Arranged by J. Mabbutt and C. Maynard NaMO September 2008.


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This presentation gives general rules for overseeing withdrawal. ... Adjusted from NSW Health Withdrawal Clinical Practice Guidelines (2007) ...
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8.1: Managing Opiate and Psychostimulant Withdrawal Prepared by J. Mabbutt & C. Maynard NaMO September 2008

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8.4: Managing sedative and psychostimulant withdrawal – Objectives 1. During the session attendants & maternity specialists will figure out how to recognize, evaluate and deal with a patient in sedative and psychostimulant withdrawal 2. By the end of the session medical caretakers & birthing specialists will have a comprehension or utilization of the sedative withdrawal scales 3. At the end the session, medical attendants & maternity specialists will have an essential comprehension & information to securely & viably distinguish, screen & oversee sedative & psychostimulant withdrawal

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8.1: Managing drug withdrawal This presentation gives general rules for overseeing withdrawal. Allude to Section 9 for particular points of interest of withdrawal manifestations and administration for the most normally utilized substances For additional data, allude to the New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007) http://www.health.nsw.gov.au/strategies/gl/2008/GL2008_011.html

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8:1 Indications and rules Opioid Withdrawal – Onset & Duration of withdrawal (1) Heroin is a moderately short-acting medication Symptoms of withdrawal typically start 6-24 hours after the last measurement, achieve a crest at 24-48 hours, & resolve following 5-10 days Methadone or other long-acting opioids withdrawal as a rule initiates 36-48 hours after the last dosage The pinnacle seriousness of methadone withdrawal has a tendency to be lower than for heroin withdrawal, however withdrawal might be more delayed, enduring 3-6 weeks

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8:1 Indications and rules Opioid Withdrawal – Onset & Duration of withdrawal (2) Buprenorphine withdrawal is like different opioids yet is by and large milder than withdrawal from methadone or heroin as a result of its moderate separation from the opioid receptors Symptoms begin by and large inside 3–5 days of the last dosage and can keep going for a few weeks

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8:1 Indications and rules Opioid Withdrawal – Onset & Duration of withdrawal (3) Following intense withdrawal, extended, poor quality side effects of uneasiness (mental and physical) may last numerous months Table 9.5 shows times of appearance of withdrawal disorder in ward opioid clients

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8:1 Table 9.5: Withdrawal disorder (Adapted from NSW Dept of Health, (2000) and (2006)

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8:1 Indications and rules Withdrawal – Onset & Duration of withdrawal (4) The opioid withdrawal disorder can be extremely uncomfortable & troubling, yet not life-undermining unless there is an extreme basic ailment Patients may have a low resistance to torment because of the impact of long haul opioid use & this should be recognized & treated adequately The accompanying Graph – Figure 9.2 demonstrates the advancement of the intense period of opioid withdrawal after last measurement

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8:1 Figure 9.2: Progress of the intense period of opioid withdrawal Adapted from NSW Health Withdrawal Clinical Practice Guidelines (2007)

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8:1 Table 9.6 Symptoms and indications of opioid withdrawal

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8:1 Indications and rules Pharmacological treatment for opioid withdrawal The restorative officer or medication & liquor attendant expert may endorse the favored pharmacological alternative for opioid withdrawal: Buprenorphine Symptomatic solutions

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8:1 Buprenorphine Treatment for opioid withdrawal – Hospital Setting (1) Buprenorphine is appropriate in the doctor\'s facility setting as it mitigates side effects of withdrawal without essentially drawing out the term of side effects There ought to be some capacity to tailor measurements to level of withdrawal as evaluated by the Clinical Opiate Withdrawal Scale (COWS) (see Appendix 4 ) Buprenorphine ought not be initiated until target withdrawal is available (COWS score more noteworthy than eight) to decrease probability of hastening withdrawal

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8:1 Buprenorphine Treatment for opioid withdrawal – Hospital Setting (2) Commencing buprenorphine before the patient has withdrawal signs can make them go into an a quick withdrawal disorder & cause extraordinary misery to them Using the COWS as noted can diminish this danger Buprenorphine will tie more tightly to the sedative receptor locales than the sedative medication (e.g. heroin/methadone) the individual is ordinarily on. This will divert the sedative from the receptor site & put the patient into to a hastened (serious) withdrawal

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Table 9.7: Example of buprenorphine dose

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8:1 Table 9.8 Symptomatic treatment Note: Caution is prescribed in surpassing expressed term of benzodiazepine use to abstain from substituting for heroin reliance. Term of treatment may should be longer than expressed above for withdrawal from long-acting opioid (e.g. methadone, Kapanol and so forth ).

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8:1 Table 9.8 Symptomatic treatment Note: Caution is prescribed in surpassing expressed length of benzodiazepine use to abstain from substituting for heroin reliance. Term of treatment may should be longer than expressed above for withdrawal from long-acting opioid (e.g. methadone, Kapanol and so on ).

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8:1 Indications and rules Withdrawal – Psychostimulant withdrawal – Case Study Present applicable contextual analysis for psychostimulant inebriation or other medication withdrawal from Guidelines CD Rom Section 01 Discuss every segment in little gatherings or as an expansive gathering and criticism

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8:1 Indications and rules Managing psychostimulant withdrawal (1) Psychostimulants are: Amphetamines, cocaine & joy Amphetamines will be: amphetamines (speed), methamphetamines (\'ice\') & dexamphetamine (Ritalin), Repeated and delayed utilization of psychostimulants prompts stamped resilience, neuro-adaption & reliance, & withdrawal on end Withdrawal from cocaine or amphetamines is not life-debilitating Depression coming about because of withdrawal can prompt self-destructive ideation, self-hurt and perhaps demise

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8:1 Amphetamines Three types of Amphetamines Powder, Base & Crystal meth/amphetamine powder approx 10% immaculate meth/amphetamine base approx 20% unadulterated methamphetamine crystal–\'ice\' approx 80% unadulterated Powder Base Crystal

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8:1 Indications and rules Managing psychostimulant withdrawal (2) Suicidal ideation ought to be overseen according to clinic strategy & NSW Department of Health Policy Directive No. PD2005_121 Suicidal Behavior – Management of Patients with Possible Suicidal Behavior at http://www.health.nsw.gov.au/strategies/PD/2005/PD2005_121.html Also allude to the Framework for Suicide Risk Assessment and Management for NSW Health Staff at http://www.health.nsw.gov.au/bars/2005/suicide_risk.html See likewise: NSW Health 2006: Psychostimulant Users – Clinical Guidelines for Assessment and Management: GL2006_001:

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8:1 Indications and rules Managing psychostimulant withdrawal (3) Withdrawal is portrayed by three stages: Crash Withdrawal Extinction Table 9.12 demonstrates the periods of amphetamine & cocaine withdrawal

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Table 9.12 Amphetamine and Cocaine withdrawal

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Table 9.11 Amphetamine and Cocaine withdrawal

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Table 9.11 Amphetamine and Cocaine withdrawal

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8:1 Indications and rules Managing psychostimulant withdrawal – Monitoring Four-hourly observing is suggested as medical caretakers/birthing specialists should know about changing signs & side effects that the patient may give as they go through the accident & withdrawal stages Mood & vitality levels may vacillate e.g. a patient may at first present with a low mind-set and psychomotor hindrance & then swing towards being fretful & fomented later that day Assess for hidden psychological wellness issues as these may have been covered amid the accident stage however gotten to be apparent later in the withdrawal time frame Withdrawal scales have not been routinely utilized as a part of clinical practice

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8:1 Indications and rules Pharmacological treatment To date, no comprehensively viable pharmacological treatment has been distinguished However, symptomatic pharmaceutical might be gainful, for instance: Benzodiazepines for uneasiness, tumult, sleep deprivation & forceful upheavals – not be utilized for over two weeks without audit Antipsychotic drug for maniacal side effects (dreams, pipedreams and so forth) Antidepressants for manifestations of discouragement that persevere after stimulant withdrawal