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A n e s t h e s i a - A s s i s t e d R a p i d

O p i a te D e t o x i f i c a t i o n :A N e w P r o c e d u r e in t h eP o s t a n e s t h e s i a C are U n i t

L I N D A B . W I L S O N , P hD (c), R N, C P A N , C A PA , C

P E T E R A . D E M A R I A , Jr, M D , F A SA M

H . L Y N N K A N E , M SN , R N, M B A, C CR N

K A R E N M . R E I N I N G , M SN , R N, C C RN , C PA N

Heroin detoxi f ica t ion by anes thes ia -ass i s ted rap id op ia te de toxi f ica t ion( A A R O D ) ca n b e a ch i eved i n a p p r o x i m a t e l y 1 h o u r u s i n g i n tr a ven o u sadmin is t ra t ion o f m ida zo lam , propo fo l, and na loxone. Opia te dependen ceand detoxi f ica t ion techn iques are rev iewed . Impo r tan t aspects o f pa t ien tcare a nd per ianes thes ia nurs ing are descr ibed us ing a case s tudy . To ass i s t incar ing for the pa t ien t undergo ing a nes thes ia -ass i s ted rap id op ia te de toxif i' ca -t ion , the per ianes thes ia nurse shou ld unders tand the methodology andcontroversy o f th is ne w procedure .

9 1 9 9 9 b y A m e r i c a n S o c i e t y o f P e r i A n e s t h e s i a N u r s e s .

O b j e c t i v e s - - B a s e d o n t h e c o n t e n t o f t h e f o l l o w i n g a r t i c l e , t h e r e a d e r w i l l b e a b l e t o : ( 1 ) d e s c r i b e t h e

cu r r en t ly av a i lab le meth o d s o f o p ia te d e to x i f ica t io n , in c lu d in g an es th es ia - as s i s ted r ap id o p ia te d e to x i f ica t io n

( A A R O D ) ; ( 2 ) l is t t he p h a r m a c o l o g i c a l a g e nt s m o s t c o m m o n l y u s e d f o r A A R O D ; a n d ( 3 ) i d e n t if y im p o r t a n t

n u r s in g imp l ica t io n s wh en ca r in g fo r a p a t ien t u n d erg o in g AA RO D.

T H R O U G H T H E 1 9 9 0 s , a n e w g e n e r a t i o n o f

y o u th in th e Un i ted S ta tes h as b een ex p er i -

men t in g w i th an d , in so me cases , b eco min g ad -

d ic ted to h e ro in . Th is in c r ease i s in p a r t a r esu l t o f

m o r e p u r e a n d m o r e r e a d i l y a v a il a b l e h e r o in t h a nwas av a i lab le to th e b ab y b o o mer s in th e 1 9 6 0 s .

Acco rd in g to G a lan te r an d K leb er , 1 h e ro in ad d ic -

t io n in th e Un i ted S ta tes co s t s ap p ro x im ate ly $ 1 4 4

b i l l io n a y ear in h ea l th ca r e co s t s an d jo b lo s s .

R e c e n t e s t i m a t e s o f h e r o i n c o n s u m p t i o n q u o t e

ap p ro x imate ly 5 0 0 ,0 0 0 to 7 5 0 ,0 0 0 ad d ic t s in th e

Un i ted S ta tes . 2 Hea l th ca r e p e r so n n e l n eed to b e

Linda B. Wilson, PhD(c), RN, CPAN , CAPA , C, is an Education

Specia l i s t for N ursing Cont inuing E ducat ion and Perianesthe-

sia, Thomas Jefferson University Hospital, Philadelphia, PA;

Pete r A. DeMaria , Jr, MD, FASAM , i s an Assis ta nt Professor o f

Psych ia try and Huma n Behavior, Jef ferson Medical Co l lege andMed i ca l D i rec t o r o f J e f f er so n ' s Na rco t i c Ad d i c t Reh a b i l it a t io n

Program, Philadelphia, PA; H. Lynn Kane, MSN, RN, MBA , C CRN,

is a C linician in the Nursing Acu te Pain Management Service and

Karen Reining, MSN, RN, CCRN , CPAN, is the Nurse Manager of the

PACU a nd SP U at Presbyterian Medical C enter, Philadelphia, PA.

Address correspondence to Linda B. W ilson, PhD(c), RN, CPAN,

CAPA, C, 834 Chestnut St, Ap t #1721, Philadelphia, PA 19107.

9 1 9 9 9 b yAm er i ca n S o c i e ty o f Per i An es t h es ia Nu rse s.

1089-9472/99/1404-0004503.00/0

Journa l o f PeriAnesthesia Nurs ing , Vo114, No 4 (Augu st) , 1999: pp 207-216 207

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2o8 W I L S O N E T A L

aware o f th e in c r ease in h e ro in ad d ic t io n an d th e

t r ea tmen t o p t io ns .

The negative consequences of hero in addict ion are

the daily need to obtain more h ero in as well as the in-

creasing amount of money needed to buy i t . Feed-ing a heroin habit follows a downward spiral leading

to med ica l , p sy ch o lo g ica l , an d leg a l co n seq u en ces .

Fo r man y h ero in ad d ic t s , t r ea tmen t co n s is t s o f

th e fo l lo win g two p h ases : d e to x i f ica t io n , f o l lo wed

b y lo n g - te rm t r ea tmen t th a t in c lu d es co u n se l in g

an d o th er p sy ch o s o c ia l s e rv ices , an d in so me cases ,

m e d i c a t i o n . T h e s u c c e s s o f a n y t r e a tm e n t m e t h o d ,

h o wev er , d ep en d s o n th e in d iv id u a l ad d ic t ' s g o a ls .

F r eq u en t ly , an ad d ic ted p er so n w i l l s ee d e to x i f ica -

t i o n t r e a t m e n t a s t h e e n d - - r a t h e r t h a n t h e b e g i n -

n in g o f - - th e r ap y . Un fo r tu n a te ly , o th er ad d ic t s may

seek d e to x i f ica t io n fo r th e sak e o f le s sen in g th ed eg ree o f h e ro in d ep en d en ce an d , th e r e fo r e , th e

b u rd en o f su p p o r t in g th e h ero in h ab i t , r a th e r th an as

a mean s to ab s t in en ce an d r eco v ery .

Trea t in g h ero in ad d ic t io n can b e d isco u rag in g

b ecau se o f th e h ig h r a te o f r e lap se . To imp ro v e

su ccess r a tes , ex p er t s h av e so u g h t t r ea tmen t meth -

o d s to imp ro v e d e to x i f ica t io n an d su ccess fu l lo n g -

te rm t r ea tmen t o u tco mes fo r o p io id ad d ic t io n .

Cl in ic ian s co n t in u e to sea r ch fo r a r eg imen th a t w i l l

d e to x i fy th e p a t ien t wh i le m ax imiz in g p a t ien t s a f e ty

an d co m fo r t d u r in g w i th d rawal , a s we l l a s p ro m o te

patient compliance with long-term treatment. In thisarticle, the traditional methods are briefly reviewed.

A m o r e c o n t r o v e r s i a l m e t h o d f o r r a p i d o p i a t e

d e to x i f ica t io n , k n o wn as an es th es ia - as s i s ted r ap id

o p ia te d e to x i f ica t io n (AAR OD ) , i s a p ro ced u re th a t

i s g a in in g p o p u la r i ty an d i s b e in g p er fo rmed in

PACUs . Th is meth o d i s p r esen ted th ro u g h a case

s tu dy . F in a l ly , th e p ro ced u re , m ed ica t io n s , p e r so n -

n e l , eq u ip men t , an d p o s tan es th es ia ca r e in v o lv ed in

th is p ro ced u re a r e d esc r ib ed . Imp o r tan t t e rms r e l -

ev an t to th i s a r t ic le a r e d e f in ed in th e Ap p en d ix .

HEROIN (DIACETYLMORPHINE)

H e r o i n ( d i a c e t y l m o r p h i n e ) i s t h e m o s t c o m -

m o n l y a b u s e d o p i a t e ) I t i s d e r iv e d fr o m m o r p h i n e

th ro u g h a ch emica l p ro cess ca l led ace ty la t io n .

M o rp h in e an d co d e in e a r e th e o n ly n a tu ra l ly o ccu r -

r in g o p ia te an a lg es ics . Th ey a r e ex t r ac ted f ro m th e

m i l k y e x u d a t e o f t h e u n r i p e s e e d c a p s u l e s o f t h e

p o p p y p lan t . 4 He ro in i s a mo re p o ten t an a lg es ic

th an m o rp h in e , h as a g r ea te r eu p h o r ic e f f ec t th an

mo rp h in e , an d i s n o t u sed th e r ap eu t ica l ly in th e

Un i ted S ta tes . 5 I t i s so ld o n th e s t r ee t s ty p ica l ly as

1 0 d o l la r b ag s o f wh i te o r b ro wn ish p o wd er .

D e a l e r s t a k e p u r e h e ro i n a n d d i l u t e o r " c u t " i t w i t h

o th er ch emica ls su ch as su g ar , s ta r ch , p o wd ered

mi lk , o r q u in in e . 6 Th e ad d ic t d i s so lv es th e p o w d er

in wa ter and injects it, or, in the c ase of pure r heroin,sn o r ts i t. An av erag e h ero in h ab i t co s t s a b o u t $ 1 0 0

p e r d a y . 7 T h e m a j o r i t y o f p a ti e n ts w h o p r e s e n t f o r

A A R O D a r e a d d i c t e d t o h e r o i n ; h o w e v e r , s o m e

p a t ie n t s m a y p r e s e n t f o r d e t o x if i c a ti o n f r o m o t h e r

o p ia tes ( eg , o x y co d o n e , co d e in e , meth ad o n e) .

OPIOID DEPENDENCE

O p i o i d d e p e n d e n c e i s a c o m p l e x b i o p s y c h o s o -

c ia l d i sease th a t imp ac ts man y o r a l l a sp ec ts o f a

p er so n ' s l i f e . I ts h a l lmark i s a p h y s ica l w i th d rawal

sy n d ro me o n th e ab ru p t ces sa t io n o f d ru g u se .

S imi la r to a lco h o l i sm, o p ia te ad d ic t io n can b ed ef in ed as a p r imary , ch ro n ic d i sease , w i th g en e t ic ,

p sy ch o so c ia l , an d en v i ro n men ta l f ac to r s in f lu en c-

in g i ts d ev e lo p me n t an d man i f es ta t io n . Th e d isease

is o f ten p ro g ress iv e an d f a ta l . I t i s ch arac te r ized b y

co n t in u o u s o r ep iso d ic imp a i r ed co n t ro l o v er o p ia te

u se , p r eo ccu p a t io n w i th o p ia tes , u se o f o p ia tes

d esp i te ad v er se co n seq u en ces , an d d is to r t io n s in

th in k in g , mo s t n o tab ly d en ia l . 8

OPIOID WITHDRAWAL SYNDROME

In an opiate-dependent individual, signs and sy mp-

to ms o f w i th d rawal ap p ear ap p ro x imate ly 8 to 1 2

h o u r s a f te r th e las t d o se o f h e ro in o r o th er o p io id

s u c h a s m o r p h in e . T h e s y m p t o m c o m p l e x i s s i m i l a r

to a sev ere r esp i r a to ry o r g as t ro in tes t in a l v i r a l

i l ln ess . Sy mp to ms in c lu d e in c r eas in g r es t les sn ess ,

d i la ted p u p i l s , p i lo e r ec t io n , wa te ry ey es , r u n n y

nose, yawning , sweating , t remor , i r r i tab il i ty , an-

o rex ia , an d c r amp in g o f th e s to mach , as w e l l a s

mu sc le a n d jo in t p a in . Th e sev er i ty p eak s 4 8 h o u r s

a f te r th e las t d o se o f th e o p ia te an d las t s 7 to 1 0

d ay s . I t may b e lo n g er w i th lo n g er ac t in g o p ia tes

( eg , m eth ad o n e) . 3

Pro t r ac ted w i th d rawal can fo l lo w acu te w i th -

d rawal , an d i s ch arac te r ized b y g en era l mala i se ,f a t ig u e , d ecr eased sen se o f we l l -b e in g , p o o r s t r es s

to le r an ce , an d c r av in g fo r o p ia tes wh ich may las t

fo r mo n th s . 9 A h ig h r a te o f r e lap se i s s een d u r in g

b o th th e acu te an d p ro t r ac ted w i th d rawal p h ases .

DETOXIFICATION

Galan te r an d K leb e r 1 o u t l in e th e fo l lo win g s ix

g o a ls o f d e to x i f ica t io n :

1 . To r id th e b o d y o f th e n a r co t ic ' s p h y s io lo g ic a l

e f f ec t ;

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O P I A T E D E T O X I F I C A T I O N 20 9

2 . t o e l i m i n a t e o r d e c r e a s e t h e d i s c o m f o r t o f

opio id dr ug w i thdr aw al ;

3 . to pr ovide a s a f e , humane t r ea tment tha t

as s is t s the addic ted ind iv idu a l to ge t ov er the

in i t ia l hur d le of s topping the na r co t ic use ;

4 . t o p r o v i d e a s i tu a t io n t h a t p r o m o t e s c o m m i t -

m e n t t o l o n g - t e r m t r e a t m e n t ;

5 . to t r ea t med ica l p r oblems ; and

6 . to in i t i a te educ a t ion and r e f e r r a l s a s needed .

T h e t h r e e m o s t c o m m o n m e t h o d s u s e d f o r o p i o id

de toxi f ica t ion a r e : me thado ne w i thdr aw al , c lon i -

d i n e w i t h d r a w a l , a n d c l o n i d i n e / n a l t re x o n e w i t h -

d r a w a l . A l t h o u g h t y p i c a l l y p e r f o r m e d i n a n i n p a -

t ien t s e t t ing , ou tpa t ien t de tox i f ica t ion pr ogr ams

h a v e r e c e n t l y b e c o m e m o r e p r e v a l e n t .

Methadone Withdrawal

M e t h a d o n e ( D o l o p h i n e ; L i l ly , I n d ia n a p o l i s, I N )

i s an or a l ly e f f ec t ive , syn the t ic op ia te w i th a

h a l f - li f e o f a p p r o x i m a t e l y 2 4 h o u r s . T h i s 2 4 - h o u r

ha l f - l i f e pe r mi t s da i ly adm inis t r a t ion an d a gr adua l

decr ease in b loo d leve l dur ing de toxi f ica t ion . Metha-

done i s used as a subs t i tu te f or shor te r - ac t ing

o p i a t es s u c h a s h e r o in , m o r p h i n e , h y d r o m o r p h o n e

( D i laudid ; K nol l , Mt O l ive , N J ) , and meper id ine

( D e m e r o l ; W i n t h r o p , N e w Y o r k , N Y ) t o p r e v e n t t h e

w i thdr aw al syndr ome. O nce s tab i l i zed , the metha-

d o n e d o s e i s g r a d u a ll y t a p e r e d o v e r 3 t o 1 0 d a y s .

T h e p a t i e n t i s r e f e r r e d f o r l o n g - t e r m t r e a t m e n t

t h r o u g h a s u b s t a n c e a b u s e t r e a t m e n t p r o g r a m .

Leg ar da and G o ssop 1~ c i te r e lapse r a tes a f te r inpa-

t i e n t d e to x i f i c a ti o n t o b e 4 6 % a t 6 m o n t h s a n d 9 7 %

at 1 year . 1~ S ta r k show ed dr op - out r a tes f or inpa-

t i e n t d e t o x i f ic a t i o n b e t w e e n 2 0 % t o 3 0 % a n d a s

h i g h a s 8 0 % f o r o u t p a t i e n t d e t o x i f ic a t i o n .2

F o r s o m e p a t i e n t s w h o h a v e f a i l e d m u l t i p l e

d e t o x i f ic a t i o n a t t e m p t s a n d h a v e a l o n g h i s t o r y o f

o p i a t e d e p e n d e n c e , m a i n t e n a n c e t r e a t m e n t w i t h

m e t h a d o n e i s i n d i c a t e d . T h e l o n g - a c t i n g m e t h a -

done i s subs t i tu ted f or shor t - ac t ing her o in . When

p r e s c r i b e d p r o p e r ly , m e t h a d o n e i s n o t i n t o x i c a ti n g

or seda t ing . Ra ther , i t suppr es ses na r co t ic w i th-

d r a w a l a n d t h e d r u g c r a v i n g f o r h e r o i n f o r 2 4 t o 3 6

hour s . l Pa t ien t s a r e then engage d in a r ehabi l i t a t ion

p r o g r a m t h a t i n c l u d e s c o u n s e l i n g a n d o t h e r p s y c h o -

soc ia l s e r v ices and a r e encour aged to a t tend se l f -

h e l p ( e g , N a r c o t i c s A n o n y m o u s ) p r o g r a m s . T h e

ul t imate goa l i s long- te r m, gr adua l , medica l ly super -

v i s e d w i t h d r a w a l o f m e t h a d o n e .

Table 1. S edat ive Agents, Opiate Antagonists,

and Adjunct ive Medicat ions

Sedat ive Agents

M i d a z o l a m h y d r o -

ch lor ide (Versed;

Roche, N ut ley, N J)

P ropo fo l (D ip r i van ;

Zeneca, Wi lm-

i ng ton , DE)

Opiate Antagonists

N a l o x o n e h y d r o c h l o -

r i de (Na rcan ;

DuPon t Pha rmaceu -

t i ca ls , Wi lm ing ton ,

DE )

N a l t r e x o n e h y d r o -

ch lor ide (Revia ;

DuPon t Pha rmaceu -t ica ls)

Adjunct ive Medicat ions

C l o n i d in e h y d r o c h l o -

r ide (Catapres;

Boeh r i nge r , Inge l -

he lm R idge f i e l d , CT)

D i c y c l om i n e h y d r o -

ch lo r i de (Ben ty l ;

H o e c h s t M a r i o nRoussel, Kansas

Ci ty, MO)

M e t o c l o p r a m i d e

(Reglan; Robins,

Phi lade lph ia , PA)

N iza t i d i ne (Ax id ;

Wh i teha l l -Rob ins ,

M a d i s o n , NJ)

Ondanse t ron (Zo f ran ;

G laxo We l l come ,

Pla in f ie ld , N J)

Oxazepam (Se rax ;

Wye th -Aye rs t ,

Ph i lade lph ia , PA)

An i n t r avenou s benzod iazep ine

tha t possesses seda t ive , an t i -

anx ie ty , and amnes i c e f fec ts .

A n i n t ra v e n o u s h y p n o t i c a g e n t

w i th a sho r t du ra t i on o f ac t ion

tha t p roduces rap id seda t i on .

A pu re op io i d an tagon i s t ava i l ab le

fo r p a ren te ra l use on ly . Na l -

o x o n e h y d r o c h l o r i d e c o m p l e t e l y

i nh ib i t s op ia te agon i s ts a t

r ecep to r s ites and p reve n ts o r

reve rses h e e f fec ts o f op ia tes .

A p u re an tagon i s t ava i l ab le fo r

o ra l use on ly . Na l t r exone hyd ro -

ch lo r i de comp le te l y i nh ib i tsop ia te agon i s ts a t r ec ep to r s i tes

and p reven ts o r r eve rses the

e f fec ts o f op ia tes .

An a lpha2 - recep to r agon i s t tha t

supp resses s i gns and symp-

t o m s o f o p i o i d w i t h d ra w a l . I t

acts a t the loc us ceru leus to

decrease symp a the t i c ou t f l ow

wh ich i s i nc reased i n and

t h o u g h t r e s p o n s ib l e f o r o p i a t e

w i t h d r a w a l s y m p t o m s .

An an t i cho l i ne rg i c w i th spasm o-

l y t ic ac t i on on smoo th musc le o f

the gastro in test ina l t ract .

A d rug w i th an t i eme t i c e f fec ts

de r i ved f r om i t s an tagon i sm o f

dopa mine recep to rs and i nh ib i-

t i o n o f c h e m o r e c e p t o r s .

A h i s tam ine - recep to r b l ocke r tha t

i nh ib i t s the ac t i on o f h i s tam ine

at the stoma ch receptor si tes de-

creasing gastr ic acid sec ret ion.

A se ro ton in recep to r an tagon i s t

w i th an t i eme t i c p rope r ti es .

A benz od iazep ine w i th anx io l y t i c

and s eda t i ve p rope r t i es . I t

dep resses the cen t ra l ne rvou s

sys tem a t the l imb i c and subco r -

t ica l leve ls o f the bra in .

Da ta f r om Drug Fac ts and Compar i sons . M

Clonidine Withdrawal

C l o n i d i n e h y d r o c h l o r i d e , a n a l p h a - 2 - a d r e n e r g i c

a g o n i s t c o m m o n l y u s e d t o t r e a t h y p e r t e n s i o n , h a s

a l so be en used to as s i s t op io id w i thdr aw al . 11 F r e -

q u e n t l y c o m b i n e d w i t h a s e d a t i v e s u c h a s o x a z -

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210 W I L S O N E T A L

ep am, i t i s ad min is te r ed in d o ses u p to 1 .2 mg /d

o v e r a 7 - to 1 4 -d ay p er io d to d ecr ease w i th d rawa l

s y m p t o m s . S o m e s t u d i e s c o m p a r i n g m e t h a d o n e -

ass i s ted o p ia te w i th d rawal w i th c lo n id in e- as s i s ted

wi th d rawal sh o w th e fo rm er meth o d to h av e marg in -a l ly b e t te r co mp le t io n r a tes an d f ewer w i th d rawal

s y m p t o m s . 9

Clonidine/Naltrexone Withdrawal

Nal t r ex o n e i s a p u re o p io id an tag o n is t w i th a

lo n g d u ra t io n o f ac t io n las t in g u p to 4 8 to 7 2 h o u r s .

R e s e a r c h e r s h a v e f o u n d t h a t, w h e n c o m b i n e d w i t h

c lo n id in e , i t can sh o r ten th e d e to x i f ica t io n t ime

from 7 to 14 days to 3 to 5 days . 12 Use d al one as a n

o p io id w i th d rawal th e r ap y , n a l t rex o n e cau ses imm e-

d ia te an d sev ere w i th d rawal sy mp to m s . Few o p ia te -

d ep en d en t p a t ien ts co u ld to le r a te su ch a h a r shd e to x i f ica t io n . Ho wev er , o n ce th e p a t ien t i s co m-

p le te ly d e to x i f ied , n a l t r ex o n e can p r ev en t r e lap ses

to h e ro in b y b lo ck in g th e eu p h o r ic e f f ec ts o f

h ero in .

AAROD

In an a t temp t to in c r ease su ccess r a tes , sh o r ten

th e d e to x i f ica t io n t ime , an d in c r ease th e n u m b er o f

p a t ien ts tak in g n a l t r ex o n e , a n ew tech n iq u e ca l led

A A R O D h a s e m e r g e d . T h e t e c h n i q u e h a s b e e n

c a l l e d b y a n u m b e r o f n a m e s i n c l u d i n g r ap i d o p i a t e

d e to x i f ica t io n , u l tr a r ap id o p ia te d e to x i f ica t io n , an drap id an es th es ia - as s i s ted d e to x i f ica t io n . So me c l in i-

c ian s h av e p a ten ted th e i r v e r s io n o f th e tech n iq u e .

Lo im er et a l , 13 wor king in V ienna in th e 1980s,

was th e f i r s t to u se g en era l an es th es ia to su p p ress

o p i a t e w i t h d r a w a l s y m p t o m s d u r i n g n a l o x o n e -

p rec ip i ta ted d e to x i f ica t io n . I n 1 9 9 4 , Leg ard a an d

Go sso p 1~s tu d ied 1 1 p a t ien ts u n d erg o in g d e to x i f ica -

t i o n w i t h m i d a z o l a m h y d r o c h l o r i d e a n d n a l t re x o n e .

Deto x i f ica t io n fo r th i s g ro u p was ach iev ed in

ap p ro x im ate ly 4 h o u r s . 1~ S t r an g an d Go sso p TMrepor ted in 1997 that at leas t 10 ,000 opiate addicts

h ad u n d erg o n e an acu te w i th d rawal b y o p ia tean tag o n is t s w i th u se o f g en era l an es th es ia . Th e

p ro ced u re c an co s t $ 3 ,0 0 0 o r m o re . 15 An u n p u b -

l i sh ed s tu d y f ro m an I s r ae l i CITA In te rn a t io n a l

( C e n t e r f o r R e s e a r c h a n d T r e a t m e n t o f A d d ic t i o n )

a f f i l i a ted c l in ic f o u n d 6 0 % o f p a t ien ts r emain ed

r e l a p s e - f r e e u p t o 1 8 m o n t h s a f t e r t h e i r " l - d a y "

AA RO D t r ea tmen t . 16

T h e a c t ua l p r o c e d u r e a n d m e d i c a t i o n s u s e d h a v e

v ar ied amo n g in v es t ig a to r s . A l th o u g h so me in v es t i -

g a to r s h av e u sed meth o h ex i ta l a s th e sed a t in g

ag en t , o th e r s r ep o r t u s in g mid azo lam o r p ro p o fo l

fo r sed a t io n . Th e t im e p er io d o f d e to x i f ica t io n h as

v ar ied f ro m as sh o r t a s 1 h o u r u p to 4 h o u r s . I n

so me r ep o r t s , n a lo x o n e a lo n e was u sed to p r ec ip i -

ta te o p ia te w i th d rawal , w h i le in o th er s , n a l t rex o n e

o r a c o m b i n a t i o n o f n a l o x o n e a n d n a l t r e x o n e w e r eu sed . To p ro tec t th e a i rway f ro m p o ss ib le emes is

an d asp i r a t io n , so me in v es t ig a to r s h av e ro u t in e ly

in tu b a ted p a t ien ts , wh i le o th er s d o n o t r o u t in e ly

in tu b a te . Rep o r t s in th e l i t e r a tu r e h av e ten d ed to b e

smal l case se r ies , an d n o wel l - co n t ro l led s tu d ies

h av e b een r ep o r ted . 16

SETTING/PERSONNEL/EQUIPMENT

T h e s e tt i ng o f A A R O D c a n v a r y f r o m i n p a ti e n t,

sh o r t - s tay (2 3 h o u r s ) , o r o u tp a t ien t u n i ts , d ep en d -

in g o n in s t i tu t io n a l p o l icy . I n th e p a r t icu la r caser ep o r ted h er e , th e p a t ien t was ad mi t ted to th e

p sy ch ia t r ic u n i t o f th e h o sp i ta l th e d ay b efo re th e

p ro ced u re an d d isch arg ed th e d ay a f te r th e p ro ce-

d u re . P r ead miss io n en su red th a t th e p a t ien t wo u ld

h a v e n o t h i ng b y m o u t h b e f o r e t h e p r o c e d u re , a n d

e n a b l e d t h e p a t i e n t t o r e c e i v e p r e p r o c e d u r e m e d i c a -

t io n u n d er su p erv is io n to p r ev en t emes is an d th e

r i sk o f asp i r a t io n d u r in g th e p ro ced u re .

T h e p e r s o n n e l p r e s e n t f o r t h i s p r o c e d u r e v a r y

wi th each in s t i tu t io n ' s p o l icy . Fo r th i s case , an

ad d ic t io n p sy ch ia t r i s t , an an es th es io lo g is t , an d two

PAC U reg is te r ed n u r ses were p r esen t .S p e c i f ie d e q u i p m e n t m u s t b e r e a d y a n d a v a i l a b le

a t th e s i te wh ere th e AAROD p ro ced u re i s to tak e

p lace , an d sh o u ld in c lu d e co n t in u o u s ca rd iac mo n i -

to r in g , n o n in v as iv e b lo o d p r es su re mo n i to r in g ,

co n t in u o u s p u lse o x im et ry , o x y g en d e l iv e ry eq u ip -

m e n t , a n d e m e r g e n c y e q u i p m e n t . T h i s e m e r g e n c y

e q u i p m e n t m u s t i n c l u d e a i r w a y m a n a g e m e n t m a t e -

r ia l s in c lu d in g in tu b a t io n eq u ip men t an d a ca rd iac

ar res t car t .

A r eg im en o f sed a t iv e ag en ts , o p ia te an tag o n is t s ,

an d ad ju n c t iv e d ru g s i s u sed fo r AA RO D. Tab le 1

r ev iews th e ca teg o r ies o f d ru g s an d th e i r sp ec i f ic

c l in ica l e f f ec ts as r e la ted to th i s p ro ced u re . Th e

sp ec i f ic med ica t io n s an d d o sag es m u s t b e in d iv id u -

a l ized to th e p a t ien t u n d erg o in g th e p ro ced u re .

CASE STUDY

M r. N i s a 3 0 -y ear -o ld ma n wi th an 8 -y ear

h is to ry o f o p ia te d ep en d en cy . H is cu r r en t h e ro in

h ab i t co s t s $ 6 0 to $ 8 0 p er d ay . He d en ied u se o f

o th er r ec r ea t io n a l d ru g s o r a lco h o l . Th e p a t ien t h ad

n o o th er p sy ch ia t r ic o r med ica l h i s to ry . He was

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O P I A T E D E T O X I F I C A T I O N 211

a d m i t t e d t o t h e h o s p i ta l t h e d a y b e f o r e t h e A A R O D

p r o c e d u r e .

A p a t i e n t i n t e r v ie w w a s c o n d u c t e d o n t h e d a y o f

admiss ion by the admi t t ing r eg is te r ed nur se . I n -

f or med consent f or the pr ocedur e w as ob ta ined by the

addic t ion psychia t r i s t and the an es thes io log is t . Wi th

t h e p a t i e n t d o c u m e n t a t i o n c o m p l e t e d , t h e p a t i e n t

r e c e i v e d c lo n i d i n e h y d r o c h l o r i d e a n d o x a z e p a m a s

needed to suppress the opiate withdrawal symp toms

t h e e v e n i n g b e f o r e t h e p r o c e d u r e . H e t o o k n o t h i n g

b y m o u t h a f t e r m i d n i g h t e x c e p t f o r m e d i c a t i o n s.

A t 5 :00 AM on the d ay of the pr oced ur e , Mr . N

r e c e i v e d m u l t i p l e p r e p r o c e d u r a l o r a l m e d i c a t i o n s

w h i c h i n c l u d e d 0 . 3 m g c l o n i d i n e h y d r o c h l o r i d e to

s u p p re s s w i t h d r a w a l s y m p t o m s . O n e h u n d r e d f i f ty

m i l l i g r a m s n i z a t i d i n e a n d 1 0 m g m e t o c l o p r a m i d e

w e r e g i v e n t o d e c r e a s e g a s tr i c a c i d i ty a n d p r e v e n tn a u s e a a n d v o m i t i n g .

A t 8 :00 A M, Mr . N w as adm i t ted to a bay in the

P A C U . T h e i s o l a t i o n b a y w a s s e l e c t e d f o r t h i s

p r o c e d u r e t o e n s u r e p r i v ac y . T h e a d d i c t i o n p s y c h i a -

t r i s t and the anes thes io log is t w er e pr esen t dur ing

t h e p r o c e d u r e w i t h t w o P A C U n u r s e s r e a d i l y a v a il -

a b l e . T w o p e r i p h e r a l i n t r a v e n o u s l i n e s w e r e i n -

s e r t e d i n t h e p a t i e n t a n d h e w a s p l a c e d o n a

c o n t i n u o u s c a r d i a c m o n i t o r , p u l s e o x i m e t e r , a n d a

n o n i n v a s i v e b l o o d p r e s s u r e m o n i t o r . O x y g e n w a s

in i t i a ted a t 2 L /min v ia nasa l cannula . Base l ine

p r e p r o c e d u r e v i t a l s i g n s a n d a p u l s e o x i m e t e rr e a d i n g w e r e r e c o r d e d . E m e r g e n c y r e s u s c i t a t i o n

e q u i p m e n t w a s r e a d i l y a v a i l a b le .

At the o nset of the procedure, the p at ient was g iven

2 m g m i d a z o l a m h y d r o c h l o r i d e a n d 8 m g o n d a n s e -

t r o n i n t r av e n o u s l y . A f t e r i n f u s i o n o f t h e s e m e d i c a -

tions, the patient rece ived two bolus intravenous inje c-

t ions of propo fol , 1 mg/kg , result ing in l ight sedation.

A f ew minutes l a te r , an addi t iona l p r opof o l bo lus

w a s g i v e n t o i n c r e a s e s e d a ti o n a n d a m a i n t e n a n c e

i n t r av e n o u s i n f u s i o n o f p r o p o f o l w a s s ta r te d .

V i t a l s i g n s w e r e m o n i t o r e d a n d d o c u m e n t e d b y

t h e a n e s t h e s io l o g i s t e v e r y 5 m i n u t e s t h r o u g h o u t t h ep r o c e d u r e u s i n g t h e a n e s t h et i c p a t i e n t r e c o rd . A p -

p r o x i m a t e l y 1 5 m i n u t e s in t o t h e A A R O D , a 1 0 m g

i n t r a v e n o u s b o l u s o f n a l o x o n e h y d r o c h l o r i d e w a s

adminis te r ed . This bo lus in jec t ion r esu l ted in the

i m m e d i a t e o n s e t o f w i t h d r aw a l s i gn s a n d s y m p -

t o m s . M r . N d e v e l o p e d m y d r i a s i s a n d p i l o e r e c t i o n

w i t h m i l d e l e v a t i o n o f h e a r t r a t e a n d b l o o d p r e s -

s u r e . T h e p a t i e n t t o l e r a t e d t h e s e s y m p t o m s w e l l

w h i l e u n d e r t h e e f f e c t s o f s e d a t i o n .

A f t e r 4 5 m i n u t e s , t h e p r o p o f o l i n f u s i o n w a s

d e c r e a s e d a n d t h e n d i s c o n t in u e d . A l m o s t i m m e d i -

a t e l y , M r . N a w a k e n e d . T w o c h a l l e n g e d o s e s o f

i n t r a v e n o u s n a l o x o n e h y d r o c h l o r i d e fa i l e d t o p r o -

d u c e a n y s i g n s o r s y m p t o m s o f h e r o i n o r o p i a t e

w i t h d r a w a l. O n a w a k e n i n g , t h e p a t i e n t c o m p l a i n e d

o f a b d o m i n a l c r a m p i n g f o r w h i c h h e w a s m e d i -c a t e d w i t h 2 0 m g o f d i c y c l o m i n e h y d r o c h l o r i d e . H e

w a s a l s o g i v e n 2 0 0 m g o f n a l t re x o n e o r a l l y to

m a i n t a i n o p i a t e - r e c e p t o r b l o c k a d e . A f t e r t h e p r o c e -

d u r e , M r . N r e m a i n e d i n t h e P A C U f o r r e co v e r y .

T h e P A C U n u r s e s m o n i t o r e d t h e p a t ie n t c l o s e l y

f o r a p p r o x i m a t e l y 1 h o u r a c c o r d i n g t o t h e i n s t i tu -

t i o n ' s r e c o m m e n d e d g u i d e l i n e s . T h e l e n g t h o f

p o s t a n e s t h e s ia c a r e i s b a s e d o n t h e t y p e o f a n e s t h e -

s ia adminis te r ed as w e l l a s the pa t ien t ' s p r ogr es s

t h r o u g h r e c o v e r y . I n t h i s c a s e , t h e p a t i e n t r e m a i n e d

in the same PA CU bay . V i ta l signs , inc lud ing hear t

r a te , b lood pr es sur e , r e sp i r a t ions , and pulse ox im-e t r y v a l u e s , w e r e d o c u m e n t e d a t a m i n i m u m o f

e v e r y 1 5 m i n u t e s u s i n g t h e P A C U n u r s i n g r e c o r d .

T h e P A C U n u r s e m u s t c l o s e l y m o n i t o r t h e p a t i e n t,

and , a s w i th a l l pa t ien t s hav ing under gone anes the -

s ia , r e sp i r a tor y s ta tus mu s t be c los e ly obse r ved . I n

a d d i ti o n , a w a r e n e s s o f t h e p o t e n t i al f o r n a u s e a a n d

v o m i t i n g a n d t h e p o t e n t i a l r i sk o f a s p i ra t i o n m u s t

be ca r e f u l ly as ses sed . A s a lw ays , pa t ien t comf or t

and sa f e ty mu s t be cons ider ed . I n th i s case , Mr . N ' s

P A C U s t a y w a s u n e v e n t f u l a n d h e v e r b a l i z e d n o

complaints . Emotional suppor t and reassurance were

a l s o p r o v i d e d a s n e e d e d . W h e n t h e p o s t a n e s t h e si aper iod was completed, a te lephoned repor t was given

t o t h e r e c e i v i n g n u r s e o n t h e p s y c h i a t r ic u n i t , a n d

escor t personnel t ranspor ted the pat ient to his room .

T h e d a y a f t e r t h e p r o c e d u r e , M r . N w a s d i s -

c h a r g e d h o m e w i t h p l a n n e d o u t p a t i e n t f o l l o w - u p a t

the hosp i ta l ' s psychia t r ic ou tpa t ien t subs tance abuse

t r e a t m e n t p r o g ra m . M r . N ' s d i s c h a r g e m e d i c a t i o n s

i n c l u d e d t h e f o l l o w i n g : 5 0 m g o f o r a l n a l t r e x o n e

e v e r y m o r n i n g , 0 .1 m g o f o r a l c l o n i d i n e h y d r o c h l o -

r i d e t w i c e a da y , a n d 3 0 m g o f o r a l o x a z e p a m t h r e e

t i m e s a d a y a s n e e d e d f o r w i t h d r a w a l s y m p t o m s .

D u r i n g t h e w e e k s a f t e r t h e p r o c e d u r e , M r . N

a t tended tw o counse l ing ses s ions bu t , a f te r tha t ,

w a s l o s t t o f o l l o w - u p w h e n h i s p a r t - ti m e j o b

b e c a m e f u l l - ti m e .

DISCUSSION

A l t h o u g h s t il l e x p e r i m e n t a l , A A R O D i s a w i d e l y

p e r f o r m e d p r o c e d u r e . 17 W h i l e a t e c h n i q u e f o r d e -

t o x i f ic a t i o n , o n e m u s t k e e p i n m i n d t h a t i t is n o t a

cur e f or addic t ion . D e toxi f ica t ion r educes the phy s i -

o l o g i c a l d e p e n d e n c y b u t d o e s n o t a d d r e s s t h e

p s y c h o s o c i a l i s s u e s o f d r u g d e p e n d e n c e . T h e

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212 W I L S O N E T A L

A A R O D p r o c e d u r e n e e d s t o b e e v a l u a t e d a n d

i n d i v i d u a l i z e d to e a c h p a t ie n t . A s s e s s m e n t o f

w h e t h e r t h e r i s k o f a n e s t h e s i a o u t w e i g h s t h e b e n -

e f it s o f t h e d e t o x i f i c a t i o n m u s t b e d e t e r m i n e d .

M o r e r e s e a r c h c o m p a r i n g A A R O D w i t h t r ad i -

t i o n a l d e t o x i f i c a f i o n m e t h o d s i s n e e d e d . T h i s r e s e a r c h

s h o u l d i n v e s t i g a t e t h e c o m p l e t i o n a n d r e l a p s e

r a t e s , s a f e t y , l o n g - t e r m e f f e c t s , a n d f u n c t i o n a l

l e v e l o f i n d i v id u a l s h a v in g u n d e r g o n e A A R O D .

W h e t h e r t h i s n e w p r o c e d u r e c o u l d a s s i s t i n a d e -

c r e a s e d l e n g t h o f s t a y i n t h e h o s p i t a l , i n c r e a s e d c o m -

p l i a n c e w i t h n a l t r e x o n e t h e r a p y , a n d r e d u c e d c o s t

c o m p a r e d w i t h o l d e r d e to x i f i c a t i o n m e t h o d s i s y e t

t o b e d e t e r m i n e d . E d u c a t i o n i s v i t a l f o r b o t h

p a t i e n t s a n d h e a l t h c a r e p r o f e s s i o n a l s a l i k e t o b e t t e r

u n d e r s t a n d a n d r e f i n e t h e p r o c e d u r e , u l t i m a t e l y

s e e k i n g t o i m p r o v e q u a l i t y o f l if e f o r th e i n d i v i d u a l

p a t i e n t .

A P P E N D I X

I M P O R T A N T T E R M S

A d d i c t i o n : A p r i m a r y , c h r o n i c d i s e a s e , w i th g e n e t i c , p s y c h o s o c i a l , a n d e n v i r o n m e n t a l f a c t o r s in f l u e n c i n g it s

d e v e l o p m e n t a n d m a n i f e s t a t io n . T h e d i s e a s e i s o ft e n p r o g r e s s i v e a n d f a t a l . It is c h a r a c t e r i z e d b y

c o n t i n u o u s o r e p i s o d i c i m p a i r e d c o n t r o l o v e r d r i n k i n g o r d r u g u s e , p r e o c c u p a t i o n w i t h a l c o h o l o r d r u g s ,

u s e o f a l c o h o l o r d r u g s d e s p i t e a d v e r s e c o n s e q u e n c e s , a n d d i s t o r t i o n s i n t h i n k i n g , m o s t n o t a b l y d e n i a l . 8

A g o n i s t : A d r u g t h a t h a s a n a f f i n i ty fo r a n d s t i m u l a t e s p h y s i o l o g i c a l a c t i v i ty a t c e l l re c e p t o r s n o r m a l l y

s t i m u l a t e d b y n a t u r a l l y o c c u r r i n g s u b s t a n c e s ( e g , h e r o i n o r m e t h a d o n e ) ; a c t i v a te s s p e c i f ic m u o p i a t e

r e c e p t o r s . 1

A n t a g o n i s t : A d r u g t h a t h a s a n a f f i n it y f o r c e ll re c e p t o r s n o r m a l l y s t i m u l a t e d b y n a t u r a l l y o c c u r r i n g

s u b s t a n c e s , h o w e v e r , r e v e r s e s o r n u l l i fi e s th e a c t i o n s o f t h e s e s u b s t a n c e s ( e g , n a l o x o n e a n d n a l t r e x o n e ) ;

b i n d s t o m u o p i a t e r e c e p t o r s , a n d r e v e r s e s t h e o p i a t e e f f e c ts . 1

D e t o x i f i c a t i o n : T h e p r o c e s s i n w h i c h a n i n d i v i d u a l w h o i s p h y s i o l o g i c a l l y d e p e n d e n t o n a d r u g i s t a k e n o f f

t h a t d r u g e i t h e r a b r u p t l y o r g r a d u a l l y . 1

O p i a t e : A d r u g d e r i v e d f r o m o r h a v i n g s i m i l a r p r o p e r t ie s a s d r u g s d e r i v e d f r o m o p i u m . T h e y a r e e x t r a c te d

f r o m t h e m i l k y e x u d a t e o f u n r i p e s e e d c a p s u l e o f t h e p o p p y p l a n t . M o r p h i n e a n d c o d e i n e a r e t h e o n l y t w o

n a t u r a l l y o c c u r r i n g o p i a t e s . 4

O p i o i d : A n y a g o n i s t d ru g w i t h m o r p h i n e - l i k e a c ti v it y .4

REFERENCES

1. Galanter M, Kleber H: Te xtbo ok of Sub stance Abuse

Treatment. Washington, DC, A merican Psychiatric Press, 1994

2. Neuradd Treatment Center: Comprehensive Narcotic De-

toxification, 199 8. Available at: http://ww w.neuradd.com/

facts.htm. Accessed September 30, 1998

3. Jaffe JH: Opioid related disorders, in Kaplan HI, Saddock

BJ (eds): Comprehensive Textbook of Psychiatry, vol 1 (ed 6).

Baltimore, MD, Williams and W ilkins, 1995, p 842

4. Julien RM: A Primer of Drug Action (ed 8). New York,

NY, W.H . Freeman and Co, 1998

5. Hardman JG, Limbird LE: Goodman and Gilman's The

Pharmacological Basis of Therapeutics (ed 9). New York, NY,

McG raw Hill Health Professions Division, 1996

6. National Institute of H ealth : VIDA R esearch Report-

Heroin Abuse and Ad diction. (NIH Publication No. 97-4165).

Washington, DC, N IH, 1997

7. DeM aria PA, Weinstein SP: Methadone maintenance reat-

ment: When and how to refer patients. Post Grad Med 97:83-92,

1995

8. National Council on Alcohol and D rug Dependence:

Definition of Alcoholism. New Yo rk, NY, NCAD D, 1990

9. Mattick RP, Hall W : Are detoxification programs effec-

tive? Lancet 347:97-100, 1996

10. L egarda JJ, Gossop M : A 24 -h detoxification treatment

for heroin addicts: A preliminary investigation. Drug A lcohol

Dependence, 35:91-93, 1994

11. Gold M S, P ottash AC, Swe eney DR, et al : Opiate

withdrawal using clonidine. JAMA 243:343-346, 1980

12. Charney DS, Heninger GR, Kleber HD: The combined

use of clonidine and naltrexone as a rapid, saf e, and effective

treatment of abrupt withdrawal from m ethadone. Am J Psychia-

try 143:831-837, 1986

13. Loimer N, Linzmayer L, Schm id R, et al: Similar efficacy

of abrupt and gradual opiate detoxification.Am J Drug Alcohol

Abuse. 17:301-312, 1991

14. StrangJ, Gossop M : O piate detoxificationunder anesthe-

sia: Enthusiasm must be tempered with caution and scientific

scrutiny. BMJ 315:1249-1250, 1997

15. Tyer B: Heal T hyself--Rapid Deto x Leaves a Nurse

Suffering Unforeseen Side Effects 1998 . Houston Press. com.

Available at: http://www.houstonpress.com.Accessed Septem-

ber 30, 1998

16. S tephenson J; Experts d ebate merits of one day opiate

detoxificationunder anesthesia. JAMA 277:363-364, 1997

17. O 'Connor PG , Kosten TR: Rapid and ultra rapid opioid

detoxification echniques. JAM A 279:229-234, 1998

18. Drug Facts and Comparisons (1999 edition). St Louis,

MO, W aiters Kluwer, 1999

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O P I A TE D E T O X I F I C A T I O N 213

ANESTHESIA-ASSISTED RAPID OPIATE DETOXIFICATION

POST-TEST

1.0 CONTACT HOUR

D i r e c t i o n s : T h e m u l t i p l e - c h o i c e e x a m i n a t i o n b e l o w i s d e s i g n e d t o t e s t y o u r u n d e r st a n d i n g o f th e

a n e s t h e s i a - a s s is t e d r a p i d o p i a t e d e t o x i f i c a ti o n p r o c e d u r e a c c o r d i n g t o t h e o b j e c t i v e s l i s t e d a t t h e b e g i n n i n g o f

t h e a rt ic l e . T o e a r n c o n t a c t h o u r s f r o m t h e A m e r i c a n S o c i e t y o f P e r i A n e s t h e s i a N u r s e s ( A S P A N ) C o n t i n u i n g

E d u c a t i o n P r o v i d e r P r o g r a m : ( 1 ) r e a d t h e a r t i c le ; ( 2 ) c o m p l e t e t h e p o s t - t e s t b y i n d i c a t in g t h e a n s w e r s o n t h e

t e s t g ri d p r o v id e d ; ( 3 ) t e a r o f f t h e b o t t o m p o r t i o n a n d s u b m i t p o s t m a r k e d b e f o r e A u g u s t 3 1 , 2 0 0 1 , w i t h c h e c k

p a y a b l e to A S P A N ( A S P A N m e m b e r , $ 1 2 .0 0 p e r t e st ; n o n m e m b e r , $ 1 5 . 0 0 p e r t es t ); a n d r e t ur n t o A S P A N ,

6 9 0 0 G r o v e R d , T h o r o f a r e , N J 0 8 0 8 6 . N o t i f i c a t io n o f c o n t a c t h o u r s w i l l b e s e n t t o y o u i n 4 t o 6 w e e k s .

POST-TEST QUEST IONS

1 . D e t o x i f ic a t i o n is t h e p r o c e s s i n w h i c h a n i n d i v id u a l w h o i s p h y s i o l o g i c a l l y d e p e n d e n t o n a d r u g i s

t ak en o f f th a t d ru g e i t h e r ab ru p t ly o r g rad u a l ly . In an d o f i t se l f i t is n o t a cu re fo r ad d ic t i o n , r a th er t h e

b e g i n n i n g o f a t r e a tm e n t p r o c e s s .

a . True.

b . Fa l se .

2 . Ga lan t e r an d K leb e r 1 o u t l i n ed th e g o a l s o f d e to x i f i ca t i o n as fo l lo ws :

a . t o r id t h e b o d y o f th e p s y c h o l o g i c a l e f f e c t s o f t h e n a r c o t ic , t o i n c r e a s e t h e d i s c o m f o r t o f w i t h d r a w a l ,

a n d t o p r o v i d e s a f e a n d h u m a n e t r e a t m e n t .

b . p r o m o t e c o m m i t m e n t t o s h o r t -t e r m t r e a t m e n t , to t r e a t m e d i c a l p r o b l e m s , a n d t o i ni t ia t e e d u c a t i o n

c . t o ri d t h e b o d y o f p s y c h o l o g i c a l e f f e c t s o f th e n a r c o t i c , t o d e c r e a s e t h e d i s c o m f o r t o f w i t h d r a w a l ,

a n d t o p r o v i d e s a f e a n d r i g o r o u s t r e a t m e n t .

d . t o r id t h e b o d y o f p h y s i o l o g i c a l e f f e c ts o f t h e n a r c o ti c , t o d e c r e a s e t h e d i s c o m f o r t o f w i t h d r a w a l ,

a n d t o p r o v i d e s a f e a n d h u m a n e t r e a t m e n t .

3 . T h e u s e o f n a l tr e x o n e w i t h c l o n i d i n e c a n s h o r t e n t h e t i m e c o u r s e o f a n o p i a t e d e t o x i fi c a t io n .

a . T ru e .b . Fa l se .

4 . A A R O D i s a p r o c e d u r e t o d e t o x i f y o p i a t e a d d i c te d p a t i e n ts u s i n g a r e g i m e n o f d r u g s t h a t i n c l u d e s

sed a t iv e ag en t s , o p i a t e an t ag o n i s t s , an d ad ju n c t iv e m ed ica t io n s .

a . True.

b . Fa l se .

5 . A p a t ie n t u n d e rg o i n g A A R O D w i l l n e e d t h e fo l l o w i n g e q u i p m e n t r e a d y a n d a v a il a b l e :

a . n o e q u i p m e n t i s n e e d e d .

b . co o l in g b l an k e t .

c . t h o r o c o t o m y t r ay .

d . e m e r g e n c y e q u i p m e n t s u c h a s c a r d i a c a r r e s t c a r t, i n t u ba t i o n , a n d r e s u s c i ta t i o n m a t e r i a l s .

6 . Al l o f t h e fo l l o win g a re t ru e except:

a . N a l o x o n e i s a d m i n i s t e r e d o r a l l y w h i le n a l t r e x o n e i s a d m i n i s t e r e d p a r e n t e ra l l y .

b . P r o p o f o l ( D i p r i v a n ) is a n i n tr a v e n o u s h y p n o t i c a g e n t p r o d u c i n g r a p i d s e d a ti o n .

c . Niza t id in e (Ax id ) i n h ib i t s t h e ac t i o n o f h i s t am in e a t t h e r ecep to r s i t e s d ecre as in g g as t r i c sec re t i o n .

d . O x a z e p a m ( S e r a x ) d e p r e s s e s t h e c e n tr a l n e r v o u s s y s t e m a t t h e li m b i c a n d s u b c o r t i c a l l e v e l o f th e

b ra in .

7 . i s a se ro to n in r ecep to r an t ag o n i s t wi th an t i em et i c p ro p er t i es .

a . m e t o c l o p r a m i d e (R e g l a n ) .

b . o n d a n se t ro n (Zo f ran ) .

c . p r o c h l o r p e r a z i n e ( C o m p a z i n e ) .

d . i n ap s in e (Dro p er id o l ) .

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214 W I L S O N E T A L

8 . W h ic h o p ia t e a n t a g o n i s t i s p re sc r ib e d fo r p a t i e n t s a t d i sc h a rg e a f t e r A A R O D to a ss is t in t h e i r r e c o v e ry

f r o m o p i a t e d e p e n d e n c e ?

a . Na lo x o n e .

b . Na l t r e x o n e .

c . N a l m e p h e n e .

d . Na l lo rp h in e .

9 . A l l o f t h e f o l l o w i n g a r e tr u e a b o u t m e t h a d o n e except:

a . I t c a n b e u se d a s a d e to x i f i c a t i o n o r m a in t e n a n c e a g e n t t o t r e a t o p i a t e d e p e n d e n c e .

b . I t h a s a sh o r t (4 h o u r ) h a l f - li f e .

c . I t i s a l so k n o wn a s Do lo p h in e .

d . I t is o ra l l y e f f e c t i v e .

1 0. P o s t a n e s t h e s i a c a re o f t h e A A R O D p a t i e n t i n c lu d e s w h i c h o f t h e fo l l o w i n g :

a . Mo n i to r in g p a t i e n t v i t a l s i g n s .

b . O b s e r v i n g f o r n a u s e a a n d v o m i t i n g .

c . P r o v i d i n g c o m f o r t m e a s u r e s .

d . Al l o f t h e a b o v e .

1 1. T h e m o s t c o m m o n l y a b u s e d o p i a te is

a . D i l a u d i d ( h y d r o m o r p h o n e ) .

b . D e m e r o l ( m e p e r i d in e ) .

c . H e ro in (d i a c e ty lm o rp h in e ) .

d . P e r c o c e t ( o x y c o d o n e / a c e t o m i n o p h e n ) .

1 2. A l l o f t h e fo l l o w i n g a r e s i g n s o r s y m p t o m s o f o p ia t e w i t h d r a w a l except:

a . m id r i a s i s .

b . p i l o e re c t io n .

c . a b d o m i n a l c r a m p i n g .

d . se izures .

t 3 . I n a h e r o i n - d e p e n d e n t i n d iv i d u a l, s i g n s a n d s y m p t o m s o f o p ia t e w i th d r a w a l a p p e a r

d o s e o f h e r o i n .

a . 8 to 12 min utes .

b . 8 to 12 hours .

c . 12 to 24 min utes .

d . 12 to 24 hours .

1 4. T h e s e v e r i ty o f o p i o i d w i t h d ra w a l s y n d r o m e p e a k s a t

a . 1 2 h o u r s a f t e r l a s t d o se o f o p i a t e .

b . 2 4 h o u r s a f t e r la s t d o se o f o p i a t e .

c . 3 6 h o u r s a f t e r la s t d o se o f o p ia t e .

d . 4 8 h o u r s a f t e r l a s t d o se o f o p ia t e .

1 5. T h e t h r ee m o s t c o m m o n m e t h o d s u s e d f o r o p i o i d d e to x i f ic a t io n a r ea . m e t h a d o n e w i t h d ra w a l , c l o ni d i n e w i t h d r a w a l , A A R O D .

b . c l o n id i n e w i t h d r a w a l , A A R O D , c l o n i d in e / n a l tr e x o n e w i t h d r aw a l .

c . A A R O D , c l o n i d i n e / n a lt r e x o n e w i th d r a w a l , m e t h a d o n e m a i n te n a n c e .

d . m e th a d o n e wi th d ra w a l , c lo n id in e wi th d ra w a l , c lo n id in e /n a l t r e x o n e wi th d ra wa l .

1 6 . He ro in a d d ic t i o n i n t h e Un i t e d S t a t e s c o s t s a p p ro x im a te ly

a . $ 1 4 4 th o u sa n d a y e a r .

b . $ 1 4 4 m i l l i o n a y e a r .

c . $144 b i l l ion a year .

d . $144 t r i l l ion a year .

a f te r the las t

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O P I A T E D E T O X I F I C A T I O N 21s

1 7 . Re g a rd in g th e t r e a tm e n t o f h e ro in a d d ic t i o n , a l l o f t h e fo l lo w in g a re t ru e except:

a . P a r t ic i p a ti o n i n a p s y c h o l o g i c a l c o u n s e l i n g p r o g r a m s h o u l d b e e n c o u r a g e d .

b . De to x i f i c a t i o n i s u su a l ly t h e o n ly n e c e ssa ry t r e a tm e n t .

c . De to x i f i c a t i o n sh o u ld b e fo l lo we d wi th l o n g - t e rm o u tp a t i e n t c o u n se l in g .

d . I n d i v i d u a l a n d g r o u p c o u n s e l i n g a r e c o m m o n c o m p o n e n t s o f f o l l o w - u p a f t e r d e t o x if i c at i o n .

1 8 . H e ro in i s

a . a l e s s p o t e n t a n a lg e s i c t h a n m o rp h in e .

b . a p o t e n t a n t i e m e t i c .

c . a pote nt an t iana lge sic .

d . a m o re p o te n t a n a lg e s i c t h a n m o rp h in e .

1 9 . Me th a d o n e (Do lo p h in e ) i s

a . a n o ra l l y e f f e c t iv e sy n th e t i c o p i a t e .

b . a m ix e d o p ia t e a g o n i s t / a n t a g o n i s t .

c . a top ica l anesthe t ic .

d . a sy n th e t i c b e n z o d ia z e p in e .

2 0 . Al l o f t h e fo l lo win g a re t ru e a b o u t h e ro in except:

a . I t c a n b e sn o r t e d , sm o k e d , o r i n j e ct e d .

b . I t i s d e ri v e d f r o m m o r p h i n e t h r o u g h a c h e m i c a l p r o c e s s k n o w n a s a c e t y l a ti o n .

c . W i t h d r a w a l s y m p t o m s in d e p e n d e n t i n d i v i d u a ls c a n i n c l u d e m u s c l e a c h e s a n d p a i n s , d i la t e d p up i l s ,

a n d a b d o m i n a l c r a m p i n g .

d . In t h e Un i t e d S t a t e s , i t c a n b e p re sc r ib e d fo r c a n c e r p a t i e n t s su f fe r in g f ro m s e v e re p a in .