What is the most common mistake made when treating withdrawal?

What is the most common mistake made when treating withdrawal in a correctional facility?

Consider these two patients:

  • A jail patient booked yesterday is referred to medical because of a history of drinking.  He has a mild hand tremor and “the look” of a heavy drinker. But he says he feels fine and has no complaints. His blood pressure is 158/96 and his heart rate is 94.
  • A newly booked jail patient says that she is going to go through heroin withdrawal.  She is nauseated but still eating and has no gooseflesh or rhinorrhea.  Her heart rate mildly elevated.

In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical.  But this would be a mistake!  Both patients should be started on treatment for withdrawal immediately.

The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!

Both of these patients have the potential to slide downhill rapidly.  And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.

Let’s look at these cases in more detail.

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Opioid Withdrawal Not Deadly? Wrong!

One thing I always tell practitioners who are beginning a jail medical practice: you’re going to see a lot of withdrawal cases — study up! In particular, since the opioid epidemic hit, the number of patients I’ve seen in my jails withdrawing from heroin and other opioids of all stripes has skyrocketed. I’ve seen enough patients withdrawing from opioids that I think I am reasonably knowledgeable on the topic. Because of this, I was quite surprised when I ran across this sentence in a recent edition of The Medical Letter:

“Opioid withdrawal is not life-threatening.” — The Medical Letter

The problem is that although this sentence seems quite self-assured, it is flat out wrong. In fact, it is not just wrong; it is also dangerous. People do die from opioid withdrawal. I know of several such cases from my work with jails. Opioid withdrawal needs to be recognized as a potentially life-threatening condition, just like alcohol withdrawal and benzodiazepine withdrawal. Continue reading

Is It Possible to Withdraw From both Alcohol and Opiates at the Same Time?

Medicine in the Future.

I recently participated in a Webinar entitled “Managing Alcohol Withdrawal in the Correctional Setting.” During the question and answer section of the Webinar, a question was posed about how to manage the patient withdrawing from both alcohol and heroin at the same time.  I have been thinking about this question since.  In all my years of practice in correctional settings, I personally have never seen a patient who was simultaneously withdrawing from both alcohol and narcotics.  Is such a thing even possible?

After thinking about it, I have decided that this question this question has two answers:  a theoretical answer and a practical answer.  The theoretical answer first:

Theoretically, if a patient was truly suffering from both alcohol withdrawal and heroin withdrawal at the same time, our primary concern would be alcohol withdrawal rather than heroin withdrawal.  The reason for this is that patients die from alcohol withdrawal; it is a potentially lethal problem.  Heroin withdrawal, on the other hand, can be a serious medical problem, but does not tend to be lethal.  I was an emergency physician before I came to corrections, and this principle was drilled into us over and over–you deal with the life threatening concern first. Continue reading