L02

Question 1

What is withdrawal?

Answer 1

Longer the half-life of a drug the longer the symptoms will last
General depression is a symptom of withdrawal due to the lack of the substance or lack of the relaxation effect.
For sedatives, hypnotics and anxiolytics withdrawal can peak in 24 hours or take up to a week to be out of the system.
Lorazepam and oxazepam are 6-8 hours after ended will lead to withdrawal.
Diazepam may not develop withdrawal for a week or two and decrease of withdrawal in three or four weeks.
15mg of diazepam can produce withdrawal
Higher doses of diazepam can produce seizures or delirium.

Question 2

DSM-5 Criteria for Substance Withdrawal

Answer 2

Criteria A: the essential feature is the development of a substance-specific problematic behavioural change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged use of a substance.
Criteria C: substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criteria D: symptoms are not due to another medical condition and are not better explained by another mental disorder.
NOTE: withdrawal is USUALLY, not always, associated with a substance use disorder. Most individuals with withdrawal have an urge to re-administer the substance to reduce the symptoms.

Question 3

Alcohol (ETOH)

Answer 3

Long term use influences how withdrawal is experienced
Onset of withdrawal is 6-24 hours and can continue for 3-5 days
Symptoms of alcohol withdrawal: anxiety, memory loss, psychomotor issues, delirium tremens, tremors, agitation, restlessness, nausea, insomnia, concentration issues, diaphoresis, increased blood pressure, temperature, and heart rate.

Question 4

Medical emergency related to alcohol withdrawal

Answer 4

-disorientation, delusions, visual hallucinations, seizures
Wernicke’s Encephalopathy- ataxia, eye normalities, mortality rate of 15-20%
Korsakoff’s Syndrome(chronic phase) alcohol amnestic/ neurocognitive disorder (thiamine deficiency).
Persisting dementia (alcohol dementia).

Question 5

Clinical institute withdrawal assessment of alcohol scale (CIWA)

Answer 5

Initial assessment- any client who reports and ETOH use should have a CIWA done
Subsequent monitoring- scores over 10 should have CIWA redone every 12 hours until withdrawal is finished.
As needed- CIWA can be administered at any time when the nurse feels necessary.

Question 6

What is detoxification?

Answer 6

An early tx stage in which the body eliminates the substance
Alcohol- abstinence syndrome that develops is medically more severe and more likely to cause death than withdrawal from opioid drugs.
With alcohol, untreated advanced stages, mortality can be as high as 1 in 7, due to this it is highly recommended that initial period of detox should be in an inpatient medical setting.

Question 7

Detoxification

Answer 7

Pharmacological interventions are initiated in two different phases of dependence cycle: detoxification and maintenance.
Detox: initial and immediate goal to have meds alleviate unpleasant withdrawal symptoms.
Maintenance: long term strategy to help dependent avoid relapsing to the abused drug.
3 major strategies are used:
1) agonist or substitution therapy- used to induce cross tolerance to the abused drug, typically safer routes of administration and diminished psychoactive effects.
2) antagonist therapy- used to produce extinction by preventing user from experiencing the reinforcing effects of abused drug.
3) aversion therapy- used to produce aversive reaction following ingestion of abused drug

Question 8

ETOH Detox

Answer 8

Medications that can aid in ETOH detoxification: benzodiazepines, barbiturates, beta blockers, and Antabuse.

Question 9

Benzodiazepines

Answer 9

Diazepam (Valium)- drug of choice, long half life, more effective.
Alprazolam (Xanax)- used when symptoms need to be controlled rapidly.
Lorazepam (Ativan)- lower risk of sedation, safer in those with liver deficiencies.
Oxazepam (Serax)- can be given IM or oral, short term use.

Question 10

Non benzodiazepine detoxification

Answer 10

Barbiturates- can be used in those who are tx resistant to benzodiazepines. Ex Phenobarbital
Beta Blocker- use in later stages in conjunction with benzodiazepines. Ex Atenolol for 7/7
Neuroleptics-drug of choice is haldol, does not lower seizure threshold, monitor for EPS
Antabuse- used in maintenance of abstinence; causes many unpleasant side effects such as facial flushing, diaphoresis, nausea and vomiting, tachycardia, MI, convulsions, respiratory depression, and death.
Naltrexone- blocks the effects of the substance that cause the “high” feeling that makes you want to use.
SSRI- treating the underlying cause of the alcoholism.

Question 11

Stimulant

Answer 11

Bradycardia is often present and is a reliable measure of stimulant withdrawal.
Anhedonia and drug craving are not part of criteria but can often be present
Acute withdrawal symptoms “a crash” can be seen after repetitive high dose uses “runs” or “binges” that have intense and unpleasant feelings of lassitude, depression, increased appetite-generally requiring several days of rest and recuperation.

Question 12

Tobacco

Answer 12

Withdrawal symptoms impair the ability to stop use.
Symptoms after abstinence are in large part due to nicotine deprivation
Symptoms much more intense for people who smoke or smoke less tobacco compared to those who use nicotine medications.
Typically heart rate decreases 5-12 bpm in the first few days of stopping smoking and weight increases an average of 4-7 lbs over first year of stopping smoking.
Craving for sweet and sugary foods and impaired performance in vigilant tasks are associated with tobacco withdrawal.
Abstinence can increase constipation, coughing, dizziness, dreaming/nightmares, nausea and sore throat.
Smoking increases metabolism of many medications so cessation of smoking can increase blood levels of these medications and can produce clinically significant outcomes.
50% of smokers start to experience symptoms after 2 or more days of cessation
Typically begin within 24 hours, peaks at 2-3 days and lasts 2-3 weeks

Question 13

Stimulant withdrawal

Answer 13

1) Dysphoria- general dissatisfaction with life
2) Hypersomnia- fatigue, inability to stay awake and alert despite adequate sleep
3) Psychomotor- retardation or slowing down of thought and reduction of physical movements
4) Agitation- irritable
5) Anhedonia- absence of pleasure
6) Increased appetite

Question 14

Stimulant half-life

Answer 14

Amphetamine 12-36 hours
Cocaine 45-90 minutes
Methamphetamine- 8-17 hours
MDMA/Ecstasy 7-9 hours

Question 15

Stimulant Detoxification

Answer 15

No medication has been developed for the specific tx of stimulant withdrawal
Symptom management
Supportive and sympathetic care

Question 16

Opioids

Answer 16

Characterized by patterns of signs and symptoms that are opposite to the acute agonist effects.
First are subjective- complaints of anxiety, restlessness, achy feeling located in back and legs typically along with irritability and increased sensitivity to pain.
Speed and severity of withdrawal associated with opioids depend on the half life of the opioid used.
Short-acting (heroin) - symptoms within 6-12 hours, acute withdrawal symptoms usually peak within 1-3 days and gradually subside over 5-7 days.
Long acting (methadone, buprenorphine)- symptoms may take 2-4 days to emerge.
Less acute withdrawal symptoms can last from weeks to months, more chronic symptoms include anxiety, dysphoria, anhedonia, and insomnia.

Question 17

Physical Examination of opioid withdrawal

Answer 17

Insomnia
Lacrimation- watery eyes, pupil size
Yawning-nose running
Body aches- restlessness, tremors, goose flesh
Irritability- anxiety
GI upset- nausea, vomiting, loss of appetite

Question 18

Opioid/Detox Management

Answer 18

Acetaminophen plus Codeine
Gravol- for nausea
Clonidine- for symptom reduction anxiety, sweating
Methadone- low dose therapy
Suboxone- Buprenorphine/Naloxone

Question 19

Clinical Opioid Withdrawal Scale (COWS)

Answer 19

Initial assessment- any client who reports any opioid use should have a COWS done
Subsequent monitoring- scores over 13 should have COWS redone every 12 hours until withdrawal is finished.
As needed- COWS can be administered at any time when the nurse feels necessary.

Question 20

Naloxone

Answer 20

Fast acting drug used to temporarily reverse the effects of opioid overdose.
Can restore breathing within 2-5 minutes.
Blocks the effects of opioid on your body
Only works if opioids are in your system (fentanyl, heroin, morphine, codeine).
Safe for all ages and cannot be used improperly.

Question 21

Opioid Detoxification

Answer 21

Symptom management
Supportive and symptomatic care
Acetaminophen for pain
Dimenhydrinate for nausea
Clonidine for anxiety and sweating
Methadone and Suboxone for harm reduction
Encourage fluids and nutrition supplements

Question 22

Hallucinogens withdrawal

Answer 22

Not all produce withdrawal symptoms, PCP and Ketamine do. Can start 30 minutes post and last up to 2-5 hours.
Stiff muscles, depressed breathing, convulsions, rapid heart rate, changes in body temp, anxiety, social isolation, cravings, headaches, sweating, seizures, flashbacks, irritability, delusions, suicidal ideation.

Question 23

Cannabis

Answer 23

Many users report smoking cannabis or taking other substances to help relieve withdrawal symptoms, many report that withdrawal make quitting difficult or have contributed to relapse.
Symptoms are not of sufficient severity to require medical attention.
Abducts and adolescents enrolled in tx or heavy cannabis users 95% report withdrawal.
Amount, duration, and frequency of cannabis smoking that is requires to produce an associated withdrawal disorder during a quit attempt are unknown.
Most symptoms have an onset of 24-72 hours of cessation, peak within first week and last approximately 1-2 weeks.

Question 24

Caffeine

Answer 24

Symptoms usually begin 12-24 hours after last caffeine dose and peak after 1-2 days of abstinence, symptoms can last for 2-9 days.
Caffeine is the most widely used behaviourally active drug in the world, it is present in many types of beverages- coffee, tea, soft drinks, energy drinks, foods, medications, and dietary supplements.
Caffeine is migrated into social customs and daily rituals therefore some people may be unaware of their physical dependence therefore caffeine withdrawal symptoms could be misattributed to other causes.
Probability and severity generally increase as a function of usual daily dose.
Caffeine abstinence has been shown to be associated with impaired behavioural and cognitive performance.
More than 85% of adults and children in the US regularly consume caffeine, adults ingesting about 280mg/day

Question 25

Impatient vs. Outpatient

Answer 25

Inpatient
Social detox- 7-14 days
Need to be medically cleared to attend
Provides safe environment, food, medication, group therapy.
Outpatient
Can remain at home
Daily check ins
Reviewed by physician
Community paramedics detox at home program

Question 26

Youth drug detox and stabilization act

Answer 26

Youth 12-17 years old
Involuntary detox for up to 15 days
Form A submitted to judge
Criteria to be met:
Suffering from a severe drug addiction/ abuse.
At risk of serious harm or danger to the,selves or others.
Need to be examined by a physician to determine whether admittance to a detox facility or receive stabilization services.