In-patient detoxification

This can be carried out either in an acute medical or psychiatric ward, or in a special drug-dependency in-patient unit. The advantages of the latter will include the initiation of a rehabilitation programme particularly geared towards the problems of addictions. However, some patients may well prefer a straightforward detoxification and then work in the community supported by other services, for example, from the Community Drug Team. There are several options for the in-patient detoxification of opiate dependents. These include ... 

Methadone, a synthetic narcotic, may be used for the relief of pain, but it also is used in the detoxification and maintenance treatment of those addicted to narcotics. Detoxification involves withdrawing the patient from the narcotic while preventing withdrawal symptoms. 

Gossop M, Bradley B, Phillips GT An investigation of withdrawal symptoms shown by opiate addicts during and subsequent to a 21 -day in-patient methadone detoxification procedure. Addict Behav 12 1-6, 1987 GreenJ, Jaffe JH Alcohol and opiate dependence. J Stud Alcohol 38 1274-1293,1977 Green L, Gossop M Effects of information on the opiate withdrawal syndrome. Br J Addict 83 305-309, 1988... 

Clinical situations in which detoxification is indicated can be grouped into three categories 1) for patients who have been taking a maintenance therapeutic dosage for moderate to long periods of time and for whom a trial without medication is warranted, 2) for patients taking supratherapeutic doses (usually in the context of benzodiazepine dependence), and 3) for patients who use benzodiazepines as part of mixed substance dependence. Detoxification should be approached differently in each category. 

To date, 16 GST isozymes have been found in humans [48]. Studies of several cancer tissues have revealed the overexpression of different GST isozymes, with GST Pl-1 (GST Pi, GST ji) being the most predominant. For this reason, GST Pl-1 is regarded as a potential tumor marker [5,49-53]. The high expression levels of GST Pl-1 (up to 2.7% of the total cytosolic protein [52]), combined with its detoxification role against xenobiotics, make GST Pl-1 a major player responsible for drug resistance in patients undergoing anticancer chemotherapy [49]. 

One group of people who may be at greater risk are those who are exposed to cyanide but are unable to smell the chemical (Kirk and Stenhouse 1953 Snodgrass 1996). Patients with motor neuron disease (amyotrophic lateral sclerosis) possess a disorder in cyanide detoxification that may result in their higher susceptibility to cyanide (Kato et al. 1985). 

Patients with partial deficiency of this enzyme are at risk of developing severe 5-FU-associated toxicity as DPD is responsible for detoxification of pyrimidine-based antimetabolite analogs, such as 5-FU and capecitabine. The onset of toxicity occurs, on average, twice as fast in patients with low DPD activity compared with patients with normal DPD activity (13-16). 

When used for detoxification, phenobarbital is given in equal doses four times a day. The maximum daily dose of phenobarbital is 600 mg, but much lower doses are usually sufficient. The phenobarbital dose is lowered (i.e., tapered) by about 20% per day. If the patient is too drowsy, then a dose should be skipped. If breakthrough withdrawal symptoms continue to occur, then the pace of the detoxification should be slowed. Before using phenobarbital, liver function tests should be obtained. All barbiturates depend greatly on the liver to be metabolized. Alcoholics with cirrhosis or other forms of liver impairment may have difficulty clearing phenobarbital. Phenobarbital should not be used in patients with poor liver function. In addition, the barbiturates can worsen a medical condition known as porphyria and should be avoided in those with this disorder. Phenobarbital, as noted, is seldom used today for alcohol detoxification. 

The assessment of basic hematological indicators and endotoxemia blood indices such as creatinine, urea and bilirubin in patients treated by standard hemosorption procedure revealed the insufficiency of its detoxification effect. Only after three hemosorption sessions (HS) were positive clinical dynamics and reduction of endotoxemia indices seen in patients of the control group, hi the treatment group... 

The described sorbent modification techniqne by nsing nentral anolite solntion improves the efficiency of blood detoxification by hemosorption. It has a stimulating effect and improves treatment resnlts in patients with mnltiple organ failure. 

As mentioned earlier in the chapter, in the UK lofexidine is far more frequently selected in opiate detoxification than clonidine because of its better safety for outpatients, and a large comparative study of this and buprenorphine was carried out by Raistrick et al. (2005). Two hundred and ten patients were randomized, and the same comparisons in standard drug misuse outcomes and satisfaction measures were also studied in 271 individuals who did not wish to be in the randomized study. Many outcomes were similar with the two medications, but 65% of buprenorphine patients completed detoxification against 46% of those on lofexidine. That study was an example of one which included a follow-up to see whether patients had been abstinent after detoxification, with this being the case at the measurement point of one month for 38% of lofexidine completers and 46% with buprenorphine. This important aspect of whether successful detoxification does indeed lead to further abstinence has attracted attention in several buprenorphine studies, as reviewed by Horspool et al. (2008). Across five qualifying studies, they found detoxification completion rates of 65 to 100%, but low rates of abstinence at follow-up points, with more patients having returned to opioid maintenance than had complied with naltrexone. 

Banbery J, Wolff K Raistrick D (2000). Dihydrocodeine a useful tool in the detoxification of methadone-maintained patients. Journal of Substance Abuse Treatment, 19, 301-5... 

Buntwal N, Bearn J, Gossop M Strang J (2000). Naltrexone and lofexidine combination treatment compared with conventional lofexidine treatment for in-patient opiate detoxification. Drug and Alcohol Dependence, 59, 183-8... 

Drug takers using the service have typically been in their twenties and early thirties (with a mean age of 28). During the first twelve months of operation 57 per cent of clients had problems with opiates (mainly heroin) and 22 per cent with stimulants (mainly amphetamine sulphate). A large number (57 per cent) took their drugs by injection. Half of the team s contacts took place in clients homes, half in their own premises. Some in-patient contacts are made in the local psychiatric hospital, some in the regional detoxification unit at... 

As the withdrawal progresses, symptoms can become episodic, ranging unpredictably from mild to severe. Treatment typically focuses on providing support and managing symptoms, such as sedation with benzodiazepines and barbituates. In-patient hospitalization is recommended for detoxification. 

Cysteine is considered a nonessential nutrient because it can be synthesized from methionine via the transsulfuration pathway (Figs. 21-1 and 21-2). Production of cysteine is metabolically important because it serves as a source of sulfur for incorporation into proteins and detoxification reactions. A lack of cysteine needed for incorporation into the structural protein collagen may be responsible for the musculoskeletal abnormalities seen in patients with CBS deficiency. A major metabolic use of cysteine is in the production of glutathionine (y-glutamylcysteinylglycine), an important antioxidant. Another important pathway for cysteine metabolism is its oxidation to cysteinesulfinate, which serves as a precursor for taurine, an amino acid that stabilizes cell membranes in the brain. 

A large variation of the duration of the detoxification was noted (Table 1). Only five patients could be treated for less than 10 weeks, while twelve other patients had to be treated for up to 91 weeks. The treatment was discontinued in patients in whom both s-Al and the increment of s-Al after desferrioxamine treatment were below 50 pg/L at two successive occasions). The treatment duration was significantly related to the residual diuresis as all patients with a residual diuresis of a liter/day or more could be treated for less than two months (Fig. 2). Other studies have also established the protective capacity of an even minimal functioning kidney [30, 67]. None of the patients died during treatment with desferrioxamine, and six patients (patient Nos. 11-13, 22, 25, 26) died more than one year after termination of the desferrioxamine treatment, due to causes unrelated to the A1 intoxication. As of November 2001, more than five years after the intoxication episode, 12 of the 17 surviving patients (patient Nos. 11, 12, 14, 16-24) are still alive and none of the patients developed any clinical signs of Al toxicity, like speech disturbances, cognitive defects, bone fractures or dementia-like symptoms. 

Tiapride appears to be useful in alcohol withdrawal as an alternative to the benzodiazepines (2). It facilitates the management of ethanol withdrawal, but its use in patients at risk of severe reactions in acute withdrawal should be accompanied by adjunctive therapy for hallucinosis and seizures. Since it may prove difficult to identify such patients and since there is also a small risk of the neuroleptic malignant syndrome (particularly with parenteral administration), the usefulness of tiapride in this setting is likely to be limited. The potential risk of tardive dyskinesia at the dosage used in alcoholic patients following detoxification (300 mg/day) requires evaluation and necessitates medical supervision. It is unlikely to produce problems of dependence or abuse. 

Nitric oxide formed from amyl nitrite inhibits cytochrome P450 (117) and ritonavir inhibits CYP2D6 (118), which has a major role in metamfetamine detoxification (119). This interaction could have led to fatal plasma concentrations of metamfetamine. It is therefore suggested that patients who take protease inhibitors are made aware of the potential risk of using any form of recreational drugs metabolized by CYP2D6, particularly metamfetamine. 

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