Protocols for Outpatient Detoxification
Brian Johnson M.D. Cell: 617-872-8442
When beginning detox, please do the following:

Sober Support Person (SSP): takes the initial
prescription to a pharmacy. The SSP immediately
brings medications back to the Addiction Medicine
Program where medications are given under the
supervision of the physician or nurse.

Starting Detox: If the pt’s detox is being started
in another facility, eg, the ED, it must be started
by first determining how long the pt has been off
all Alcohol, Benzos or Opioids. Starting the
medication induction varies by substance and
requires the pt be in actual withdrawal when
receiving meds. For example, the pt must be off
short acting opioids for 10h and long acting for 20h
in order to be ready to receive a supervised one
time dose of buprenorphine. However, do not
prescribe buprenorphine for opioid withdrawal if
referring to us;only use opioid meds #3-8 for that.
Alcohol Detoxification and Withdrawal
Alcohol withdrawal starts about 8 hrs after the last
drink and peaks at about 24 hrs.
1. If pulse >100 or BP >140/90 in the context of a hx
of loss of control of drinking and drinking within the
last 24 hrs, start treatment with chlordiazepoxide
100mg po and valproic acid 2,000 mg po.
2. If pulse and BP < criteria, and the pt complains of
anxiety and dysphoria from the alcohol withdrawal,
start treatment with valproic acid 2,000 mg po.
3. On Day 1, give chlordiazepoxide 100 mg q1h if
pulse >100 or BP >140/90 in the context of alcohol
withdrawal.
4. If the withdrawal syndrome is not arrested by the
end of Day 1, the physician determines to either
continue with outpatient treatment including sending
the Sober Support Person home with a prescription for
chlordiazepoxide and continue to check pulse q2h
while awake, or admit the patient to inpatient detox.
5. If there are intolerable side effects from valproic
acid, especially vomiting, switch to carbamazepine 200
mg q4h until a total daily dose of 800 mg is reached.
6. If the patient vomits up their chlordiazepoxide
within 30 minutes, it may be readministered.
7. On Day 2, administer valproic acid 1,000 mg bid.
8. On Day 2, continue with chlordiazepoxide 100 mg
q1h prn for pulse > 100 or BP > 140/90 in the context
of ongoing alcohol withdrawal. No chlordiazepoxide is
given after Day 2.
9. For repeated vomiting, give prochlorperazine 25 mg
po, rectally or IM. Route of admin is decided by the
physician in consultation with the patient.
10. On Day 3 give valproic acid hs: 1500 mg for pts >
150 lbs, 1000 mg for < 150 lbs.
11. On Day 4 pts have valproic acid levels and LFTs
(AST, ALT, LDH) drawn at the UH lab before taking
their morning dose and appt. Valproic acid dosing is
adjusted to a blood level of 60 – 100 ng/dl.
12. If LFTs are > 3x normal, then stop valproic acid;
please consult Dr. Johnson or the covering attending.
13. Continue Valproic acid (optional) as long as it is
helpful to the patient. After Day 2, give it qhs.
14. If the pt is being treated with carbamazepine,
draw blood levels on Day 4 before the first dose, and
adjust dose to a blood level of 7 – 12 ng/dl. Draw CBC
for white count and LFTs for AST, ALT and LDH. If
WBCs are < normal or LFT > 3x normal, then stop
carbamazepine and consult Dr. Johnson or the
covering attending.
15. As soon as the Blood Alcohol Level is zero,
whether on Day 1 or Day 2, and on all subsequent
days during detox, the pt takes Disulfiram 250 mg po,
supervised by the sober support person (SSP) or
physician. Contraindications to disulfiram are
documented coronary artery disease or esophageal
varices.
16. Give the disulfiram prescription to the SSP and
ask them to meet with the pt daily for the first year of
sobriety, usually first thing in the morning. If
necessary, the SSP can give 500 tiw. Ask the SSP to
bring the pt in for a discussion if the pt stops taking
the disulfiram before the completion of one year sober.
Benzodiazepine withdrawal
The protocol for benzodiazepine withdrawal is the
same as for alcohol withdrawal, except that benzo
withdrawal starts at 24 hrs for short-acting benzos, eg,
alprazolam and lorazepam, and at about 72 hrs for
longer acting benzos, eg, diazepam and clonazepam.
Opioid withdrawal
Opioid withdrawal starts about 6 hrs after the last
opioid taken orally, sniffed or injected. The peak of
withdrawal is about 72 hr after the last opioid. No
meds should be given until the pt is clearly in opioid
withdrawal. Obtain baseline pulse and BP. Meds #3#8 are for transitory detox s/s.
1. For patients in opioid withdrawal and a hx of
<180 mg/day of morphine, 15 bag/day of heroin, or
the equivalent (oxycodone 120 mg/day, hydrocodone
150 mg/day), give buprenorphine 24mg SL once.
2. For pts in opioid withdrawal and a hx of higher daily
intake, give buprenorphine 32 mg SL once.
3. Clonidine 0.1 mg po tid prn for anxiety, agitation.
Hold if drop from baseline for SBP >20 or DBP >10. If
hx is consistent with orthostatic hypotension, check BP
lying and standing and hold clonidine if orthostatics
drop SBP >20 or DBP >10.
4. Trazodone 100 mg hs prn for insomnia (may
increase dose by 100mg qhs to a maximum of 600 mg
qhs according to patient response).
5. Dicyclomine 20 mg po qid prn for gut cramps or
diarrhea.
6. Loperamide 4mg po qid prn for diarrhea.
7. Ibuprofen 600 mg po qid prn pain. If intolerant,
then acetaminophen 500 mg po qid prn pain. The
physician may also try gabapentin 300 mg po qid prn
pain; it can be added to ibuprofen or APAP.
8. Chlorpromazine 50 qid prn nausea, vomiting and
anxiety. (Chlorpromazine addresses nausea and
vomiting by influencing the CNS center for this, while
dicyclomine diminishes the cholinergic gut driver; note
the complementary actions.)