1 / 27

Ambulatory Withdrawal Management

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?.

genera
Download Presentation

Ambulatory Withdrawal Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Ambulatory Withdrawal Management Greg Sutmiller MS, LPC, LADC

  2. 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?

  3. “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?

  4. 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?

  5. 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?

  6. 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?

  7. 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?

  8. Why is it needed?

  9. 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?

  10. Why is it needed?

  11. 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?

  12. 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?

  13. 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 Why is it needed?

  14. Alcohol and Opiates • Focus on Opiate Withdrawal • Opiate Dependent • Mild to Moderate Withdrawal Symptoms • COWS • ASAM Dimensions • Assessment Driven Who’s it for?

  15. COWS Who’s it for?

  16. Stabilization • Manage Withdrawal Symptoms • Eliminate Illicit Opiate Use What’s the goal?

  17. Get Started • Feel better • Engage in treatment • Manage responsibilities What’s the goal?

  18. 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?

  19. Assessment • COWS • Physical • Psychological • Case Management What’s the process?

  20. 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?

  21. 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?

  22. 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?

  23. Drug Screens • Screen for the Standards • Screen for Specific Opiates • Screen for Metabolites What’s the process?

  24. 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’s the process?

  25. Coordination • Communication • Team members • Other service providers • Adequate Team Representation • Medical professional(s) • Innovation • Creativity • Caution What does a specialty court need to consider?

  26. Hallford, J. (2014, July 25). Personal interview. • http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-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. References

  27. Greg Sutmiller gsutmiller@ctioklahoma.org (918) 384-0002 Contact

More Related