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The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.

Dr. Chris Stock was a substance use disorder pharmacist at the Salt Lake City VA for 25 years. He started a pharmacist managed outpatient detoxification clinic there in 1999, and in 2004, a buprenorphine/naloxone clinic was started. Dr. Stock and other pharmacists with expanded scope of practice within the VA provided medication management services for patients in that clinic. Dr. Stock now works for the Harm Reduction Action Center in Denver. HRAC is the largest syringe access program in Colorado.

Dr. Abril Atheron was a mental health pharmacist at the Salt Lake City VA for 9 years. She participated in a pharmacist managed outpatient detoxification clinic for approximately 5 years with Chris Stock as the lead clinician. Abby was the Salt Lake City VA PGY2 Psychiatric Pharmacy Residency director from 2011-2016 and an inpatient psychiatric unit clinical pharmacist. She currently is a regional academic detailing program manager at the Salt Lake City VA medical center. Her academic detailing service currently focuses on substance use disorder treatment improvement. She also teaches a course on psychoactive substance and medication assisted treatments to substance use disorder counselor trainees at the University of Utah School of Social Work.

What patient elements would warrant referral to inpatient withdrawal management?

Any patient with a medical or psychiatric condition that would warrant medical attention if worsened by withdrawal should be referred for inpatient withdrawal management.1 If a patient is initially seen in the emergency room, generally a medical workup has been done. This information, along with patient interview, physical assessment and chart review, should be used to rule out conditions such as electrolyte imbalances, liver disease and cardiovascular conditions that can increase the risk of complications. Patients should be referred to an inpatient setting in the following additional examples1:

  • History of complicated withdrawals, such as delirium tremens or seizures with alcohol withdrawal
  • Lack of social support or unable to attend clinic daily
  • Presenting with severe withdrawal symptoms (i.e. Clinical Opiate Withdrawal Scale≥ 25 or Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised3 ≥ 20
  • Special populations, such as elderly, very young and pregnant patients
  • Polysubstance use, which may require more complex management
  • Cognitive impairment identified through mental status exam or chart review

Which regimens have you found to be most successful for alcohol and opioid withdrawal in the outpatient setting?

For alcohol withdrawal, benzodiazepines are generally the drug of choice. When a provider, such as pharmacists, cannot prescribe controlled substances, gabapentin, carbamazepine and divalproex are used as alternatives to benzodiazepines. I have the most experience with carbamazepine tapers over 5-7 days (i.e. carbamazepine 200 mg qid x 4 doses, then 200 mg tid x 3 doses, then 200 mg bid x 6 doses) with supplemented folic acid and thiamine. Patients also receive as needed medications to help treat symptoms, such as trazodone for sleep, hydroxyzine for anxiety, and promethazine for nausea. For most people with opioid withdrawal, buprenorphine/naloxone or methadone is used relieving withdrawal symptoms. Additional symptomatic treatment, as indicated with alcohol, may be used. Additionally, loperamide can be added for diarrhea and dicyclomine for stomach cramps. If a controlled substance is inappropriate or unavailable for management of withdrawal, clonidine may be an alternative in some patients. Patients being treated with buprenorphine/naloxone will require a DEA waivered prescriber in an office based setting or use in a registered Opioid Treatment Program (OTP). Methadone can only be used in a registered OTP. After initial stabilization, the most robust evidence indicates that methadone or buprenorphine/naloxone should be maintained to reduce the risk of relapse. In our facility, we worked collaboratively with a DEA waivered prescriber to provide buprenorphine/naloxone for management of withdrawal and maintenance treatment. For patients needing higher levels of care, they were referred to an OTP for either methadone or buprenorphine/naloxone. In general, patient preference and medical history is used to choose the appropriate medication for withdrawal management.

What barriers to care do you see and how are they overcome?

Regarding pharmacist-run services, I recommend collaborating with experienced providers to create protocols with built-in safety measures and outcome monitoring to ensure safety and effectiveness of the withdrawal clinics. It is especially important to identify a champion prescriber to support decisions and review complicated patients. For opioid withdrawal, a waivered prescriber will be necessary to use buprenorphine products. To obtain referrals, collaborate with emergency rooms and substance use counselors to identify patients who are interested in evaluation for withdrawal management. Establish a referral system that allows quick referral to an emergency room or inpatient unit for withdrawal management if complications arise. If possible, have medications available on site to reduce the risk of a patient not filling the prescription. The timing of the clinic and cross-coverage are important to consider. We had walk-in availability Monday through Friday with scheduled follow-up appointments. Multiple pharmacists or providers should be available to cover the clinic for vacation or sick leave. We incorporated students, PGY1 and PGY2 pharmacy residents with increasing levels of responsibility, such as patient interview and medication management, as trainee experience improved.   

What is the most common myth/misconception about outpatient management of withdrawal?

I have met many prescribers in mental health who believe alcohol withdrawal should only be managed on an inpatient setting. ASAM endorses outpatient withdrawal management as ASAM Level 1-Withdrawal Management (Outpatient), ambulatory withdrawal management without extended on-site monitoring and ASAM Level 2-Withdrawal Management (Intensive Outpatient and Partial Hospitalization), ambulatory withdrawal management with extended on-site monitoring.iv My colleagues and I have successfully managed over 200 patients experiencing alcohol withdrawal in an ASAM Level 1 setting in appropriate patients and had few complications. 

References

  1. The Management of Substance Use Disorders Work Group. (2015). VA/DoD clinical practice guideline for the management of substance use disorders. Version 3.0. Washington, DC: Veterans Health Administration and Department of Defense.
  2. Wesson, D. R., & Ling, W. (2003). The clinical opiate withdrawal scale (COWS). Journal of psychoactive drugs, 35(2), 253-259.
  3. Sullivan, J. T., sykora, K., Schneiderman, J., naranjo, C. A. and sellers, E. M. (1989), Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction, 84: 1353–1357. doi:10.1111/j.1360-0443.1989.tb00737.x
  4. Mee-Lee, D (ed). (Withdrawal Management appendix) The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions Publication Date: October 24, 2013 ISBN: 978-1-61702-197-8
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