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.

Case one:  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.

With his history of drinking and having “the look” of a heavy drinker, this patient has a high risk of going through significant withdrawal.  Because of his hand tremor, he already has at least one sign of withdrawal.  The problem is that the alcohol withdrawal scale most commonly used to assess the severity of alcohol withdrawal, The Clinical Institute Withdrawal Assessment for Alcohol–revised (CIWA-Ar), would only score this patient as, at most, a 2 and does not recommend treatment for scores less than 8-10. 

However, (as I have written about before—here) CIWA is almost entirely subjective and relies heavily on patient cooperation in answering questions about symptoms truthfully and accurately.  Many patients just don’t provide accurate information.  Maybe this patient is not a complainer.  Maybe he is just cranky.  Maybe he has some dementia. In the end, there is a good chance that CIWA has underscored this particular patient.

But even if CIWA has scored his current status correctly, what are his chances of getting worse over time?  By not treating him, you are gambling that he will not get worse.  I personally think that if you look at the potential outcomes, that gamble is foolish.  What do you gain if you are right and he does OK over time?  You saved one dose of Valium. On the other hand, what could happen if he has an alcohol withdrawal seizure or otherwise deteriorates rapidly into serious withdrawal? He could suffer permanent harm.  You will have to spend much more time and effort monitoring and treating him than if you had just treated him in the first place. You will have placed yourself at risk medico-legally.

In the end, this patient should receive his first dose of Valium (or other benzodiazepine) now. There is no good reason to wait.

Case two:  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.

Like the last patient, this woman is starting to show signs of withdrawal (tachycardia, nausea) and will assuredly get worse over time.  Yet she also may not get treated immediately in the average jail. The temptation to not treat her heroin withdrawal comes from two sources.

First, many have the erroneous belief that opioid withdrawal does not kill patients the way that alcohol withdrawal does and that, therefore, “Cold Turkey” withdrawal is ok. This, of course is wrong (and I have written about this before, here)

Second, many believe that methadone and buprenorphine (MAT) are the only two drugs effective in treating opioid withdrawal.  And since these two drugs are highly regulated and a kind of a hassle to prescribe and use, they are only used if a withdrawal patient gets sick enough.  They are usually not given to every patient with mild opioid withdrawal.

However, the belief that only MAT works to treat opioid withdrawal is also incorrect (see my thoughts on that here).  According to the Cochrane review of the literature, the alpha-adrenergic drugs clonidine and lofexidine work just as well as methadone in treating the initial symptoms of opioid withdrawal.  Clonidine is not a scheduled drug, it is easy to administer and, if given in the correct dosage, very effective in making heroin withdrawal more tolerable for the patient. 

Patient two should immediately be given her first dose of several doses of clonidine and scheduled for routine re-evaluations to see if she needs even more clonidine.  Giving her clonidine now does not, of course, mean that buprenorphine cannot be used later. But it does mean that there again is no reason to deny treatment for this patient with early heroin withdrawal.

The most common mistake made in the treatment of withdrawal in jails is not to treat at all.  Don’t make this mistake!  Best medical practice is to treat everyone showing symptoms of alcohol or opioid withdrawal.

As always, what I have written here is my opinion, based on my training, experience and research.  I could be wrong!

What do you think is the most common mistake made in the treatment of withdrawal?  Please Comment.