The purpose of admission and treatment is to facilitate discontinuation of all mood altering drugs with addictive potential. Drugs included in this category are:

1. Depressants including
1. Alcohol
2. Benzodiazepines including triazolam (Halcion), clonazepam (Klonipen), temazepam (Restoril), flurazepam (Dalmane), lorazepam (Ativan)
3. Benzo-like sedatives including zolpidem (Ambien), eszopiclone (Lunesta).
4. Barbiturates including phenobarbital, butalbital (Fiorinal, Fioricet)
5. Barbiturate-like (ethchlorvynol (Placidyl), glutethamide (Doriden)
6. Carisoprodol (Soma) which is metabolized into meprobamate
2. Stimulants
1. Amphetamines including amphetamine (Aderrall, Focalin) and
2. Amphetamine-like methylphenidate (Ritalin, Concerta), modafanil (Provigil), “diet pills including phenteramine (Fastin), diethylpropion (Tenuate), benzphetamine (Didrex), phendimetrazine (Plegine)
3. Cocaine (including crack)
3. Opioids – Narcotics
1. Opioids – including hydrocodone, oxycodone, morphine, meperidine, methadone, buprenorphine (Subutex, Suboxone, Butrans) and
2. Opioid-like including tramadol (Ultram, Ultracet), tapentadol (Nucynta).
4. IV. Cannabinoids including marijuana, hashish
5. V. Hallucinogens (LSD, PCP, and others)

Because of the physical dependence induced by many of these drugs, other drugs are often used to facilitate withdrawal safely. Common protocols for detoxification are attached.

Studies suggest that when using protocols with PRN dosage of medication (versus fixed dosage), less meds are used and symptoms are controlled, however, PROTOCOLS MUST BE INDIVIDUALIZED AND ASSESSED DAILY WITH APPROPRIATE ADJUSTMENTS INSTITUTED AS NECESSARY IF PROTOCOL IS NOT CONTROLLING SYMPTOMS.

1. A stat dose of sedative medication may be indicated for acute withdrawal if patient’s signs and symptoms are unmanageable on admission or during treatment. CIWA scores are measured on admission; see attached (>15 is significant). When using stat doses of meds (30-60- mg oxazepam (Serax), 10-20 mg diazepam (Valium) or 60-120 mg Phenobarbital) assess size of patient tolerance (high CIWA score in face of intoxication. i.e. high BAL) and current signs and symptoms. If patient does not respond to stat dose within 20-30 minutes, consider repeating dose each ½-1hr until sedated.
2. If patients are not responding to PRN doses as scheduled, consider increasing protocols (5 mg/dose for diazepam (Valium), 15-30 mg/dose for phenobarbital and 13-30 mg/dose for oxazepam (Serax)).
3. If increased meds are necessary, wean doses of sedatives over the next 1-3 days as tolerated (indicated by patient report, efficacy indication on withdrawal flow sheets, total meds used and scores on withdrawal flow sheets. Once stabilized, goal is to decrease dose by 20-50% of sedative per day as tolerated by patient.

To effectively remain in recovery, all cross-reacting sedatives must be discontinued, prior to discharge. Benzodiazepines are contra-indicated for patients with addiction histories even if primary drug of choice is alcohol, opiate or stimulants. Alternative management of anxiety and sleeplessness should be considered (e.g. non medication, or if necessary, antihistamines, buspirone (Buspar), major tranquilizers). The use of substitute, nonaddicting drugs is acceptable, but not encouraged (if necessary, use minimal dose for minimal amount of time; e.g. antihistamines or major tranquilizers or buspirone). The treatment program will provide behavioral alternatives for symptom control (i.e. anxiety, sleeplessness, etc.)

If patient has true panic disorder, institute use of tricyclics or serotonin reuptake inhibitors as soon as possible, thus avoiding the need for use of addicting drugs such as benzodiazepines. Much anxiety is relieved within the first 30 days of abstinence from addicting drugs like alcohol, benzodiazepines, opiates and stimulants.

Pain Control. The goal of addiction treatmentis abstinence from all addicting, mood altering drugs. Co-occurring pain in a drug addict presents a challenging syndrome. Whenever possible, avoid opiates in addicted patients (including alcoholics). Follow WHO guidelines for pain control utilizing the weakest effective med to control pain. Addicts often have difficulty accepting non-opioid pain relievers.

Typically, meds used for detox are:

1. Alcohol - Benzodiazepines e.g. diazepam 5-20 mg (Valium), oxazepam 15-60 mg (Serax), chlordiazepoxide 25-100 mg (Librium)) – Avoid Valium and Librim IM as the are poorly absorbed OR Barbiturates (phenobarbital 15-6- mg - (PO or IM) as needed. Use oxazepam (Serax) if liver disease is suspected since it is not metabolized by the liver. Use Phenobarbital if concurrent treatment of Benzodiazepine abuse/dependence.
2. Opioids - Clonidine plus PRN doses of methocarbamal (Robaxin) for muscle Cramps, dicyclomine (Bentyl) for stomach cramps, hydroxazine (Atarax) for sleeplessness and anxiety and phenobarbital as needed for anxiety/sleeplessness. A high dose of phenobarbital may be necessary for sleeplessness for a few days. Tramadol (Ultram) is used for the pain of withdrawal in doses of 50-100 mg q 4-6 hours as needed for pain. Buprenorphine (Subutex) is added if withdrawal symptoms are not relieved by the protocol 48-72 HOURS AFTER LAST DOSE OF OPIOID. *It is recommended that benzodiazepines be avoided in opioid withdrawal since they are often associated with drug seeking and craving
3. Stimulants - PRN benzodiazepines (short term)
4. Benzodiazepines - Avoid using benzodiazepines for benzodiazepine withdrawal because of the psychological dependence many benzodiazepine addicts experience. Gabapentin (Neurontin) 300 mg TID with Phenobarbital PRN anxiety works well. Continue gabapentin (Neurontin) for 2 weeks; wean off phenobarbital over 3-5 days. Valproic acid (Depakote) may also be used instead of gabapentin (Neurontin).