How do psychiatrists do outpatient alcohol detox?

[Slingshot]

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I have seen more and more doctors including PCP's and psychiatrists offer outpatient alcohol detox for patients. How would they dose people or what kind of taper would they use? Clearly there is no easy conversion of number of drinks to dose of benzo's. Even if the patient came in daily, I would not be sure what to send them home with initially. Obviously the patient would need to be reliable and I would think requiring a reliable family member being there.

I probably would not do it but as I was thinking about it I was not sure how this would work!

 

[billypilgrim37]

We actually have an ambulatory detox program where folks come in almost every morning pretty early (similar to a short term methadone clinic) with an RN and an MD. They get quickly evaluated for symptoms, given their doses for the next 24-48 hours, and when they're complete w/ detox, they can be set up with further services, whether's that's an iop or a rehab or whatever they need.

Folks w/ hx of complicated withdrawal or excessive medical problems do not qualify for the detox program.

For alcohol/benzos, most folks start out w/ Librium 50mg q6 prn withdrawal and 7 days of thiamine.

For opiates, most folks get clonidine, lomotil, vistaril, and trazodone.

I don't know how common programs are like this in other places, but I can't say enough good things about our ambulatory detox.

 

[whopper]

Outpatient detox is something I don't like because if you write a script for a benzo, you have no assurances the patient will not take it with alcohol and possibly kill themselves doing so.

I'd love to hear what your experiences with this has been Billy because you can teach me something.

 

[billypilgrim37]

Outpatient detox is something I don't like because if you write a script for a benzo, you have no assurances the patient will not take it with alcohol and possibly kill themselves doing so.

I'd love to hear what your experiences with this has been Billy because you can teach me something.

Well, I think the nice thing is that folks are getting a pretty small amount of benzodiazepine at a time. I work in the emergency room thursday nights, and so I give them about 30-36 hours worth of meds to come back on saturday morning. if they seem higher risk, i'll have them come back the next morning, but that's pretty rare. I'm not sure that an extra few hundred milligrams of librium would necessarily change much as far as their actual risk of dying.

Again, people w/ hx of seizures/dt's/big med problems can't do the program, so that actually eliminates a LOT of the folks who would be at risk anyway.

Fortunately, that's been mostly a theoretical risk. Sure, there are noncompliance issues, but the program has been going on for a while. plus, we typically engage families and other folks that support people coming in, and some folks even go to our crisis center for a day or two to get support while they get started.

To get started in the program, you are probably going to be sitting in the emergency room for however many hours. It is SOOOOO much easier to get benzos on the street, and we give such a small amount, I think people aren't too incentivized to come just to get benzos or if they're not wanting to engage treatment. There are exceptions, but generally, librium just isn't worth it to most people.

We spend a decent bit of time doing education and have them sign sheets that we have talked about the dangers of withdrawal and about using the medications. If we can, we have family members hold the meds for them.

So I can totally understand the concerns, and I would probably have the same ones if I hadn't seen this particular program work out so darn well. It's run through a licensed d&a program and the infrastructure is all there for ongoing treatment.

I think a program like this would have more pitfalls if it were just office-based and not in the context of a broader program.

 

[Poetic Silence]

Just curious, but do these programs do alcohol blood level testing in order to evaluate compliance with the program standards?

 

[F0nzie]

Outpatient ETOH detox may be suitable for individuals without a hx of complicated ETOH withdrawl, seizures, or medical problems. A thorough psychiatric and medical assessment focused on risk factors should be performed by the physician to deem the appropriateness of this type of intervention. A family member or friend should be present during the meeting with the physician, accompany the patient for all office visits, and agree to stay with the patient for several days until the detox is complete. At home, the friend/family member should be made responsible for administering the medications, provide continuous support to keep them away from ETOH, and always be present with the patient in case of emergencies that may require someone else to call 9-11. Require that a family member or friend sign an agreement. Make sure the patient DOES NOT DRIVE to your office and have the family member or friend agree to provide transportation.

Valium is also an excellent choice as it has a long half life and a long-acting metabolite that lasts weeks. Prescribe a 1 day supply of Valium with some PRNs of Lorazepam and insist that the patient return every day for an office visit for an examination and assessment of withdrawl symptoms until the taper is complete. You should also be available to the patient by pager to handle emergencies for any of the numerous problems that may arise with this type of intervention.

Taking all of this into consideration, this type of intervention is really only suitable for low risk patients and may be altogether be unnecessary as in most cases the patient can simply taper the ETOH without the need for a medication substitute. The whole process may be more hassle than it's worth. The patient may, however, benefit from the extra support and reassurance, which may in the end make a difference. Given the chronic, relapsing and remitting nature of alcoholism assess their level of motivation and see if they are willing to engage in individual, group therapy, and AA. If they are motivated to engage in therapy and support groups, medications may have greater utility. ie, high dose SSRIs (in particular if they have a hx of depression) in combination with Naltrexone, Gabapentin, may prolong their next relapse.

 

[vistaril]

I have seen more and more doctors including PCP's and psychiatrists offer outpatient alcohol detox for patients. How would they dose people or what kind of taper would they use? Clearly there is no easy conversion of number of drinks to dose of benzo's. Even if the patient came in daily, I would not be sure what to send them home with initially. Obviously the patient would need to be reliable and I would think requiring a reliable family member being there.

I probably would not do it but as I was thinking about it I was not sure how this would work!

If you have some degree of trust in the pt, it's a great idea. Health resources are scarce, and inpt detox is expensive......especially for places that don't have a specific high volume detox only unit.

I think a relaible family member/collateral is key.

Dosing benzos for etoh withdrawl isn't rocket science. In most patients, You don't have to guess exactly right. If you undershoot it they are a little uncomfortable. If you overshoot it they are a little drowsy.

Example: 40 year old male with hx of etoh dependence comes in to me as an outpt. He is a pretty good historian and wants to stop drinking. He brings his wife in who is reliable and he lives with. No hx of severe withdrawl symptoms, but 2 years ago when he stopped drinking for a few weeks he got mildly tremulous with no meds. He drinks 6 american light beers and just short of a half pint of 80 proof liquor per day. (meaning total consumption of ~11 or so units etoh daily). He is about 200 lbs and fairly healthy. Recent labs normal.

There are a ton of options to use in this pt. I'd be more than comfortable doing this and sending him home:

day 1: Ativan 2mg q4 hrs
day 2: Ativan 2mg q6 hrs
day 3: Ativan 1.5mg q6 hrs

call office to check in after each day on day 1, 2, 3.....

day 4: Ativan 1mg q6 hrs
day 5: Ativan 1mg q8 hrs
day 6: Ativan 0.5mg q 6 hrs
day 7: come see me for outpt re-eval

I would also tell the wife or whoever to hold for sedation. If I'm real concerned I may want them to come back to the office in 48 hrs or whatever and have their pulse and bp checked.

But this is much more preferable than, imo, admitting pts onto psych units for 3-4 day hospitalizations for the sole point of detox. In the *right* pt population

 

[vistaril]

Outpatient detox is something I don't like because if you write a script for a benzo, you have no assurances the patient will not take it with alcohol and possibly kill themselves doing so.

Of course not, but that's why you have to do it with the right pt population.......I wouldn't do it with someone I just met in the ER.

My unit does *not* do detox only. Not for opiates, benzos, or etoh. The er docs all the time will try to consult us on pt's who present "wanting detox", and I explain that they are welcome to contact our addictionologist to see if he wants to use one of his beds to do detox, but we won't take them.

I feel bad for residents who dont have a detox only unit and upwards of 1/3 of their pts are detox only on the inpt unit. This is not educational(after a certain pt obviously) and robs them of pts they could learn from.

 

[Slingshot]

Valium is also an excellent choice as it has a long half life and a long-acting metabolite that lasts weeks. Prescribe a 1 day supply of Valium with some PRNs of Lorazepam and insist that the patient return every day for an office visit for an examination and assessment of withdrawl symptoms until the taper is complete. You should also be available to the patient by pager to handle emergencies for any of the numerous problems that may arise with this type of intervention.

.

I am a bit saddened to see a fellow psychiatrist suggest this. Valium with prn ativan? Valium has a faster onset of action so for a prn valium is more effective. Only time not to use valium is in very old or compromised liver function or if you are simply more comfortable dosing ativan but using 2 together never makes sense.

Just hope someone did not teach you this in an addiction program.

Great advice thought from everyone!

 

[vistaril]

I am a bit saddened to see a fellow psychiatrist suggest this. Valium with prn ativan? Valium has a faster onset of action so for a prn valium is more effective. Only time not to use valium is in very old or compromised liver function or if you are simply more comfortable dosing ativan but using 2 together never makes sense.

Just hope someone did not teach you this in an addiction program.

Great advice thought from everyone!

onset of action is just one aspect of a prn. In terms of onset of action valium is appropriate as a prn, but it's half life means it is less favorable as a prn. I don't want to use prns that stick around that long.

I don't use a scheduled valium/prn ativan approach(would prefer librium as a scheduled taper and ativan prn), but it's not going to make some major difference.

benzo dosing during detox is very easy. It's pretty darn hard to mess up. Pretty much anyone can do it....occasionally we get asked to do it not because it's hard but because other people would just rather not fool with it.

 

[F0nzie]

I am a bit saddened to see a fellow psychiatrist suggest this. Valium with prn ativan? Valium has a faster onset of action so for a prn valium is more effective. Only time not to use valium is in very old or compromised liver function or if you are simply more comfortable dosing ativan but using 2 together never makes sense.

Just hope someone did not teach you this in an addiction program.

Thanks for clarifying how benzo's work and how not to use them. General residency program currently PGY-III and... not Harvard :

 

[Slingshot]

onset of action is just one aspect of a prn. In terms of onset of action valium is appropriate as a prn, but it's half life means it is less favorable as a prn. I don't want to use prns that stick around that long.

I don't use a scheduled valium/prn ativan approach(would prefer librium as a scheduled taper and ativan prn), but it's not going to make some major difference.

benzo dosing during detox is very easy. It's pretty darn hard to mess up. Pretty much anyone can do it....occasionally we get asked to do it not because it's hard but because other people would just rather not fool with it.

I was referring to his post saying he was already using scheduled valium and adding ativan as a PRN. In that case if you are already using valium than to me it makes no sense to use ativan. To each their own.

It is also a misconception that valium stays around for a long time with acute, short-term use. It actually enters the brain very quickly but exits the brain very quickly and than distributes rapidly into peripheral fat. That is why its typically dosed 3-4 times a day when starting out.

It is the one drug I see mis-understood the most because it has a "long half-life" however with benzo's lipophilicty trumps half-life when you want to evaluate kinetics.

Overtime once an equilibrium occurs with valium stores in peripheral fat, than yes, as it constantly "seeps" out slowly, it stays around for a long-time but it takes time of it to accumulate and then re-distribute back into the brain from peripheral tissues.

Also have to take into account how fat someone is. Someone with almost no fat will not have valium stick around for that long even with chronic usage.

I always wondered in residency why it was being dosed 3-4 times daily. Then I finally learned and understood. Most do it because that is what epocrates says but do not know why!

Benzo's are tricky. You can prescribe how you like. There is an art to doing it and no completely right way. Just have to take more into account for valium than most other benzo's.

 

[vistaril]

I was referring to his post saying he was already using scheduled valium and adding ativan as a PRN. In that case if you are already using valium than to me it makes no sense to use ativan. To each their own.

It is also a misconception that valium stays around for a long time with acute, short-term use. It actually enters the brain very quickly but exits the brain very quickly and than distributes rapidly into peripheral fat. That is why its typically dosed 3-4 times a day when starting out.


Benzo's are tricky. You can prescribe how you like. There is an art to doing it and no completely right way. Just have to take more into account for valium than most other benzo's.

good points......