JFK Detox Protocols

General Notes

All protocols are a general starting point intended to work for many, but not all, individuals. The initial protocol should be considered an "initial best guess" based on the initial presentation and history.
All protocols can be modified when placing the initial protocol order or later in the admission. Ensure any modifications are clearly documented in your note, the handoff, and hospital course.
When in doubt, contact your attending or the backup psychiatric provider (if after hours).

Detox Protocols — Alcohol/Benzo Withdrawal

PHENobarbital (Luminal) — 5-Day Taper

Alcohol withdrawal syndrome

PRN · 3 days

64.8 mg PO q3h PRN

For signs/symptoms of alcohol or benzodiazepine withdrawal

Taper Schedule

Day	Dose	Schedule
Days 1–2	64.8 mg PO TID	0800, 1400, 2200
Days 3–4	64.8 mg PO BID	0800, 2200
Day 5	32.4 mg PO BID	0800, 2200

Preferred Protocol

PHENobarbital protocols (5-day and 3-day) are the preferred protocols for alcohol withdrawal at JFK

Reasons Not to Choose PHENobarbital

Cirrhosis or other significant liver impairment
Pregnancy
Drug interactions — PHENobarbital has an extensive list of interactions. Common ones in this population include:
- Paxlovid, HIV medications, lamotrigine
- Direct oral anticoagulants: dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa)

PHENobarbital also induces the metabolism of methadone, buprenorphine, and many antipsychotics — not an absolute contraindication, but be mindful that this occurs.

PHENobarbital in Benzodiazepine Withdrawal

Less evidence supports its use in treating benzodiazepine withdrawal; anecdotally effective, but less supported by studies and guidelines than using benzodiazepines to treat benzo withdrawal

Protocol Duration

Generally a total of 5 days but can be modified

PHENobarbital (Luminal) — 3-Day Taper

Alcohol withdrawal syndrome

PRN · 3 days

64.8 mg PO q3h PRN

For signs/symptoms of alcohol or benzodiazepine withdrawal

Step one is typically ordered for one (1) day.

Taper Schedule

Day	Dose	Schedule
Day 1	64.8 mg PO TID	0800, 1400, 2200
Day 2	64.8 mg PO BID	0800, 2200
Day 3	32.4 mg PO BID	0800, 2200

Preferred Protocol

PHENobarbital protocols (5-day and 3-day) are the preferred protocols for alcohol withdrawal at JFK

Reasons Not to Choose PHENobarbital

Cirrhosis or other significant liver impairment
Pregnancy
Drug interactions — PHENobarbital has an extensive list of interactions. Common ones in this population include:
- Paxlovid, HIV medications, lamotrigine
- Direct oral anticoagulants: dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa)

PHENobarbital also induces the metabolism of methadone, buprenorphine, and many antipsychotics — not an absolute contraindication, but be mindful that this occurs.

PHENobarbital in Benzodiazepine Withdrawal

Less evidence supports its use in treating benzodiazepine withdrawal; anecdotally effective, but less supported by studies and guidelines than using benzodiazepines to treat benzo withdrawal

Protocol Duration

Generally a total of 3 days but can be modified

DiazePAM (Valium)

Alcohol withdrawal syndrome

PRN · 3 days

10 mg PO q6h PRN

For withdrawal-PSY, symptoms of alcohol withdrawals

Do not administer within 1 hour of other diazepam doses without contacting provider
If CIWA-Ar >15 after two PRN CIWA doses, contact provider

Taper Schedule

Day	Dose	Schedule
Day 1	20 mg PO QID	0800, 1400, 2000, 2200
Days 2–3	10 mg PO QID	0800, 1400, 2000, 2200
Days 4–5	10 mg PO BID	0800, 2200

Long-Acting Benzodiazepine

DiazePAM and clonazePAM are long-acting benzos with significant hepatic metabolism; choice between them is largely based on clinician preference
Meta-analytic data supports diazepam as the most effective benzodiazepine in alcohol withdrawal

Advantages of Long-Acting Benzos

Longer coverage — less between-dose rebound/breakthrough symptoms
Active metabolites provide self-tapering even after protocol completion, resulting in a smoother course

Disadvantages of Long-Acting Benzos

Longer-acting means prolonged sedation and/or delirium if the protocol overshoots
Significant hepatic metabolism — in the setting of liver disease, can "stack" and result in overmedication, sedation, delirium, or respiratory depression

Avoid This Protocol In

Cirrhosis or other significant liver impairment
Third trimester of pregnancy (use lorazepam) [ASAM Guideline]
Light drinkers (this protocol contains a significant load of benzodiazepine)

Protocol Duration

Generally a total of 5 days but can be modified

LORazepam (Ativan) — High Dose

Alcohol withdrawal syndrome

PRN · 3 days

2 mg PO q6h PRN

For signs/symptoms of alcohol withdrawal

Not to exceed 6 mg in 24 hours
Notify provider if patient has received maximum allowable PRN doses but has ongoing withdrawal symptoms of concern

Taper Schedule

Day	Dose	Schedule
Day 1	2 mg PO q4h	0800–0400
Day 2	2 mg PO q6h	0800–0200
Day 3	1.5 mg PO q6h	0800–0200
Day 4	1 mg PO q6h	0800–0200
Day 5	0.5 mg PO q6h	0800–0200

Hepatic Advantage

Lorazepam is considered to have less dependence on hepatic metabolism than diazepam or clonazepam
Preferred agent in patients with cirrhosis or significant liver impairment
May also be preferable in the elderly or severely medically compromised

When to Use High-Dose Protocol

May be most appropriate in heavy drinkers for whom PHENobarbital, diazepam, or clonazepam protocols are contraindicated, or when a shorter-acting benzodiazepine is preferred
Cumulative dosing is comparable to the clonazepam and diazepam protocols

Protocol Duration

Generally a total of 5 days but can be modified

LORazepam (Ativan) — Low Dose

Benzodiazepine abuse

PRN · 3 days

1 mg PO q2h PRN

For withdrawal-PSY, symptoms of benzodiazepine withdrawal

Not to exceed 3 mg in 24 hours

Taper Schedule

Day	Dose	Schedule
Day 1	2 mg PO TID	0800, 1400, 2200
Day 2	1.5 mg PO TID	0800, 1400, 2200
Day 3	1 mg PO TID	0800, 1400, 2200
Day 4	0.5 mg PO TID	0800, 1400, 2200
Day 5	0.5 mg PO BID	0800, 2200

Hepatic Advantage

Lorazepam is considered to have less dependence on hepatic metabolism than diazepam or clonazepam
Preferred agent in patients with cirrhosis or significant liver impairment
May also be preferable in the elderly or severely medically compromised

When to Use Low-Dose Protocol

May be most appropriate in patients with relatively lower alcohol consumption for whom PHENobarbital, diazepam, or clonazepam protocols are contraindicated
May also be appropriate for the treatment of benzodiazepine withdrawal (assuming cumulative dosing is appropriate for the patient's reported amount used)
This is the "lightest" of all alcohol withdrawal protocols at JFK

Protocol Duration

Generally a total of 5 days but can be modified

ClonazePAM (KlonoPIN)

Benzodiazepine abuse

PRN · 3 days

1 mg PO q2h PRN

For withdrawal-PSY, signs/symptoms of severe benzodiazepine withdrawal

MAX 8 mg in 24 hours for all PRN clonazepam orders

Taper Schedule

Day	Dose	Schedule
Day 1	1 mg PO QID	0800, 1400, 2000, 2100
Day 2	1 mg PO TID	0800, 1400, 2100
Day 3	1 mg PO BID	0800, 2000
Day 4	0.5 mg PO BID	0800, 2000

Long-Acting Benzodiazepine

DiazePAM and clonazePAM are long-acting benzos with significant hepatic metabolism; choice between them is largely based on clinician preference

Advantages of Long-Acting Benzos

Longer coverage — less between-dose rebound/breakthrough symptoms
Active metabolites provide self-tapering even after protocol completion, resulting in a smoother course

Disadvantages of Long-Acting Benzos

Longer-acting means prolonged sedation and/or delirium if the protocol overshoots
Significant hepatic metabolism — in the setting of liver disease, can "stack" and result in overmedication, sedation, delirium, or respiratory depression

Avoid This Protocol In

Cirrhosis or other significant liver impairment
Third trimester of pregnancy (use lorazepam) [ASAM Guideline]
Light drinkers (this protocol contains a significant load of benzodiazepine)

Protocol Duration

Generally a total of 5 days but can be modified

Opioid Withdrawal Supportive Medications

Opioid Withdrawal Supportive Protocol

Opioid withdrawal — supportive management

PRN · 5 days

0.1 mg PO q4h PRN

For signs/symptoms of opiate withdrawal

Hold if SBP <90 mmHg or patient exhibits dizziness or faintness
Max 1.2 mg total clonidine per 24 hours

Ondansetron 4 mg PO/ODT q4h PRN

For nausea

Give IM (4 mg) if unable to take orally or vomited PO dose

Dicyclomine 20 mg PO q6h PRN

For abdominal cramping

Cyclobenzaprine 10 mg PO q8h PRN

For muscle spasms/aches

Scheduled

0.1 mg PO BID (2200, 0800)

Hold if SBP <90 mmHg or dizziness/faintness

Clonidine Challenge Monitoring

Begin 60 minutes after the very first clonidine dose:

Assist patient to standing position, then have them stand under observation for 2 minutes
Obtain blood pressure while patient is still standing
Discontinue clonidine and call PE/MD if systolic BP <90 or if patient has signs/symptoms of low blood pressure (i.e., dizziness)
Repeat above steps in 60 minutes × 1

Opioid Withdrawal Supportive Protocol

A supportive protocol for symptomatic management of opioid withdrawal is the initial starting point at JFK for patients expected to experience opioid withdrawal
Subsequently, MOUD should be offered by the patient's primary psychiatric provider when possible

Prescribing Notes

Be mindful of the risks associated with individual medications within this protocol and modify based on patient-specific risk factors and medical comorbidities
The initial dose of scheduled clonidine should be ordered to begin when withdrawal is anticipated to begin

Protocol Duration

Generally a total of 5 days (with 3 days of scheduled doses) but can be modified

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