Learning more complex detox regimens

[Psychresy]

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Hi, so I have an interest in doing addiction work after residency. I've been told by more than one attending to skip the fellowship and just learn what I can during residency and then in practice. Problem is our chemical dependency rotation is quite weak. Aside from the basics of Suboxone, methadone, etoh detox there isn't much more learning opportunities. Any recommendations of where to learn more about more complex detox management?

 

[michaelrack]

Detox is simple, keeping them off alcohol and drugs is hard

 

[hallowmann]

Hi, so I have an interest in doing addiction work after residency. I've been told by more than one attending to skip the fellowship and just learn what I can during residency and then in practice. Problem is our chemical dependency rotation is quite weak. Aside from the basics of Suboxone, methadone, etoh detox there isn't much more learning opportunities. Any recommendations of where to learn more about more complex detox management?

Do you guys have an addiction/MAT clinic? If so, is there a way you could incorporate that into your outpatient year?

If your goal is addiction work, detox is something that any psych residency should be able to expose you to on a regular basis. Actually managing addiction requires some longitudinal experience. If you don't have access to this, strongly consider more electives in the area to get some of that exposure. Try to reach out to faculty on the chemical dependency service directly and see if they have recommendations for more experienced in-house.

 

[NickNaylor]

What do you mean by “complex detox?” The principles of management are pretty much the same in all cases…

 

[Sushirolls]

I got one patient recently who wasn't pleased with knowing they were at a benzo dose they could simply just stop, and use of other meds to further smooth over any residuals were not tolerated... Physician PCP seized opportunity to cut off after learning I was taking over benzo taper/management (as they should).

So the person switched their outpatient detox to a new "amazing" ARNP PCP who pan lab tested, started cytomel for the thyroid, and has the person putting the benzo into a cup of 100-200mL then, extracts out increasing 1-3mL increments daily to do their own "Microdosing"

I fear if this is the future of healthcare and what people want; this old tractor is just going to sit out in the pasture and rust. No room for placebo trinkets on this Pharm tool.

So, the point of this, is you could learn the art of "microdosing" tapers from dissolving xanax 0.25mg, klonopin 0.5mg, ativan 0.5mg you will have learned to master the plasma point of: science, placebo, patient demands

 

[FlowRate]

the person putting the benzo into a cup of 100-200mL then, extracts out increasing 1-3mL increments daily to do their own "Microdosing"

This is an established strategy for resistant benzo tapers. I believe Stahl mentions it especially regarding venlafaxine. He also accurately notes that it may be less of a pharmacologic intervention than a psychological one.

 

[Sushirolls]

psychological one.

That is the key.

 

[hallowmann]

I actually have a guy cutting tabs in quarters to reduce by 0.125 mg Klonopin every few weeks. Honestly, whatever gets people to the point of stopping a med they've been on for 20+ yrs is good enough for me, even if it takes a year. I have no problem with psychologically therapeutic tapers as long as they keep progressing.

 

[FlowRate]

I actually have a guy cutting tabs in quarters to reduce by 0.125 mg Klonopin every few weeks. Honestly, whatever gets people to the point of stopping a med they've been on for 20+ yrs is good enough for me, even if it takes a year. I have no problem with psychologically therapeutic tapers as long as they keep progressing.

Although you may already know this, FYI they make 0.125mg ODT's for clonaz.

 

[hallowmann]

Although you may already know this, FYI they make 0.125mg ODT's for clonaz.

Not covered by pt's insurance, and he's very "sensitive" to the idea of change. I have a couple others that have used the ODT (after a prior auths of course), but I honestly think it would complicate things more for this guy, even just the change from regular oral tab to ODT.

 

[FlowRate]

Not covered by pt's insurance, and he's very "sensitive" to the idea of change. I have a couple others that have used the ODT (after a prior auths of course), but I honestly think it would complicate things more for this guy, even just the change from regular oral tab to ODT.

I had a guy I was working with on getting him off of 5mg TDD of clonazepam and we ran into a similar issue. He accidentally got his 1's and 0.5's mixed up and reduced to 2.5mg. He actually tolerated it really well until we figured that out and for psychological reasons ended up going back up to 4-something because he couldn't tolerate the idea of having made such a significant reduction.

 

[Candidate2017]

Although you may already know this, FYI they make 0.125mg ODT's for clonaz.

But there's something to be said about the physical act of the patient cutting 0.25 in half.

 

[Sushirolls]

... for psychological reasons ended up going back up to 4-something because he couldn't tolerate the idea of having made such a significant reduction.

LOL. The tricky part of tapers for a handful of patients.

 

[birchswing]

Apropos:



Also a great movie.

(Does not represent my views on benzos and tapering which I'm refraining from commenting on, but just wanted to share a great scene on the power of the mind over the body.)