Drs. Paul Martin and Michael Baca-Atlas co-presented a talk on “Detox Updates: Alcohol, Opioids, Benzodiazepines and Stimulants” at the Governor’s Institute’s recent Addiction Medicine 2020 conference. We followed up with several questions posed during the presentation.
Conference participants can view the Powerpoint and video at eeds.com.
Question for Paul Martin, MD: I’m curious about home detoxing options. During this pandemic, the ED is sending more patients home requesting a home detox. Do you have any medication protocols for alcohol and opioid detoxing at home? Also, who would you consider to be a safe versus an unsafe candidate for a home detox if someone does not feel comfortable going to the hospital right now?
A: Home detox should be done only if a responsible person can be present to administer medication on a scheduled basis and to assure that the patient is abstaining from alcohol. Because of the potential interaction of alcohol and medication, if the individual resumes drinking at home, benzodiazepines are probably safer than phenobarbital. The dosing is somewhat dependent upon the individual’s size, alcohol tolerance and intercurrent health conditions (e.g. COPD).
A rather standard protocol for adults of normal body mass and no other health conditions would be 75 mg TID with an extra dose if needed to control agitation for 2 days, then 50 mg TID for 2 days, then 25 mg TID for 1 day then 25 mg BID for 1 day, then 25 mg qd for one day.
Without a history of severe detoxification complications (DTs, seizures, etc.) or medical complications (e.g .severe angina, severe hypertension, epilepsy, poorly controlled diabetes), home detox is probably safe if the maximum BrAC is less than 150 mg/dl. For those with tolerance (i.e. used to a BrAC>200) or who show significant withdrawal symptoms with above dosing, treatment at a Facility Based Crisis/Detox Center or hospital would be recommended. Nausea can be treated with prn Phenergan 12.5 – 25 mg. Individuals should be encouraged to maintain hydration.
Questions for Michael Baca-Atlas, MD: Recommended treatment of buprenorphine induced PPT withdrawal? More Buprenorphine? Amount?
A: Precipitated withdrawal can be challenging to manage. We do not have randomized controlled trials to guide treatment, but expert opinion suggests starting with low doses of buprenorphine (2-4 mg) and titrating up until symptoms become more tolerable or resolve. If the patient is in an ER setting, be mindful if you are admitting that patient you may feel more comfortable with increasing doses further (16-24 mg) vs. a patient planning to be discharged from the ER.
Q: Are pregnant patients limited to mom product or can they now take the bup-Nal?
A: Pregnant women can utilize the combo product (buprenorphine-naloxone) in pregnancy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830675/
Q: Up to 32-40mg of bup for treatment of fentanyl? What about the ceiling effect of bup at 24mgs?
A: The ceiling effect has been well described in many studies, but this was examined with patients using heroin. Due to increased potency of fentanyl at the mu receptor, we hypothesize that patients may need higher doses. This is not based on rigorous evidence, but a limited number of cases as intentional fentanyl use is less commonly seen. 24 mg of buprenorphine does not block all mu receptors. There is 1 published case report of a patient successfully receiving 40 mg to alleviate cravings and withdrawal in the setting of fentanyl use. I have 1 patient who I followed who continues to do well on 32 mg daily for prior fentanyl use. These cases raise questions about higher doses in the setting of more potent synthetic opioids.
Q: There have been over 12 legal cases brought in response to poorly treated opioid withdrawal while incarcerated…is there data on mortality in the setting of opioid withdrawal to make sure we’re not being too confident?
A: One of the challenges in correctional health is we know inmates are obtaining methadone and buprenorphine illicitly while incarcerated, but are not receiving treatment widely in these settings. Opioid withdrawal is not fatal, but intoxication combined with other substances obtained while incarcerated can be fatal due to respiratory suppression leading to death. I think it’s important to clarify what part of substance use we are talking about (intoxication vs. withdrawal). I am not aware of any data sets that look at opioid withdrawal and fatalities specifically. However, we do know that when individuals are released they are at significantly increased risk of death due to reduced tolerance. https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.304514
Q: Great points about nicotine. I’d love to hear some of the language you use with talking to patients about nicotine with co-occurring SUD.
A: I usually bring this up with my patients at almost every visit to re-assess readiness because of the impact of tobacco on poor health outcomes. “Remind me what your tobacco use has looked like this past month?” I think a big misconception is individuals with SUD do not prioritize other health needs. Many patients are highly motivated to get their preventative health up to date and quit smoking even in the setting of ongoing substance use. I try to make a personal connection for them with smoking: a loved one who passed away, challenging symptoms including both physical health and mental health, or how it impacts their risk of relapse. This is a marathon not a sprint when it comes to something like tobacco cessation that has been a part of their lives for potentially many years. https://www.ahrq.gov/prevention/guidelines/tobacco/5rs.html
We’ll answer more questions from the virtual Addiction Medicine Conference in upcoming newsletters. Be on the lookout!