ambulatory withdrawal management
DESCRIPTION
Ambulatory Withdrawal Management. Ambulatory Detoxification & more SAMHSA: outpatient treatment services providing for safe withdrawal in an ambulatory setting. - Managing acute and post-acute withdrawal symptoms in an outpatient setting. What is it?. - PowerPoint PPT PresentationTRANSCRIPT
Ambulatory Withdrawal ManagementGreg Sutmiller MS, LPC, LADC
What is it?
• Ambulatory Detoxification & more
• SAMHSA: outpatient treatment services providing for safe withdrawal in an ambulatory setting
- Managing acute and post-acute withdrawal symptoms in an outpatient setting.
Why is it needed?
• “Opiates are outranked only by alcohol as humanity’s oldest, most widespread, and most persistent drug problem.”
• Harvard Mental Health Letter, 2004
• Dr. Leo Kadehjian
Why is it needed?
• Drug Overdose (OD): 2nd leading cause of unintentional deaths after motor vehicle fatalities
• CDC, 2010
• Opioids: 93% of prescription OD deaths• JAMA 2008
• Prescription OD deaths increased x4 since 1999 (>heroin + cocaine combined)
• CDC, 2013
• Heroin OD deaths +45% 2006–2010• SAMHSA, 2013
• Dr. Leo Kadehjian
Why is it needed?
• United States’ Drug Consumption • 4.6% of world population• Consumes 2/3 of illicit drug supply• Consumes 80% of global opioid supply• Consumes 99% of global hydrocodone supply • L. Manchikanti and A. Singh, 2008
• Dr. Leo Kadehjian
Why is it needed?
• Oxycodone per Capita • DEA 2013 Oxycodone Production Quota:
135,000 kg• 2011 U.S. Population: 311,591,917 • 135,000 kg / 311,591,917 persons =
422 mg/person!
• Dr. Leo Kadehjian
Why is it needed?
• Tolerance builds up significantly and quickly.• Tolerated dose can increase 10x in as little as two weeks and
up to 35x ultimately.
• Opiate drugs are becoming more potent.• OxyContin• Heroin• 60%-80% currently vs. 10% or less in 1970’s
• More people are abusing opiates and becoming opiate dependent.• The age of initiation is getting lower.• Baby boomers are becoming dependent.
• Steve Hanson
Why is it needed?
Why is it needed?
• Lots of people are opiate dependent!
• Lots of people need to get off opiates!
• What happens when opiate dependent people come off opiates?
Why is it needed?
Why is it needed?
• Key Component #4• “Drug courts provide
access to a continuum of alcohol, drug, and other related treatment rehabilitation services.”• Includes detoxification
Why is it needed?
• NADCP Best Practice Standards• Part of the continuum of
care• Determined by standardized
assessment (not phase or professional judgment)• ASAM-PPC
• Participants cannot be sanctioned for substance use if they are at a lower level of care than they need.
Why is it needed?
• ASAM• Least Restrictive• Level I-D: Ambulatory
Detoxification Without Extended Onsite Monitoring
• Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring• Requires specific medical
staff: RN/LPN, PA, NP, Physician
• Requires daily monitoring
Who’s it for?
• Alcohol and Opiates• Focus on Opiate
Withdrawal
• Opiate Dependent• Mild to Moderate
Withdrawal Symptoms• COWS
• ASAM Dimensions• Assessment Driven
Who’s it for?
• COWS
What’s the goal?
• Stabilization
•Manage Withdrawal Symptoms
• Eliminate Illicit Opiate Use
What’s the goal?
• Get Started• Feel better• Engage in
treatment• Manage
responsibilities
What’s the process?
• Regular Office Visits• Every few days to every day
based on need• ASAM Level I-D• ASAM Level II-D
• Check in• Vital signs• Assessment• Medication• Drug Screens• Therapy and/or other
psychosocial services
What’s the process?
• Assessment• COWS• Physical• Psychological• Case Management
What’s the process?
• Medication• Managing Symptoms• Clonidine, nausea & diarrhea
meds, hypertension meds, etc.
• Full Agonist• Methadone
• Partial Agonist• Buprenorphine (Subutex)
• Partial Agonist w/ Antagonist• Buprenorphine-Naloxone
(Suboxone)
• Full Antagonist• Naltrexone (Revia, Depade,
Vivitrol)
What’s the process?
Medically Assisted Treatment (MAT)• NADCP Best Practice Standards• “Participants are prescribed psychotropic or addiction
medications based on medical necessity as determined by a treating physician with expertise in addiction psychiatry, addiction medicine, or a closely related field.”
• MAT can…• Improve outcomes• Increase engagement in treatment• Reduce illicit drug use• Reduce other program violations
What’s the process?
Buprenorphine and Medically Supervised Withdrawal• BUP can be used to cease opiate use or to transition out
of agonist (methadone) treatment.• Cease opiate use• Withdrawal symptoms present• 1-2 initial doses on first day• Build up dose over next couple days• Make sure consumer is compliant and stable• Reduction of dose over next few days• Some consumers may need to take longer in reduction
phase or enter maintenance treatment
What’s the process?
• Drug Screens• Screen for the
Standards• Screen for Specific
Opiates• Screen for
Metabolites
What’s the process?
• Therapy and Other Psychosocial Services• VITAL• Outpatient (ASAM Level I)• Intensive Outpatient
(ASAM Level II)• Daily if necessary
• Individual, Group, Case Management, Recovery Support
• Coordination is key!
What does a specialty court need to consider?
• Coordination• Communication• Team members• Other service providers
• Adequate Team Representation• Medical professional(s)
• Innovation• Creativity• Caution
References
• Hallford, J. (2014, July 25). Personal interview.• http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/secti
on-iii-action-heroin-morphine/10-addiction-vs-dependence• http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_095.htm• http://www.nadcp.org/sites/default/files/nadcp/KeyComponents_0.pdf• http://www.ncbi.nlm.nih.gov/books/NBK64109/• http://www.ncbi.nlm.nih.gov/books/NBK64158/• http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140220/• http://www.norcen.org/addiction/ambulatory-detoxification• http://www.samhsa.gov/data/2k13/TEDS2011/TEDS2011NChp4.htm• http://www.windmoor.com/programs/ambulatory-opiate-detox.stml• National Association of Drug Court Professionals. Adult Drug Court Best Practice
Standards: Volume I. 2013, Alexandria, VA.• Substance Abuse and Mental Health Services Administration. TIP 40: Clinical Guidelines
for the Use of Buprenorphine in the Treatment of Opioid Addiction. 2004, Rockville, MD.• Substance Abuse and Mental Health Services Administration. TIP 43: Medication-Assisted
Treatment for Opioid Addiction in Opioid Treatment Programs. 2005, Rockville, MD.
