At Kolmac, we are always looking for ways to improve how we use detoxification medications. This week I will be giving a talk on some of these changes to the Georgetown Department of Psychiatry at their Grand Rounds. Here is a summary of what I will be saying.
Alcohol. Of the many ways of treating alcohol withdrawal, two protocols have become dominant. One relies on benzodiazepine tranquilizers, such as Librium, and the other on anticonvulsants, such as Neurontin. Each has its advantages and disadvantages. At Kolmac, we are piloting a combined protocol that uses both medications in a way that we hope will result in better clinical outcomes. On the first day, we give Librium every hour until symptoms are eliminated in order to gain rapid control over the withdrawal process and prevent more severe complications. On day two, we begin Neurontin and encourage patients to continue taking it for several months to reduce post-acute withdrawal symptoms which can drive relapses.
Opioids. The usually smooth treatment detoxification from heroin using buprenorphine has become more complicated because of the adulteration of heroin with synthetic opioids. The new additions are causing the intensification of withdrawal symptoms (“precipitated withdrawal”) rather than an improvement when buprenorphine is given. The solution we have evolved is to use a one-day “bridge” of tramadol, to allow the adulterant to wash out of the patient. Buprenorphine can then be safely given in the usual manner.
Cannabis (aka Marijuana). People have been using cannabis containing a significantly higher percentage of THC, leading to an intensification of the usually mild withdrawal syndrome – which can now be clinically significant. In addition to anxiety and insomnia, craving can be persistent and long-lasting, increasing the likelihood of relapse. Research studies, although still unfortunately very limited, suggest that, just as with other addictive substances, using pharmaceutical THC may be beneficial in managing these withdrawal symptoms.
Tobacco. Under pressure from increasing evidence about the safety of Chantix, the FDA finally removed the black box warning which had discouraged many physicians from prescribing this medication. In combination with patches, Nicotrol inhalers, gum, and lozenges, outcomes are improved even more. Tobacco-related illnesses are the most common cause of death of alcoholics in recovery, but reluctance to use medications – despite their effectiveness – reduces the likelihood of sustained abstinence from tobacco. At Kolmac, we encourage patients to use these medications either when they begin treatment or later on in their recovery.
I would be glad to send the slides from my presentation to anyone interested in more details. Just email me at firstname.lastname@example.org.