for food and drink. Higher doses (20+ mg/kg) of ibogaine have a larger psychoactive property, and is used ritualistically in initiation rites for its potent hallucinogenic properties. 3
Barbara E. Judd, CSW did a study on ibogaine and stated that the most difficult aspects of treatment are getting the patient to enter treatment. 4 She notes that the three major obstacles are the fear of detoxification lack of insight, and the inability of patients to control their urges to use drugs. It was in these three areas where she felt the benefits of ibogaine treatment far outweighed those of traditional methods. Judd further states that psychological fear of pain and withdrawal prevents many addicts from even attempting detox. Addicts feared having to deal with the emotions that lead them to use in the first place. Judd adds that when patients learn the benefits of ibogaine they are more willing to try it.
Like all forms of detox, ibogaine is not without risks and side effects. At therapeutic doses, ibogaine has an active window of 24 to 48 hours, is often physically and mentally exhausting and produces ataxia for as long as twelve hours.5 Nausea that may lead to vomiting is not uncommon throughout the experience. These side effects reduce the attractiveness of ibogaine as a recreational drug at therapeutic doses, however, at lower doses ibogaine is known to have stimulant effects. It is still a controversial and experimental drug and there are some cases of fatal cardiac arrhythmias.
There are two types of ibogaine treatment. The first type of treatment is oriented toward addiction, most commonly heroin dependence, and typically involves dosages in the range of 15 to 25 mg/ kg .5-8 The second type of treatment, also know as “initiatory," involves a dosage on the order of 8 to 12 mg/kg, or about half of the dose used for addiction and is used for spiritual insight and facilitating psychotherapy. 9-11. In addition to reducing craving, ibogaine often promotes a sense of wellbeing that can last from weeks to months. As the studies into the nature of ibogaine progress, scientists have discovered that ibogaine's anti-additive properties are actually two-fold. First, when the substance is consumed, the body produces a chemical called noribogaine. Noribogaine blocks the brain's receptors that control cravings. Noribogaine also increases dopamine and serotonin levels, which elevate feelings of wellbeing.
So while ibogaine is not a substitute for drugs, and is not addictive, ibogaine is a chemical dependence disruption and a chance for patients to get a head start on recovery. Ibogaine enables the patient to focus on the underlying causes of addiction without going through the intense withdrawal symptoms that accompany most types of detoxification. And, even if there are some remaining symptoms after ibogaine detox they are more tolerable than other detox approaches.13 Studies show that ibogaine has the ability to drastically attenuate drug withdrawal in all patients and, in 90 percent of treated patients during one case study, to interrupt the patient's craving to continue drug use for periods of time ranging from as short as two days to as long as two and a half years from a single treatment.14
Heroin addiction is one of the most difficult addictions to overcome. The heroin abuser’s nervous system becomes accustomed to accommodating chronic exposure to the drug, which is an opioid. Therefore, during heroin detoxification excruciating withdrawal symptoms are ubiquitous. Withdrawal symptoms begin within 12 hours of not using and peak after two to four days. The symptoms include: nausea, anxiety, diarrhea, abdominal pain, insomnia, chills, sweating, sniffing, sneezing, weakness and irritability. Even though there have been improvements in medically supervised heroin detoxification, patient discomfort and high dropout rates exist today. This has led to the growth of ultra-rapid, anesthesia-assisted opioid withdrawal procedures, which have been publicized as a fast, painless way to withdraw from opioid. Studies have also shown however, that the procedure can lead to risk of death, psychosis, increased stress, delirium, attempted suicide, abnormal heart rhythm and acute renal failure. And, the anesthesia method comes at a high price between $5,000 and $15,000.1
Francis Moraes wrote in The Little Book of Heroin, that there are three important brain chemicals or neurotransmitters that relate to heroin. First, dopamine helps to control human appetites for both food and sex. If a person has large quantities of dopamine they are considered out-going and exuberant. Persons who suffer with Parkinson’s disease and depression are said to have too little dopamine. On the other hand, people suffering from schizophrenia have too much. Heroin causes a release of dopamine. Second, norepinephrin controls the sympathetic nervous system: nerves of the body that cannot be voluntarily controlled. This neurotransmitter stabilizes blood pressure so that it does not get too low. The brain’s release of norepinephrin stimulates the fight or flight response. But heroin suppresses the middle part of the brain called the locus coeruleus and therefore provides the user with feelings of safety and contentment. Third, endorphines, which are morphine-like chemicals, used by the body to modulate mood, promote pleasure, and manage reactions to stress.2 These three chemicals are exaggerated or heightened by heroin use.
There are several forms of heroin detoxificaion including opioid agonist drugs, such as methadone, levo-alpha-acetylmethadol (LAAM), or Buprenorphine; Clonidine, which blocks some withdrawal symptomps ;ultra-rapid opioid detox under anesthesia; and an experimental method using the drug lofexidine. Opioid agonist drugs act like heroin but do not provide the same high and are administered in gradually decreasing doses. Since these medications act like heroin there are no withdrawal symptomps. 3 Clonidine can be administered by a transdermal patch, which gives the drug constantly over a seven- day period. Patients using the patch should also take Clonidine orally for the first two days since the transdermal medications takes two days to reach a steady effectiveness. Clonidine causes hypotension and sedation and therefore blood pressure monitoring is essential. Ultra-rapid detox is done under general anesthesia with intubations for six to eight hours. During this time a combination of drugs, usually naltrexone and Clonidine are administered.3 Lofexidine, a non-addictive drug brought to the market in 1992, is a centrally acting alpha-2 adrenergic agonist targeted for relief of opiate withdrawal symptomps.
Withdrawal symptoms continue to be the greatest obstacle in heroin detoxification treatment. Studies concur that there is no proof that one detoxification treatment is better than another. Relapses continue to occur in numerous cases around the world therefore making heroin detoxification a monster of an addiction. Statistics show that the average heroin addict will stop and start detox 10 to 25 times in their lifetime relapsing to heroin use every time.4
Heroin detoxification involves admitting there is a problem, seeking medical help, staying focused on the goal and rehabilitation and treatment through a continuing program. All facts conclude that there is no easy cure nor guarantee that relapse will not occur. The determination of the patient and support through family, friends, physicians or other sources must accompany the detoxification process. Long-term treatments that are drug-free or use medications as part of the treatment are useful in detoxification. Solutions 4 Recovery sights, “the best-documented drug-free treatments are the therapeutic community residential programs lasting at least 3 to 6 months.”5
Many times, although not physically dependent on heroin, psychological cravings will overcome the former user throwing him or her into relapse. Overseas studies have proven that detoxification does not work alone in the treatment process.
The body’s reaction to the removal of a substance it has become dependent on is called withdrawal. Withdrawal causes craving for more of the substance being removed. The period of time when the body is trying to overcome its addiction is called detoxifica-tion (detox). Detox is the first step in overcoming a substance addiction such as drugs or alcohol. Detox is a pertinent step for the patient is to be successfully rehabilitated.
Opiate drugs such as heroin and methadone, and prescription medications including Hydrocodone, Oxycontin, Xanax, Vicodin and Lortab, require medical detox supervision. There are however, other illegal drugs such as marijuana, crystal methampetamine, and cocaine that do not require medical detox. Since there is psychological dependence associated with these drugs, it would be wise to complete a period of stabilization.1 The process of drug detox requires the patient to be closely monitored by keeping vital signs, giving support and administering medications if needed. There are numerous withdrawal symptoms or side effects when a patient stops or dramatically reduces drugs after heavy or prolonged use. Those side effects include: sweating, shaking, headaches, drug cravings, nausea, vomiting, abdominal cramps, diarrhea, sleeplessness, confusion, agitation, depression, anxiety, and other behavioral changes.
There are two commonly used drugs to enable the patient to feel relief from these symptoms. First, Klonepin, which reduces physical symptoms, and Buprenophex, which is an anticonvulsant. These drugs must also be monitored as cessation produces withdrawal symptoms. Generally, the time period for drug detox is three to seven days under medically monitored supervision.1
Alcohol detox, like drug detox, is usually accomplished in an inpatient medical facility. Duncan Raistrick identifies the key to a successful, planned detoxification is preparation. Raistrick goes further to detail that the first job of therapy is to bring the patient to a point of readiness to change their drinking behavior. Second, patients need to be given accurate information about what to expect during detoxification.2
There are two withdrawal categories: minor, meaning early withdrawal and major, meaning late. The severity of withdrawal depends greatly on the duration of alcohol used.3 Alcohol Withdrawal Syndrome (AWS) falls into three main categories: central nervous system (CNS) excitation, excessive function of the autonomic nervous system (ANS), and cognitive dysfunction.5 Richard Saitz, M.D., M.P.H., states, since alcohol enhances gamma-aminobutyric acid's (GABA) inhibitory effects on signal-receiving neurons, neuronal activity is lowered. This lowering leads to an increase in excitatory glutamate receptors. Tolerance occurs as GABA receptors become less responsive to neurotransmitters, which in turn requires more alcohol to produce the same inhibitory effect. During detox, the GABA is ineffective and unable to suppress the excitatory glutamate receptors.6 Detox is intended to relieve physical symptoms such as: shaking or tremors, headaches, vomiting, sweating, restlessness, loss of appetite, sleeplessness, Delirium Tremens (DT’s), hyperactivity, and convulsions. Alcohol detox medications are similar to drug detox medications: Buprenophex, certain benzodiazepines and anticonvulsant medications. Alcohol detox completion can take from three to fourteen days.1
Norman S. Miller notes that medical management of alcohol and drug withdrawal during detoxification often is not sufficient to produce sustained abstinence from recurrent use. Therefore, further addiction treatments are needed to prevent to alcohol and drug use following treatment of withdrawal.4
In conclusion, drug and alcohol detoxification can effectively prepare the addicted abuser for rehabilitation and treatment.
Some physicians believe the withdrawal phase is related closely to the drug addiction - the worse the withdrawal, the more likely the continued use of the chemical to prevent withdrawal. Several factors are key to successful detoxification.
1. Acknowledge that there is a problem and decide to do something about it.
2. Get rid of all the drugs and paraphernalia.
3. Drop friends and associates that are tied to our drug problem.
4. Seek and accept spousal support, or support from friends, or relatives.
5. Prepare for symptoms with the support of a professional.
6. If tranquilizer drugs are needed for a few days or longer, they must be handled sensitively, as one addiction can easily replace another.
Close to a million individuals in US are addicted to opioids and yet less than 20% receive any treatment for their addiction. The best management for these chronic addicts is medical treatment which decreases their addiction and improves their social status in society. For the past 4 decades, methadone has been the treatment of choice for the treatment of drug addicts. However, all methadone programs have long waiting lists, have rigid admission criteria and the majority of methadone programs are only found in large urban cities. Current data indicate that buprenorphine, which is a partial opioid receptor agonist, may also be effective for treatment of opioid addiction.
The Drug Addiction Treatment Act of 2000 allowed physicians to provide office-based treatment for opioid addiction. This Federal Legislation allowed physicians to prescribe Schedule III, IV, or V "narcotic" medications that were approved by the U.S. Food and Drug Administration for patients with opioid addiction. In 2002, the FDA approved buprenorphine and combination ofbuprenorphine/naloxone (Suboxone) to manage opioid dependence.
Buprenorphine (Suboxone)
Buprenorphine, is an opioid drug with partial agonist and antagonist activity. Buprenorphine was first marketed in the 1980s as an analgesic, yet today it is primarily used for the treatment of opioid addiction. It has a longer duration of action than morphine, and sublingual administration offer an analgesic effect which lasts 6 to 8 hours. Because the drug can not be reversed by naloxone, it is not recommended for pain control.
When used for opioid dependence, buprenorphine remains effective in the body for up to 48 hours, decreases the tendency for withdrawal syhimptoms and counteracts the effects of concomitant opioids that may be taken by the patient.
Side Effects
Buprenorphine does have some side effects and these include nausea, vomiting, drowsiness, dizziness, headache, itch, dry mouth, meiosis, orthostatic hypotension, dfficulty with ejaculation, decreased libido, urinary retention, and constipation. Rare cases of liver necrosis and hepatitis with jaundice have been reported with the use of buprenorphine. For those who receive buprenorphine, the liver function is regular monitored. The most severe and serious adverse reaction associated with buprenorphine use is respiratory depression which can be fatal. This is particularly problematic with buprenorphine because unlike morphine, there is no effective antidote.
Additionally, concurrent use of buprenorphine and CNS depressants (such as alcohol or benzodiazepines) is contraindicated as it may lead to fatal respiratory depression.
Dependence
As with other opioids, buprenorphine can produce both physical and psychological dependence. However, unlike other opioids, users of buprenorphine rarely develop a tolerance to the drug. Maintenance dosages can remain at the same moderate level and in many cases even lowered, without causing withdrawal symptoms.
Treatment of Opioid Dependence
Sublingual buprenorphine preparations are often used in the management of opioid dependence (such as heroin, oxycodone, hydrocodone,morphine). The use of buprenorphine replacement therapy in the management of opioid dependence is regulated and monitored. In the United States, a special federal waiver is required to prescribe Subutex on an outpatient basis. Each Federally approved physician is allowed to manage only 30 patients on buprenorphine for opioid addiction as outpatients.
Withdrawal Symptoms
The partial agonist/antagonist activity of buprenorphine means that it may precipitate withdrawal symptoms when an opioid-dependent patient is commenced on the drug soon after the use of another opioid drug. Patients are advised to wait between 24 and 36 hours after their last use of short-acting opioids (such as heroin or oxycodone) before beginning treatment with buprenorphine. Those who are on methadone should only be treated with buprenorphine once withdrawal symptoms are present. Beginning any earlier may result in extreme cases of opioid withdrawal.
BUPRENORPHINE vs. METHADONE
Buprenorphine and methadone are both used for short-term and long-term opioid maintenance therapy. Each agent has its relative advantages and disadvantages.
Buprenorphine sublingual tablets have a long duration of action which may allow dosing every two days, compared with the daily dosing required with methadone. In the United States, following initial management, a patient may be prescribed one month supply for self-administration on the condition that the patient receives other dependence therapy.
Buprenorphine may have a lower dependence-liability than methadone. Buprenorphine treatment typically lasts several months (though sometimes for only a few weeks or up to two or three years), as opposed to an indefinite, often life-long methadone regimen.
Buprenorphine itself appears to have less-severe withdrawal effects than methadone, and thus it is easier to discontinue use. Buprenorphine, as a partial μ-opioid receptor agonist, has been claimed to have a less euphoric effect compared to the full agonist methadone, and was therefore predicted to be less likely to be diverted to the black market.
DETOX AND REHABILITATION
The practice of using buprenorphine in an inpatient rehabilitation setting is increasing rapidly. These rehabilitation programs consist of "detox" and "treatment" phases. The detoxification phase consists of medically-supervised withdrawal from the drug of dependency, sometimes aided by the use of medications such as buprenorphine and valium.
Buprenorphine is sometimes used only during the detox protocol with the purpose of reducing the patient's use of mood-altering substances. It considerably reduces opioid withdrawal symptoms that are normally experienced by opioid-dependent patients on cessation of those opioids, including diarrhea, vomiting, fever, chills, cold sweats, muscle and bone aches, muscle cramps and spasms, restless legs, agitation, gooseflesh, insomnia, nausea, watery eyes, runny nose and post-nasal drip, nightmares, etc. The buprenorphine detox protocol usually lasts about 7-10 days, provided that the patient does not need to be detoxed from any additional substances such as barbiturates, benzodiazepines, or alcohol.
Dosing
During detoxification Buprenorphine is administered on a daily basis. Generally, the patient receives a single dose each day to ensure a consistent active level of the medication remains in the patient's central nervous system. Typically, the initial daily dose totals around 8-16mg. The dosage is slowly tapered each day and the medication is usually stopped 36-48 hours prior to the end of the detox program, with the patient's vitals monitored up until discharge from the detox program.
Summary
Buprenorphine is an alternative and not a replacement agent for methadone in patients with opioid dependence for opioid agonist therapy in patients with opioid dependence. Buprenorphine is viable in the primary care setting, which enhances treatment accessibility, and may be a better initial choice for patients at greater risk of respiratory depression, such as elderly patients and those taking benzodiazepines. Choice of first-line treatment will depend on patient preference, expectations, past treatment experiences and side effect profile as well as availability, dispensing regulations, cost and government reimbursement schedules. However, regardless of choice of methadone or buprenorphine, patients with opioid dependence do best in a comprehensive program involving opioid agonist treatment, counseling and support.
What is Ativan?
Ativan, otherwise known as Lorazepam or Temesta, is a drug in the benzodiazepine class of drugs which includes most tranquilizers. Ativan has many uses which include: sedative/hypnotic effects, muscle relaxant, anxiolytic (to reduce anxiety), amnesic and anticonvulsant (or to prevent seizures). It has also been used in conjunction with other drugs as an anti-emetic, which means it can stop vomiting.
How do you take this drug and how long does it take to work?
Ativan can be taken multiple ways. Lorazepam may be administered orally, by patch, sublingually or under the tongue, through muscular injection or by IV. If administered through IV, effects can begin within one minute. If given via injection, it can take up to an hour for the recipient to feel the results. When taking Ativan by mouth it can take up to two hours in order to work. Unlike other benzodiazepines, because Ativan has been found to have a high affinity for GABA receptors in the brain which may explain the strong amnesic effect it can have. Because of the strength associated with the drug, it is important that the dosing of Ativan not be all in one shot. So, unless Ativan is prescribed just for night sedation, its best to split up the doses to several throughout the day.
Under what conditions is Ativan usually prescribed?
• Substance Abuse Withdrawal – Treatment and prevention of symptoms of alcohol withdrawal.
• Vomiting and Nausea- Often administered with chemotherapy treatment to treat nausea and vomiting. It’s usually combined with other medications to prevent vomiting.
• Anxiety- For severe anxiety disorders.
• Pre-medication- Often administered orally or IV before a general anesthetic which should help to reduce anxiety. Health staff must take precautions (chaperoning and avoiding ambiguous language and gestures) against patients later making unjustified allegations of sexual abuse during treatment, due to impaired memory and to drug-induced misinterpretations.
• Mania and Extreme Agitation- To quickly offer sedation to violent or agitated patients. It is usually given with haloperidol, another sedative.
• Seizures- Often administered for treatment of status epilepticus (refers to the brain being in a state of persistent seizure which can be life threatening).
• Insomnia- Short-term treatment of insomnia, particularly if associated with severe anxiety.
Is Ativan Addictive?
Like all benzodiazepines, Ativan has potential for being addictive. Since Ativan is utilized specifically to help individuals detox from alcohol, there is potential for dependence on this drug. If Ativan has been prescribed to help with detoxification, it should be done under supervision. Dependence isn’t the only reason Ativan can be a problem, since perhaps the most dangerous part of Ativan use, is mixing it with alcohol. Ativan itself is not usually fatal in overdose; however, it can cause respiratory depression, which means an individual’s breathing may slow, if taken in overdose with alcohol. This occurrence is mixed with the usual effects of alcohol which include disinhibition and anterograde amnesia or memory loss. All these factors together can lead to severe problems.
In addition, continuous Ativan use can lead to a slue of side effects that can cause immediate damage (respiratory depression, i.e. not breathing) to causing social problems (amnesia- not remembering you insulted your in-laws) to bring on serious long term damage (liver failure- which means drinking alcohol is truly no longer an option).
More side effects of Ativan are as follows:
• Cognitive Defects- Long term therapy can produce thinking problems, especially in the elderly. This may be reversible after a period of discontinuation.
• Liver failure- Though Ativan is safer than other benzodiazepines, it can still affect liver function if not monitored.
• Kidney failure- Possibility of kidney damage.
• Respiratory failure- Excessive use (especially when mixed with alcohol) can cause an individual to stop breathing.
• Pregnancy and breast feeding- If Ativan is used during the first trimester of pregancy, it can cause harm to the unborn baby. This includes= respriatory depression and neonatal jaundice. For mothers planning on breast feeding, Ativan is excreted in breast milk, so one must be careful.
• Reduced Responsiveness- After an Ativan injection, a patient should not be aloud left alone due to residual effects like: vertigo, hypotension, sleepiness. Furthermore, driving a car is probably not a good idea for about 24 hours.
• Paradoxical effects- there are some instances in which, instead of calming the person down, Ativan use results in increased hostility and aggression. This is thought to be attributed to disinhibition and the incidence is higher in people with personality disorders. These side effects are dose related and usually subside when dose is reduced, or after a complete withdrawal.
• Suicidality- There is the chance that Ativan can bring out suicidal ideations in depressed patients. The thought behind this is again, disinhibition. This may cause one to be more willing to express suicidal thoughts. This is why Ativan should be prescribed with another antidepressant.
• Amnesia- After 2-3 days of regular use, Ativan probably won’t still be causing amnesia. To avoid amnesia/sedation from being an issue, patients should not be prescribed above 2 mg a day initially, including at night.
• Tolerance- this can occur with any benzodiazepine. With Ativan, after 4-6 months, the drug is not shown to continue working. Meaning after this period of time, chances are, continued use would not have the desired effect. This does not mean, however, that use should be stopped abruptly. Doing so can cause symptoms of withdrawal which include severe anxiety, which most cases, was what the drug was being used for to begin with.
Why Would Someone Abuse Ativan?
Most likely abusers started out using Ativan to decrease anxiety and became addicted to it. In all likelyhood they did not start out using Ativan which intention of becoming addicted. However, whatever their reasons are, abuse of the drug can be deadly and does need to be treated.
