How to recognize opiate withdrawal in inmates

Whether through prescription drug abuse or IV heroin, opiate addiction is on the increase; here's how EMS providers can recognize withdrawal symptoms and know what to do

By Lorry Schoenly

The CDC has published an alarming report showing heroin overdose deaths are sky-rocketing. Between 2010 and 2012, heroin overdose deaths have doubled in the 28 states that were studied. The Substance Abuse and Mental Health Services Administration (SAMSA) is also reporting rapidly rising heroin use. This is attributed to an epidemic of prescription opiate addiction that operates as a gateway drug for heroin.

Whether through prescription drug abuse or IV heroin, opiate addiction is on the increase. With 75 percent of crimes being drug related and more than two-thirds of the incarcerated being substance involved, many individuals will enter the criminal justice system opiate addicted and suffer through withdrawal while incarcerated. Everyone working in corrections needs to be aware of the high potential for opiate abuse in the prisoner population. This starts with screening and assessment during intake into the system.

Asking the right questions
Although there are several screening tools available for determining drug involvement, one tool recommended for alcohol screening and later modified to include drug screening shows promise for the correctional setting as it is short and simple to apply.

CAGE –AID questionnaire
The original 4-question CAGE screening was exclusive to alcohol addiction. Each question had a primary concept relating to one of the letters in the word. Later editions added on drug use and were retitled CAGE-AID (adapted to include drugs). Here are the 4 quick questions to ask:

  • Have you ever felt you ought to Cut down on your drinking or drug use?
  • Have people Annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or Guilty about your drinking or drug use?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye‐opener)?

One or more "yes" responses constitute a positive screening test.

What’s in a name?
Depending on your geographic region, you will hear many names for street drugs. Keeping up with the lingo is an important part of assessing for opiate addiction. Here are some common street terms for this drug class. Do any of these sound familiar?

  • CODEINE: Captain Cody, Cody, schoolboy.
  • DILAUDID; juice, smack, D, footballs, dillies.
  • FENTANYL: Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash.
  • HEROIN – china white, fix, horse, smack, whack, mother pearl, H. junk.
  • MORPHINE: M, Miss Emma, monkey, white stuff
  • OXYCODONE – Hillbilly heroin, Blues, Kickers, OC, Oxy, OX, Oxycotton, 40 (specifically for 40-milligram pills), 80 (specifically for 80-milligram pills).
  • VICODIN: Vike, Watson-387.

Seeing the big picture
Assessment findings combined with screening responses and patient history provide a complete picture of drug use. Opiates are sometimes called downers for good reason. The body’s main response to opioid substances is sedation. Here are some common assessment findings:

Subjective: calmness, euphoria, sedation, drowsiness, weakness, dizziness, nausea, confusion, dry mouth, itching, constipation

Objective: impaired coordination, sweating, clammy skin, bradycardia, hypotension, hypothermia, pinpoint pupils, slow movement, slurred speech

When screening and assessment finding indicate opiate involvement, the patient should be placed on a protocol for ongoing withdrawal monitoring and treatment.

While opiate withdrawal is frequently described as nonlife-threatening, a quick search of the net located instances where county jail inmates died of complications of opiate withdrawal in Kentucky, Eastern Pennsylvania, and Western Pennsylvania. Untreated severe opiate withdrawal can lead to dehydration and renal failure; particularly in unhealthy or compromised individuals. Those with long addiction habits are often undernourished with untreated medical conditions.

Signs of impending troubles
The signs and symptoms of opiate withdrawal are basically the reverse of opiate addiction. The body, removed of the 'downers' now hyper-accelerates like a foot slamming down on the gas pedal after being restrained for a long time.  Symptoms to look for include:

  • Extreme agitation and anxiety.
  • Sleeplessness.
  • Gastric distress: abdominal cramping, diarrhea, vomiting.
  • Muscle and joint pain.
  • Elevated vital signs: Hypertension, tachycardia, and fever.

Monitoring and protocols
The effects of opiate withdrawal can last up to one week for heroin and two weeks for long-acting prescription opiates like oxycodone. Onset usually corresponds to the time of the next habitual drug dose. Intensity of withdrawal is related to the amount and frequency of current addiction level.

The Clinical Opiate Withdrawal Scale (COWS) is a validated evaluation tool to objectively monitor the progression of withdrawal symptoms. The scale rates the severity of 11 symptoms:

  • Resting pulse.
  • Sweating.
  • Restlessness.
  • Pupil size.
  • Bone or joint aches.
  • Runny nose or tearing.
  • GI upset.
  • Tremor.
  • Yawning.
  • Anxiety or irritability.
  • Gooseflesh skin.

The resulting scores are tallied for a total that can then be used to determine treatment or need for medical attention:

  • Mild: 5-12.
  • Moderate: 25-36.
  • Severe: over 36.

Nurses may have medically approved protocols to guide treatment based on withdrawal severity. For example, mild withdrawal may only warrant continued monitoring while moderate or severe withdrawal may indicate a need for medication to reduce the severity of symptoms.

Medical treatment
Federal Bureau of Prisons Guidelines recommends the following side effect treatment options:

  • Pain and Fever: Non-steroidal anti-inflammatories (aspirin, ibuprophen).
  • Gastrointestinal Symptoms: antidiarrheals (such as loperamide) and antiemetics (such as proclorperazine).
  • Insomina and restlessness: benzodiazepines (such as Xanax).
  • Anxiety: Buspirone (Buspar).

Moderate to severe opiate withdrawal may also require tapering doses of a substitute narcotic such as methadone or buprenorphine (Suboxone). As these medications require licensing and close stock monitoring, many correctional settings rely on the use of clonidine in combination with symptom relief. Clonidine is an antihypertensive that has been used as a nonnarcotic agent for opiate withdrawal for decades.

CAUTION: Death may be preferable
Although your patients may not die of opiate withdrawal, they may die because of it, especially if they have gone through the agony before. Withdrawal can lead to depression and increased chances of suicide, as this news account portrays.

Keep a close watch for signs of depression or suicide ideation. Any indication in this area should result in a mental health consultation.

About the author
Dr. Schoenly has been a nurse for 30 years and is currently specializing in correctional healthcare. She is an author and educator seeking to improve patient safety and professional nursing practice behind bars. Her web-presence, Correctional Nurse, provides information and support to those working in correctional health care. Her books, "Essentials of Correctional Nursing" and "The Correctional Health Care Patient Safety Handbook" are available in print and digital on amazon.

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