Donald R. Wesson

The Clinical Opiate Withdrawal Scale (COWS)

Abstract The clinical opiate withdrawal scale (COWS) is a clinician-administered, pen and paper instrument that rates eleven common opiate withdrawal signs or symptoms. The summed score of the eleven items can be used to assess a patients level of opiate withdrawal and to make inferences about their level of physical dependence on opioids. With increasing use of opioids for treatment of pain and the availability of sublingual buprenorphine in the United States for treatment of opioid dependence, clinical assessment of opiate withdrawal intensity has received renewed interest. Buprenorphine, a partial opiate agonist at the mu receptor, can precipitate opiate withdrawal in patients with a high level of opioid dependence who are not experiencing opioid withdrawal. Since development of the first opiate withdrawal scale in the mid-1930s, many different opioid withdrawal scales have been used in clinical and research settings. This article reviews the history of opiate withdrawal scales and the context of their initial use. A template version of the COWS that can be copied and used clinically is appended. PDF formatted versions of the COWS are also available from the websites of the American Society of Addiction Medicine, the California Society of Addiction Medicine, the UCLA Integrated Substance Abuse Programs, and AlcoholMD.com.

Clinical efficacy of buprenorphine: comparisons to methadone and placebo

Buprenorphine has been studied extensively since 1978 when it was initially proposed as an alternative to methadone for treatment of opioid dependence. Early work by Jasinski et al., 1978; Mello and Mendelson, 1980; Mello et al., 1982; Mello et al., 1983 and Mendelson et al., 1984 and their colleagues demonstrated buprenorphines low physical abuse potential and its ability to substitute for heroin and reduce heroin self-administration in opiate-dependent humans. The subsequent early clinical studies suggested that, in clinical settings, buprenorphine was a safe and efficacious opiate dependence pharmacotherapy. Formal approval for general clinical use, however, required that systematic data be gathered on buprenorphines safety and efficacy in larger groups and a series of controlled clinical trials was designed to evaluate its utility from a medication development perspective. In general, these trials adhered to one of three basic protocol designs: comparison of buprenorphine to methadone; dose comparisons using dose response as an indicator of efficacy; and comparison of buprenorphine to placebo. Retention in treatment, reduction in illicit drug use and craving, and patient and staff ratings of improvements were the most frequently used outcome indicators in these trials. Additional data collected included optimum dosing and dosage schedules, adverse reactions and common side-effects, and other information intended to clarify buprenorphines benefit-risk relationship and to help prepare guidelines for its safe marketing and utilization by physicians in general clinical practice. This paper presents a review of the buprenorphine/methadone comparison trials conducted in the United States and two such trials conducted in Europe. Also reviewed are three placebo-controlled trials and a buprenorphine/methadone detoxification study. Overall, this series of studies did firmly establish the efficacy of buprenorphine alone and in comparison to methadone.

Benzodiazepine Dependency Syndromes

Benzodiazepines, like other sedative-hypnotics, can induce tolerance and physical dependence. This chapter reviews three types of physical dependence that can occur with benzodiazepines:a high-dose dependency of the barbiturate type, a low-dose dependency that may occur with therapeutic doses, and dependency that may occur in the neonate from placental or breast-milk transfer of a benzodiazepine.

A Clinical Guide to the Diagnosis and Treatment of Heroin-Related Sexual Dysfunction

It is apparent that a significant degree of sexual concern exists in male and female heroin addicts in the predrug, drug and postdrug periods. The Sexual Concerns and Substance Abuse Project recommends that each opiate abuser entering in to treatment has a brief sex history taken and, if a primary or secondary sexual dysfunction is discovered, then additional evaluation is indicated. Furthermore, the Project stresses the importance of educating the patient to the physiological, as well as psychological, relationship between heroin-related sexual dysfunction and concomitant side effects. For example, in women chronically abusing high doses of heroin, one may not only see a reduction of sexual desire and performance, but also irregular menstrual cycles, and occasionally, amenorrhea, as a result of the depressive effects of the opiate on pituitary hormones. The woman may misinterpret this physiological effect and believe that such changes in her menstrual cycle are irreversible, and that she is sterile. Following the evaluation and patient education phase, the findings obtained from the evaluation of the drug cycle, as it relates to the sociosexual response cycle, should be incorporated into the overall treatment approach for counseling the opiate abuser. When a specific sexual dysfunction exists, particularly if it predates the heroin involvement, referral to a qualified sex therapist is often indicated, to work in co-therapy with the drug counselor and the referring physician. Greater awareness of heroin-related sexual dysfunction may help reduce the relapse rate back to heroin as well as improve the quality of the individuals life during the recovery period.

The Benzodiazepines : current standards for medical practice

I Clinical Pharmacology.- 1 The biological basis of benzodiazepine actions.- 2 Clinical pharmacokinetics of the benzodiazepines.- 3 Pharmacokinetic considerations in the treatment of chronic anxiety.- II Therapeutic Application.- 4 An international overview.- 5 Principles of therapeutic applications of benzodiazepines.- 6 Benzodiazepines in emotional disorders.- 7 Anxiety.- 8 Clinical comparison of benzodiazepine hypnotics with short and long elimination half-lives.- 9 Seizure disorders.- 10 Alcohol and other drug withdrawals.- 11 Additional clinical uses of benzodiazepines.- 12 Vital uses of diazepam in third world countries.- III Non-medical Use, Misuse and Abuse.- 13 Abuse and dependency: an international perspective.- 14 Experimental abuse liability assessment of benzodiazepines.- 15 Abuse liability of benzodiazepines: A review of human studies evaluating subjective and/or reinforcing effects.- 16 Acute and chronic toxicity of benzodiazepines.- IV Dependence.- 17 Benzodiazepine dependency syndromes.- V Social-Cultural Issues.- 18 The benzodiazepines: public health, social and regulatory issues. An industry perspective.- 19 Benzodiazepines: international legislation and relation to the Convention on Psychotropic Substances 1971.- Appendices.- 1 Cross-reference of investigational, generic and trade names.- 2 Books on benzodiazepines.

Prescription of opioids for treatment of pain in patients with addictive disease

Addiction medicine specialists and pain specialists can provide better patient care by combining their expertise when treating patients who are addicted to alcohol, street drugs, or prescription medications. Addiction specialists--particularly those whose primary treatment philosophy is drug free--must accept that controlled opiate maintenance is appropriate for some patients, and pain specialists need to increase their sensitivity to the possibility of addiction among their patients. Both pain and addiction are treatable conditions, and optimal care of some patients requires the coordinated services of both an addiction medicine specialist and a pain specialist.

Outpatient Barbiturate Withdrawal Using Phenobarbital

Barbiturate withdrawal has long been a subject of controversy, even in the confines of locked psychiatric hospital wards, and certainly never a technic to be attempted on a casual outpatient basis. This report will describe a phenobarbital substitution technic for barbiturate withdrawal on an outpatient basis, which we have utilized with good results in the treatment of over 50 patients at the Haight-Ashbury Free Medical Clinic. This outpatient technic was developed for the very practical reason that much of our drug abusing population simply refuse hospitalization in the available state or county hospital facilities.

Alcohol and Other Drug Withdrawals

Drug withdrawal is the process of weaning a patient from a drug to which their body has undergone cellular adaptation, i. e., physical dependence. The goal of drug withdrawal is to accomplish the weaning process with safety while reducing symptoms to a tolerable level. Although withdrawal is often a necessary step in the treatment of addictive disease drug withdrawal alone, no matter how skillfully executed, is not adequate treatment for ‘addictive disease’.

Acute and Chronic Toxicity of Benzodiazepines

Benzodiazepines have a remarkably low frequency of allergic reactions, organ toxicity and overdose lethality. Acute toxicity is produced by drug interactions, idiosyncratic reactions, and overdose. Chronic toxcitity results from accumulation of the benzodiazepine or metabolites, from tolerance to therapeutic effects with subsequent escalation of dosage, and from the development of benzodiazepine dependence. As the benzodiazepine dependency syndromes and their treatment are described in detail in Chapter 17, they will not be addressed here.

Stay Tuned and Find Out

TV news commonly poses a titillating question just before cutting to a string of commercials. Newscasters apparently hope that our need to “find out” will override temptation to “drop out,” “surf on,” or “throw up.” The authors1 of “Methadone Induction Doses: Are Our Current Practices Safe?” employ a similar device.Suspicionthatdanger lurks is justified. While pointing out that mortality rate of methadone maintained heroin addicts is lower than heroin users not in treatment, the authors’ find that induction on methadone is a hazard for which “dose-response relationships and safe dosing levels cannot be determined from studies to date.” This is a particularly curious statement coming from authors who sing the praises of “evidence-based dosing guidelines” (first line of abstract). For some clinicians, “evidence” comes only from randomized clinical trials; for others “evidence” also comes from open-label trials, case reports, and personal clinical experience. All supply evidence of a sort, but the quality of the evidence varies as do the conclusions that can be drawn. With good reason, randomized clinical trials are accorded great weight as the “gold standard” of evidence. They are indeed a very powerful tool to determine if a treatment is efficacious, or, if sufficientlypowered, if one treatment is better than another. Randomized clinical trials, however, have commonly overlooked weaknesses. Finding volunteer subjects who meet the inclusion/exclusioncriteriaof a protocol and who agree to random assignment often pose daunting recruitment challenges for clinical investigators. Subjects typically excluded from randomized clinical trials often include those with medical conditions or those with co-morbid psychiatric disorders, just the patients likelytobeseeninclinicalpractice.Yet in therush toembrace“evidence-basedpractices” the validity of results applied to patient populations who were excluded from the trial is rarely questioned. Of more immediate relevance to the issue of methadone overdose, clinical trials are not a practical way of assessing the frequency of rare side effects. Here, large epidemiological studies are the “gold standard.” The authors point out that much of the data about death rates during methadone induction “is retrospective.” Indeed, retrospective studies used to compute incidence rates of a rare