Substance Use Treatment and Withdrawal Management: - PowerPoint Presentation

1. Substance Use Treatment and Withdrawal Management:Training for JailsPresented by Kirsten Peebles, MA, LMHCErik Knudson, MSFor the Jail Technical Assistance TeamDSHS Office of ForensicMental Health ServicesMay 20, 2020

2. The DSHS Office of Forensic Mental Health Services Jail Technical Assistance Program provides informational and training support to Washington jails. Specific areas of information and training support include pre- and post-booking options, screening and access to treatment, substance use disorder treatment, transition planning, crisis de-escalation,and more.Overview2

3. Participants will learn:1. Commonly used substances2. Signs of intoxication3. Common withdrawal symptoms and risks4. Withdrawal management options5. Recommended policiesLearning Objectives3

4. SUD Stats in Washington State JailsIt’s estimated that more than 47,000 people in Washington regularly use opioids (heroin or prescription pain medications) and over half of them were incarcerated at some point in 2019A review of jail deaths showed that substance use-related deaths and suicides made up 85% of the deaths that occurred within the first 72 hours of admission(Columbia Legal Services, 2019)4

5. SUD Stats in Washington State JailsMost deaths that occurred within the first few days following booking were related to drugs or alcohol60% of the deaths within the first week of admission involved drugs or alcohol(Columbia Legal Services, 2019)5

6. AlcoholBeerWineLiquor6

7. Common Signs of Alcohol IntoxicationBreath that smells like alcoholEnlarged pupilsRapid heartbeat and slow breathingLoss of balance, or inability to walk straight or stand stillNausea and vomitingSlurred or loud speechQuick mood changes7

8. Common Signs of WithdrawalSigns in the first 6-12 hours post consumption could include: AgitationAnxietyHeadachesShakingNausea and vomiting8

9. Common Signs of Withdrawal cont.Signs in the first 12-24 hours post consumption could include: DisorientationHand tremorsSeizures9

10. Common Signs of Withdrawal cont.Possible signs that could present at about 48 hours post consumption could include:SeizuresInsomniaHigh blood pressureTactile, auditory, and visual hallucinationsHigh fever and excessive sweatingDelirium tremens10

11. Medical and Psychological Concernswith Alcohol WithdrawalMedical interventionScreening for depressionSuicidality11

12. BenzodiazepineBenzodiazepines, or benzos, are commonly prescribed as a sedative to help those with anxiety, panic attacks, stress, or insomniaPeople who abuse the substance often build a tolerance and progress to using extremely high doses to get the same effect12

13. BenzodiazepineCommon benzodiazepines include, but are not limited to:Diazepam (Valium)Alprazolam (Xanax)Clonazepam (Klonopin)Lorazepam (Ativan)Chlordiazepoxide (Librium)13

14. Benzodiazepine use with opiates14

15. Common Signs of Benzodiazepine IntoxicationMay be similar to signs of alcohol intoxicationSlurred speechUnsteady movements/poor coordinationStumblingIf benzodiazepines are used alone, blood/breath alcohol measurements should be zero15

16. Common Signs of Benzodiazepine WithdrawalAnxietyPanic attacksDifficulty sleepingNausea and/or vomitingPsychomotor agitation (difficulty sitting still)Racing heartbeatSweatingTremors or shaking hands16

17. Less Common and More Severe Signsof Benzodiazepine WithdrawalHallucinations: hearing, seeing, or feeling things that arenot thereSeizuresPsychosis Increased risk of suicidal thoughtsNote: Withdrawal from benzodiazepines can be dangerousand medical withdrawal management may be indicated17

18. OpioidsMedical use:Prescribed to treat moderate to severe painPrescribed to treat coughStreet use: HeroinAbuse of pharmaceuticals 18

19. OpioidsCommonly Prescribed Opioids: Oxycodone (OxyContin®) Hydrocodone (Vicodin®)CodeineMorphineIllicit Opioids:HeroinFentanyl (synthetic) 19

20. Trends in Opioid Purity20

21. Common Signs of IntoxicationAltered mental statusBreathing problemsLethargy (sleepiness or loss of alertness)Nausea and/or vomitingSmall pupils 21

22. Common Signs of WithdrawalEarly symptoms of withdrawal include:Agitation Anxiety Muscle aches Increased tearing Insomnia Runny nose Sweating Yawning 22

23. Common Signs of Opioid Withdrawal cont.Late symptoms of withdrawal include:Abdominal cramping Diarrhea Dilated pupils Piloerection (goosebumps) Nausea Vomiting 23

24. Medical and Psychological Concernswith Opioid WithdrawalDehydrationDepressionSuicidality24

25. StimulantsPrescribed Stimulants:AdderallRitalinConcertaIllicit Stimulants:CocaineCrackMethamphetamine25

26. Common Signs of IntoxicationDilated pupilsRestlessnessHyperactivityWeight lossSweatingAggressive behavior or anger outburstsMood swings26

27. Common Signs of Intoxication cont.JitterinessRapid heartbeatElevated blood pressureHyperfocusFlight of ideasRacing thoughtsAnxiety or nervousness27

28. Common Signs of WithdrawalFatiguePsychomotor retardationor agitationUnpleasant dreamsInability to sleep or sleeping excessivelyIncrease in appetite28

29. Common Signs of Withdrawal cont.DehydrationWeight lossChillsCravingsAnxietyIrritabilityImpaired memoryDulled sensesLack of interest in fun activitiesLack of interest in social interactions29

30. Medical and Psychological Concernswith Stimulant WithdrawalStroke Cardiovascular collapseMyocardial and other organ infarction Paranoia Violence Severe depression Suicide30

31. Synthetic DrugsCannabinoids (K2/Spice)Cathinones (Bath Salts)MDMA (ecstasy)31

32. Common Signs of IntoxicationSeizuresHallucinationsSuicidal tendenciesand attemptsHomicidal tendenciesDelusionsOverstimulationAggression32

33. Common Signs of Intoxication cont.ParanoiaChest painOverheating that causes a person to tear off clothesOther self-destructive behavior like bashing one’s bodyor head against walls33

34. Common Signs of WithdrawalAnxietyDepressionSleep disturbancesFatigueParanoiaHeadacheLoss of appetiteDifficulty concentratingTremorsCravings for the substance34

35. Medical and Psychological Concernswith Stimulant WithdrawalSuicide attemptsHeart attackDeath35

36. Club DrugsPCPGHBHallucinogens (LSD, mushrooms)36

37. Common Signs of IntoxicationSweatingJerking movements of the eyesImpaired motor skills (ex. drunken-like walk, staggering)Rapid heartbeat/or decreased heartbeat (GHB)DizzinessDilated pupilsConfusion37

38. Common Signs of Intoxication cont.Altered state of consciousness (tripping out)AgitationTerrorPanicRandomness in thoughts and/or actionsSevere anxiety and fearMood swingsHostile and violent behavior38

39. Common Signs of WithdrawalShort-term effects could include:Elevated body temperatureSeizuresMuscle twitchingAgitationHallucinations39

40. Common Signs of Withdrawal cont.Potential long-term symptoms could include:Memory lossWeight lossSpeech impairmentCognitive impairmentNote: Symptoms and severity depend on the length of use40

41. Medical and Psychological Concernswith Club Drug WithdrawalDepressionSelf-harmAggression41

42. Withdrawal Management in Jail Settings42

43. Withdrawal ManagementFacilities with nursing care:Use validated withdrawal severity screening toolsConduct medical assessment (e.g., vital signs, risk of self-harm)Provide care based on screening and assessment results43

44. Withdrawal ManagementFacilities without medical staff:Establish protocols that guide staff in determining when medical intervention is necessaryMaintain agreements with community partners to respondto medical calls at the facility44

45. Withdrawal Management Protocols • Assess for dehydration• Assess for comorbidities including advanced age, underlying chronic diseases and malnourishment• Begin targeted treatment for diarrhea and vomiting earlyin the withdrawal process• Hydrate using something that the person will actually drink• Become buprenorphine certified and use it to treat severe opiate withdrawal45

46. Medically Assisted Treatment ProgramsSome facilities use medications to treat withdrawal andto initiate treatment services that will be continued in the communityAdditionally, some facilities refer individuals to MAT programs According to the NCCHC Jail-Based Medication-Assisted Treatment guidelines, medication combined with psychological support improves recovery outcomes46

47. Policy Recommendations47

48. What to Include in PolicyProcedure for SUD screening at intakeProcedure for assessment and referral to medical for severe withdrawal symptomsProcedure for managing persons with SUD complications and needs (e.g., safe housing, frequent monitoring, open accessto hydration)48

49. ResourcesSAMHSA: Opioid Overdose Prevention TOOLKITGuide to Developing and Revising Alcohol and Opioid Detoxification ProtocolsManaging Opiate Withdrawal: The WOWS MethodMedically Assisted Treatment Implementation ChecklistNCCHC Jail-Based Medication-Assisted Treatment Guidelines49

50. Questions?50

51. Thank you!Please don’t forget to complete our training evaluation survey at https://www.research.net/r/KRD8QY8 A downloadable PDF version of this training and video is available at:https://www.dshs.wa.gov/bha/office-forensic-mental-health-services/jail-technical-assistance-program 51

52. References:National Institute on Drug Abuse (NIDA).(n.d.). Retrieved April, 1, 2020, from https://drugabuse.gov/Narconon: Drug Rehabilitation: Drug Education. (n.d.). Retrieved from https://narconon.org/https://columbialegal.org/wp-content/uploads/2019/05/Gone-But-Not-Forgotten-May2019.pdfHealth Information from the National Library of Medicine (2020, April 1). Retrieved from https://medlineplus.gov52

53. References:National Commission on Correctional Health Care. (2018). Jail-based MAT: Promising practices, guidelines. Retrieved from https://www.ncchc.org/jail-based-MATWilcox,T. (2016). Managing Opiate Withdrawal: The WOWS Method. Retrieved from https://ncchc.org53