question about withdrawal protocols!

[sassyann85]

Hi everyone!

So, I'm going to be re-entering into psych nursing. I did psych for about 6 years in the past. I'm trying to think ahead of any thing I want to brush up on before my hospital orientation. Does anyone have any insight into withdrawal protocols? I remember we used the "COWS" for opiate withdrawal. Pts were assessed something like q 4 hours and if they scored high enough, they got clonidine. They also had PRNS on board. For ETOH, we used a scale where they were asesed q 4 and sometimes q 2 depending on their s/s. Two questions:

1. For opiate withdrawl, if a pt scored high enough to get the clonidine, and was ALSO requesting, say PRN tylenol for body aches (body aches are part of the assessment in whether they need clonidine), would you give the clonidine AND tylenol at the same time? Or would you give clonidine and then see if that helps their body aches and if not, THEN give the tylenol?

2. For the ETOH withdrawal, if they are getting scheduled taper meds (say, Serax or Ativan) at set times...and you go in to assess them and give scheduled med, if they score high enough at that time, do they also get the PRN taper med along with the scheduled med at the same time? If they are on a taper, in my mind that should be 'covering' them enough to where they wouldn't score high on the withdrawal scale, but if they still scored high I would give them the scheduled taper med + the PRN taper med at the same time. Is this correct? (sorry if this is confusing)

Thanks for any insight!!

[garnetgirl29, BSN, RN]

I work in a mental health/drug detox clinic. We use the COWS for opiate withdrawal & once the client scores a 13 or higher, we use suboxone (naloxone + buprenorphine) to treat withdrawals. Within 30 minutes, the client is feeling better. We start them on 4mg BID & taper them down over a 6 day period. It works MUCH better than clonidine. We only use clonidine for HTN and if their BP can support it, we occasionally use it if someone is still having withdrawals once they've completed their suboxone protocol. Common side effects of suboxone are headache & constipation, so we treat those as needed with tylenol, ibuprophen, & laxatives. It works very well for most, but some heavy users will still have some break-through withdrawals. We just give them PRNs.

We use the CIWA for ETOH and benzo detox and treat them with librium. The first 24 hours dictates whether they will be on the moderate or severe protocol, depending on how much librium it takes to treat their withdrawals. Librium is a long acting benzodiazepine that's typically used for detox. It can effect blood pressure, so per our protocol, we never give it if BP is below 90/60. We use the CIWA to assess for DT's, but in many cases, we start the librium immediately after admission, regardless of score. We do not admit anyone with a BAL above 2.0. With our protocol, we give scheduled librium & we may give a PRN librium q6H. If we feel more is needed, we call our MD. There is a lot of wiggle room with our librium protocol and most clients can safely tolerate considerably more than we actually give, but I do try to discourage PRN doses toward the end of their protocol because it's better for them to taper down before cutting them off. If they continue to ask, I'll offer vistaril for anxiety and call our MD if I feel the protocol should be extended for this individual.

BTW, we only do our COWS until a 13 or greater is met and we only do the CIWA on admission. Our clients are with us for 7 days, unless an extension is needed for further treatment or for long term placement.

[Whispera, MSN, RN]

I never heard of using clonidine for body aches so I looked it up. Sure enough, it's used for headaches and post-herpetic neuralgia (but I found nothing about aches due to opiate withdrawal). It's for elevated blood pressure. I'd give the tylenol.

There's no need to give the prns along with the scheduled benzos. They're for breakthrough withdrawal symptoms they control.

[Meriwhen, ASN, BSN, MSN, RN]

Clonidine is often used in opiate withdrawals as it can help alleviate some of the physical discomforts as well as help with anxiety experienced during withdrawing (per my addictionologist). A lot of protocols I've seen will use TD patches as opposed to PO dosing, so the clonidine delivery is constant.

However clonidine is usually not used by itself, but in conjunction with other medications. My favorite addictionologist likes to use phenobarbital and tramadol, or suboxone, in addition to the clonidine.