Professional Documents
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Buku Detox
Buku Detox
Buku Detox
A Treatment
Improvement
Protocol
TIP
45
Detoxification and
Substance Abuse
Treatment
A Treatment
Improvement
Protocol
TIP
45
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments Electronic Access and Copies
This publication was produced under the of Publication
Knowledge Application Program (KAP) con- This publication may be ordered from or down-
tract numbers 270-99-7072 and 270-04-7049 loaded from SAMHSA’s Publications Ordering
with the Substance Abuse and Mental Health Web page at http://store.samhsa.gov. Or, please
Services Administration (SAMHSA), U.S. call SAMHSA at 1-877-SAMHSA-7 (1-877-726-
Department of Health and Human Services 4727) (English and Español).
(HHS). Andrea Kopstein, Ph.D., M.P.H, Karl
D. White, Ed.D, and Christina Currier served
as Government Project Officers. Recommended Citation
Center for Substance Abuse Treatment.
Disclaimer Detoxification and Substance Abuse
The views, opinions, and content expressed Treatment. Treatment Improvement Protocol
herein are those of the consensus panel and do (TIP) Series, No. 45. HHS Publication No.
not necessarily reflect the views, opinions, or (SMA) 15-4131. Rockville, MD: Center for
policies of SAMHSA or HHS. No official sup- Substance Abuse Treatment, 2006.
port of or endorsement by SAMHSA or HHS
for these opinions or for particular instru-
ments, software, or resources is intended or Originating Office
should be inferred. Quality Improvement and Workforce
Development Branch, Division of Services
Improvement, Center for Substance Abuse
Public Domain Notice Treatment, Substance Abuse and Mental
All material appearing in this report is in the Health Services Administration, 1 Choke
public domain and may be reproduced or Cherry Road, Rockville, MD 20857.
copied without permission from SAMHSA.
Citation of the source is appreciated. However, HHS Publication No. (SMA) 15-4131
this publication may not be reproduced or dis- Printed 2006
tributed for a fee without the specific, written Revised 2008, 2012, 2013, and 2015
authorization of the Office of Communications,
SAMHSA, HHS.
ii Acknowledgments
Contents
What Is a TIP?........................................................................................................vii
Consensus Panel ......................................................................................................ix
KAP Expert Panel and Federal Government Participants ................................................xi
Foreword ..............................................................................................................xiii
Executive Summary .................................................................................................xv
Chapter 1—Overview, Essential Concepts, and Definitions in Detoxification........................1
Purpose of the TIP .....................................................................................................1
Audience ..................................................................................................................2
Scope ......................................................................................................................2
History of Detoxification Services...................................................................................2
Definitions................................................................................................................3
Guiding Principles in Detoxification and Substance Abuse Treatment .....................................7
Challenges to Providing Effective Detoxification ................................................................8
Chapter 2—Settings, Levels of Care, and Patient Placement ...........................................11
Role of Various Settings in the Delivery of Services ...........................................................11
Other Concerns Regarding Levels of Care and Placement ...................................................20
Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification .......23
Evaluating and Addressing Psychosocial and Biomedical Issues ...........................................24
Strategies for Engaging and Retaining Patients in Detoxification ..........................................33
Referrals and Linkages ..............................................................................................38
Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .......47
Psychosocial and Biomedical Screening and Assessment .....................................................47
Alcohol Intoxication and Withdrawal.............................................................................52
Opioids ..................................................................................................................66
Benzodiazepines and Other SedativeHypnotics ...............................................................74
Stimulants...............................................................................................................76
Inhalants/Solvents.....................................................................................................82
Nicotine..................................................................................................................84
Marijuana and Other Drugs Containing THC ..................................................................95
Anabolic Steroids......................................................................................................96
Club Drugs..............................................................................................................97
Management of Polydrug Abuse: An Integrated Approach.................................................101
Alternative Approaches ............................................................................................103
Considerations for Specific Populations ........................................................................105
iii
Chapter 5—CoOccurring Medical and Psychiatric Conditions.......................................121
General Principles of Care for Patients With CoOccurring Medical Conditions .....................122
Treatment of CoOccurring Psychiatric Conditions..........................................................136
Standard of Care for CoOccurring Psychiatric Conditions ...............................................138
Chapter 6—Financing and Organizational Issues .........................................................145
Preparing and Developing a Program...........................................................................145
Working in Today’s Managed Care Environment.............................................................157
Preparing for the Future...........................................................................................168
Appendix A—Bibliography ......................................................................................169
Appendix B—Common Drug Intoxication Signs and Withdrawal Symptoms .....................223
Appendix C—Screening and Assessment Instruments ...................................................225
Section I: Screening and Assessment for Alcohol Abuse ....................................................225
Section II: Screening and Assessment for Alcohol and Other Drug Abuse ..............................228
Appendix D—Resource Panel..................................................................................231
Appendix E—Field Reviewers..................................................................................233
Index ..................................................................................................................237
SAMHSA TIPs and Publications ...............................................................................243
Figures
Figure 11 DSMIVTR Definitions of Terms .....................................................................6
Figure 12 Guiding Principles Recognized by the Consensus Panel .........................................7
Figure 21 Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred .......................................................................................21
Figure 31 Initial Biomedical and Psychosocial Evaluation Domains......................................25
Figure 32 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26
Figure 33 Strategies for Deescalating Aggressive Behaviors ...............................................28
Figure 34 Questions To Guide Practitioners To Better Understand the Patient’s Cultural
Framework ...........................................................................................................32
Figure 35 The Transtheoretical Model (Stages of Change) ..................................................36
Figure 36 Clinician’s Characteristics Most Important to the Therapeutic Alliance....................38
Figure 37 Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans...............................................................................................40
Figure 38 Strategies To Promote Initiation of Treatment and Maintenance Activities ................42
Figure 41 Assessment Instruments for Dependence and Withdrawal From Alcohol and
Specific Illicit Drugs................................................................................................49
Figure 42 Symptoms of Alcohol Intoxication ...................................................................53
Figure 43 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61
Figure 44 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67
Figure 45 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77
iv Contents
Figure 46 Other SedativeHypnotics and Their Phenobarbital Withdrawal Equivalents ............78
Figure 47 Stimulant Withdrawal Symptoms....................................................................79
Figure 48 Commonly Abused Inhalants/Solvents..............................................................83
Figure 49 DSMIVTR on Nicotine Withdrawal ...............................................................86
Figure 410 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87
Figure 411 The GloverNilsson Smoking Behavioral Questionnaire (GNSBQ) ........................88
Figure 412 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With
Other Psychiatric Conditions ....................................................................................89
Figure 413 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90
Figure 414 The “5 A’s” for Brief Intervention .................................................................91
Figure 415 Some Definitions Regarding Disabilities ........................................................111
Figure 416 Impairment and Disability Chart .................................................................112
Figure 417 Locating Expert Assistance.........................................................................114
Figure 61 Financial Arrangements for Providers............................................................162
Contents v
What Is a TIP?
vii
Consensus Panel
Note: The information given indicates each participant's affiliation during the time the panel was
convened and may no longer reflect the individual's current affiliation.
ix
Charles A. Dackis, M.D. Hendree E. Jones, M.A., Ph.D.
Assistant Professor Assistant Professor
Department of Psychiatry CAP Research Director
University of Pennsylvania School of Medicine Department of Psychiatry and Behavioral
Philadelphia, Pennsylvania Sciences
Sylvia J. Dennison, M.D.
Johns Hopkins University Center
Baltimore, Maryland
Frances J. Joy, R.N., CD, CASAC
Chief/Medical Director
Division of Addiction Services
Department of Psychiatry Manager
University of Illinois Alcohol and Drug Abuse Unit
Chicago, Illinois State of Missouri Department of Mental Health
Patricia L. Mabry, Ph.D.
Fulton State Hospital
Fulton, Missouri
Health Scientist Administrator/Behavioral
Scientist
Office of Behavioral and Social Sciences
Research
Office of the Director
National Institutes of Health
Bethesda, Maryland
x Consensus Panel
KAP Expert Panel and Federal
Government Participants
Note: The information given indicates each participant's affiliation during the time the panel was
convened and may no longer reflect the individual's current affiliation.
xi
Diane Miller Nedra Klein Weinreich, M.S.
Chief President
Scientific Communications Branch Weinreich Communications
National Institute on Alcohol Abuse Canoga Park, California
Clarissa Wittenberg
and Alcoholism
Kensington, Maryland
Harry B. Montoya, M.A.
Director
Office of Communications and Public Liaison
President/Chief Executive Officer National Institute of Mental Health
Hands Across Cultures Kensington, Maryland
Espanola, New Mexico
Richard K. Ries, M.D. Consulting Members
Director/Professor Paul Purnell, M.A.
Outpatient Mental Health Services Social Solutions, L.L.C.
Dual Disorder Programs Potomac, Maryland
Harborview Medical Center
Seattle, Washington Scott Ratzan, M.D., M.P.A., M.A.
Gloria M. Rodriguez, D.S.W.
Academy for Educational Development
Washington, DC
Research Scientist
Division of Addiction Services Thomas W. Valente, Ph.D.
New Jersey Department of Health Director, Master of Public Health Program
and Senior Services Department of Preventive Medicine
Trenton, New Jersey School of Medicine
Everett Rogers, Ph.D.
University of Southern California
Alhambra, California
Center for Communications Programs
Johns Hopkins University Patricia A. Wright, Ed.D.
Baltimore, Maryland Independent Consultant
Jean R. Slutsky, P.A., M.S.P.H.
Baltimore, Maryland
Senior Health Policy Analyst
Agency for Healthcare Research & Quality
Rockville, Maryland
xii Expert Panel
Foreword
The talent, dedication, and hard work that TIPs panelists and reviewers
bring to this highly participatory process have helped bridge the gap
between the promise of research and the needs of practicing clinicians and
administrators to serve, in the most scientifically sound and effective ways,
people in need of behavioral health services. We are grateful to all who
have joined with us to contribute to advances in the behavioral health
field.
Daryl W. Kade
Acting Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
xiii
Executive Summary
This Treatment Improvement Protocol (TIP) is a revision of TIP 19,
Detoxification From Alcohol and Other Drugs (Center for Substance
Abuse Treatment 1995d). It provides clinicians with updated informa
tion and expands on the issues commonly encountered in the delivery of
detoxification services. Like its predecessor, this TIP was created by a
panel of experts (the consensus panel) with diverse experience in detoxi
fication services—physicians, psychologists, counselors, nurses, and
social workers, all with particular expertise to share.
This diverse group agreed to the following principles, which served as a
basis for the TIP:
1. Detoxification, in and of itself, does not constitute complete sub
stance abuse treatment.
2. The detoxification process consists of three essential components,
which should be available to all people seeking treatment:
•Evaluation
•Stabilization
•Fostering patient readiness for and entry into substance abuse
treatment
3. Detoxification can take place in a wide variety of settings and at a num
ber of levels of intensity within these settings. Placement should be
appropriate to the patient’s needs.
4. All persons requiring treatment for substance use disorders should
receive treatment of the same quality and appropriate thoroughness
and should be put into contact with substance abuse treatment
providers after detoxification.
5. Ultimately, insurance coverage for the full range of detoxification ser
vices is costeffective.
6. Patients seeking detoxification services have diverse cultural and ethnic
backgrounds as well as unique health needs and life situations.
Programs offering detoxification should be equipped to tailor treatment
to their client populations.
7. A successful detoxification process can be measured, in part, by
whether an individual who is substance dependent enters and
remains in some form of substance abuse treatment/rehabilitation
after detoxification.
Among the issues covered in this TIP is the importance of detoxification
as one component in the continuum of healthcare services for sub
stancerelated disorders. The TIP reinforces the urgent need for non
xv
traditional settings—emergency rooms, medi 5. Level IVD: Medically Managed Intensive
cal and surgical wards in hospitals, acute care Inpatient Detoxification
clinics, and others—to be prepared to partici
pate in the process of getting the patient who ASAM criteria are being adopted extensively
is in need of detoxification services into treat on the basis of their face validity, though
ment as quickly as possible. Furthermore, it their outcome validity has yet to be clinically
promotes the latest strategies for retaining proven. The ASAM guidelines are to be
individuals in detoxification while also regarded as a work in progress, as their
encouraging the development of the therapeu authors readily admit. They are an important
tic alliance to promote the patient’s entrance set of guidelines that are of great help to clini
into substance abuse treatment. The TIP also cians. For administrators, the standards pub
includes suggestions on addressing psychoso lished by such groups as the Joint
cial issues that may impact detoxification Commission on Accreditation of Healthcare
treatment, such as providing culturally Organizations and the Commission on
appropriate services to the patient popula Accreditation of Rehabilitation Facilities pro
tion. vide guidance for overall program operations.
Matching patients to appropriate care repre Placement will depend in part on the sub
sents a challenge to detoxification programs. stance of abuse. The consensus panel suggests
Given the wide variety of settings and the that for alcohol, sedativehypnotic, and opi
unique needs of the individual patient, estab oid withdrawal syndromes, hospitalization (or
lishing criteria that take into account all the some form of 24hour medical care) is often
possible needs of patients receiving detoxifica the preferred setting for detoxification, based
tion and treatment services is an extraordi on principles of safety and humanitarian con
narily complex task. Addiction medicine has cerns. When hospitalization cannot be pro
sought to develop an efficient system of care vided, then a setting that provides a high level
that matches patients’ clinical needs with the of nursing and medical backup 24 hours a
appropriate care setting in the least restric day, 7 days a week is desirable.
tive and most costeffective manner. Patient A further challenge for detoxification pro
placement criteria, such as those published grams is to provide effective linkages to sub
by the American Society of Addiction stance abuse treatment services. Patients
Medicine (ASAM) in the Patient Placement often leave detoxification without followup to
Criteria, Second Edition, Revised, represent the treatment needed to achieve longterm
an effort to define how care settings may be abstinence. Each year at least 300,000
matched to patient needs and special charac patients with substance use disorders or acute
teristics. These criteria—the five “Adult intoxication obtain inpatient detoxification in
Detoxification” placement levels—define the general hospitals, while additional numbers
most broadly accepted standard of care for obtain detoxification in other settings. Only
detoxification services. The five levels of care 20 percent of people discharged from acute
are care hospitals receive substance abuse treat
1. Level ID: Ambulatory Detoxification ment during that hospitalization. Only 15
Without Extended Onsite Monitoring percent of people who are admitted to a
detoxification program through an emergency
2. Level IID: Ambulatory Detoxification With room and then discharged go on to receive
Extended Onsite Monitoring treatment.
3. Level II.2D: Clinically Managed Residential
Detoxification The consensus panel recognizes that medical
ly assisted withdrawal is not always necessary
4. Level III.7D: Medically Monitored
or desirable. A nonmedical approach can be
Inpatient Detoxification
highly costeffective and provide inexpensive
xvi Executive Summary
access to treatment for individuals seeking medication or the psychiatric condition was
aid. Young individuals in good health, with no clearly caused by substance use, then the
history of previous withdrawal reactions, may rationale for discontinuing the medication is
be well served by management of withdrawal strengthened. Finally, practitioners should
without medication. However, personnel consider withholding medication that lowers
supervising in this setting should be trained to the seizure threshold (e.g., bupropion, con
identify lifethreatening symptoms and solicit ventional antipsychotics) during the acute
help through the emergency medical system as alcohol withdrawal period or at least pre
needed. scribing a loading dose or scheduled taper of
benzodiazepine.
The consensus panel also agreed on several
guidelines for nonmedical detoxification pro Further studies are needed to confirm the
grams. Such programs should follow local gov clinical experience that psychiatric symptoms
ernmental regulations regarding their licensing (including anxiety, depression, and personali
and inspection. In addition, it is desirable that ty disorders) respond to specific treatment of
all such programs have an alcohol and drug the addiction. For example, cognitive–behav
free environment as well as personnel who are ioral techniques employed in the 12Step
familiar with the features of substance use treatment approach have been effective in the
withdrawal syndromes, have training in basic management of anxiety and depression associ
life support, and have access to an emergency ated with addiction. Although challenging,
medical system that can transport patients to treatment of both addiction and cooccurring
emergency departments and other sites for clin psychiatric conditions has proven costeffec
ical care. tive in some studies.
A major clinical question for detoxification is This TIP also provides medical information
the appropriateness of the use of medication on detoxification protocols for specific sub
in the management of an individual in with stances as well as considerations for individu
drawal. This can be a difficult matter because als with cooccurring medical conditions
protocols have not been firmly established including mental disorders. While the TIP is
through scientific studies or evidencebased not intended to take the place of medical
methods. Furthermore, the course of with texts, it provides the practitioner with an
drawal is unpredictable and currently avail overview of common medical complications
able techniques of screening and assessment seen in individuals who use substances.
do not predict who will experience lifethreat Disorders of several systems are discussed in
ening complications. some detail: gastrointestinal (including the
gastrointestinal tract, liver, and pancreas),
Although it is the philosophy of some treat cardiovascular system, hematologic (blood)
ment facilities to discontinue all medications, abnormalities, pulmonary (lung) diseases, dis
this course of action is not always in the best eases of the central and peripheral nervous
interest of the patient. Abrupt cessation of system, infectious diseases, and special mis
psychotherapeutic medications may cause cellaneous disorders. The TIP presents a cur
severe withdrawal symptoms or the reemer sory overview of special conditions, modifica
gence of a psychiatric disorder. As a general tions in protocols, and the use of detoxifica
rule, therapeutic doses of medication should tion medications in patients with cooccurring
be continued through any withdrawal if the medical conditions or mental disorders.
patient has been taking the medication as pre Overall treatment of specific conditions is not
scribed. Decisions about discontinuing the addressed unless modification of such treat
medication should be deferred until after the ment is needed.
individual has completed detoxification. If,
however, the patient has been abusing the
Executive Summary xvii
The setting in which detoxification occurs is unusual in a clinical treatment improvement
also influenced by the existence of cooccur protocol to discuss issues related to how clini
ring medical disorders. It is highly desirable cal services are reimbursed. In the field of
that individuals undergoing detoxification be substance abuse and detoxification services,
assessed by primary care practitioners (i.e., however, reimbursement issues have become
physicians, physician assistants, nurse practi so intertwined with the delivery of services
tioners) with some experience in substance that the consensus panel deemed it necessary
abuse treatment. Such an assessment should to address the conflicts and misunderstand
determine whether the patient is currently ings that sometimes arise between the care
intoxicated and the degree of intoxication; the systems and the reimbursement systems.
type and severity of the withdrawal syn
drome; information regarding past with Thirdparty payors sometimes prefer to man
drawals; and the presence of cooccurring age payment for detoxification separately
psychiatric, medical, and surgical conditions from other phases of substance abuse treat
that might require specialized care. ment, thus treating detoxification as if it
Particular attention should be paid to those occurred in isolation from that treatment.
individuals who have undergone multiple This “unbundling” of services can result in
withdrawals in the past and for whom each the separation of services into scattered seg
withdrawal appears worse than previous ments. In other instances, reimbursement and
ones. Subjects with a history of severe with utilization policies dictate that only detoxifi
drawals, multiple withdrawals, delirium cation can be authorized. This detoxification
tremens (a potentially fatal syndrome associ often does not cover the nonmedical counsel
ated with alcohol withdrawal), or seizures are ing that is an integral part of substance abuse
not good candidates for detoxification pro treatment.
grams in nonmedical settings. Finally, identifying and maintaining funding
The setting in which detoxification is carried sources is a major issue in detoxification.
out should be appropriate for the medical Substance abuse treatment in the United
and psychological conditions present and States is financed through a diverse mix of
should be adequate to provide the degree of public and private sources, with substantially
monitoring needed to ensure safety (e.g., more being spent by the public sector. The
oximetry [a measurement of the amount of existence of diverse funding streams in sub
oxygen present in the blood], greater fre stance abuse treatment funding presents both
quency of taking vital signs, etc.). Acute, life management challenges and opportunities for
threatening conditions need to be addressed program independence and stability.
concurrently with the withdrawal process and However, a program with only one major
intensive care unit monitoring may be indicat funding source is financially and clinically
ed. Detoxification staff providing support vulnerable to changes in its major source’s
should be familiar with the signs and symp budget and priorities. This situation should
toms of common cooccurring medical disor be avoided. The TIP suggests ways to diversi
ders. Likewise, personnel at medical facilities fy funding sources to create a steady stream
(e.g., emergency rooms, physicians’ offices) of resources that can withstand the loss of one
should be aware of the signs of withdrawal particular funding source.
and how it affects the treatment of the pre This TIP also makes recommendations for
senting medical conditions. fostering relationships with reimbursement
This TIP will also bring clinicians and admin organizations, such as managed care organi
istrators up to date on administrative issues zations (MCOs). These positive working rela
related to detoxification, including how the tionships are vital to successfully link the
services themselves can be paid for. It is patient to the needed services. For example,
xviii Executive Summary
the MCO may use a wide variety of specific with each MCO’s appeal or exceptions process
criteria and protocols to determine whether for those occasions when the outcome of a
or not services may be authorized for sub firstlevel review is unsatisfactory.
stance abuse, typically including the ASAM
patient placement criteria and other level of Regardless of their role in providing detoxifi
care or diagnosisbased criteria sets. cation services, all personnel should keep in
Successfully addressing the needs of the staff mind that patients undergoing detoxification
at MCOs that are responsible for authorizing are in the midst of a personal and medical
the care provided to patients is a critical ele crisis. For many patients, this crisis repre
ment in maintaining a relationship with an sents a window of opportunity to acknowledge
MCO and the program’s clinical and financial their substance abuse problem and become
viability. To do so, staff should understand willing to seek treatment. Physicians, nurses,
what MCO staff do, be well trained in con substance abuse counselors, and administra
ducting professional relationships over the tors are in a unique position, not only to
telephone, be familiar with the criteria and ensure a safe and humane withdrawal from
protocols used by the MCOs with which the substances of dependency, but also to foster
program has contracts, and have easy access the path for the patient’s entry into substance
to the abundance of clinical and service infor abuse treatment. This TIP suggests ways for
mation required by an MCO in order to help clinicians and programs to prepare the
them complete a review and authorize ser patient for treatment while addressing the
vices. Maintaining thorough, clear, and accu complex psychosocial and medical variables
rate records is essential to this process. involved in detoxification.
Detoxification staff also should be familiar
Executive Summary xix
1 Overview, Essential
Concepts, and
Definitions in
In This
Chapter…
Detoxification
Purpose of the TIP
Audience
Scope
Chapter 1 provides a brief historical overview of changes in the percep
tions and provision of detoxification services. It also introduces the core
History of Detoxification
concepts of the detoxification field, discusses the primary goals of detoxifi
Services
cation services, clarifies the distinction between detoxification and treat
Definitions ment, and highlights some of the broader issues involved with providing
detoxification within systems of care.
Guiding Principles in
Detoxification and
Substance Abuse
Treatment
Purpose of the TIP
This TIP is a revision of TIP 19, Detoxification From Alcohol and
Challenges to Providing
Other Drugs (Center for Substance Abuse Treatment [CSAT] 1995d).
Effective Detoxification Significant changes in the area of detoxification services since the publi
cation of TIP 19 include
• Refinement of patient placement procedures
• Increased knowledge of the physiology of withdrawal
• Pharmacological advances in the management of withdrawal
• Changes in the role of detoxification in the continuum of services for
patients with substance use disorders, and new issues in the management
of detoxification services within comprehensive systems of care
• Emerging issues regarding specific populations (e.g., women, cultural
minorities, adolescents)
1
This TIP provides clinicians with uptodate provide detoxification services—to be pre
information in these areas. It also expands on pared to participate in the process of getting
the administrative, legal, and ethical issues the patient who is in need of detoxification
commonly encountered in the delivery of into a program as quickly as possible to
detoxification services and suggests perfor potentially avoid the myriad possible negative
mance measures for detoxification programs. consequences associated with substance abuse
Like its predecessor, this TIP was created by (e.g., physiological and psychological distur
a panel of experts with diverse experience in bances/disorders, criminal involvement,
detoxification services—physicians, psycholo unemployment, etc.). Furthermore, it pro
gists, counselors, nurses, and social workers, motes the latest strategies for retaining indi
all with particular expertise to share. viduals in detoxification while also encourag
ing the development of the therapeutic
alliance to promote the patient’s entrance into
Audience substance abuse treatment. This includes sug
The primary audiences for this TIP include gestions on addressing psychosocial issues
substance abuse treatment counselors; adminis that may affect detoxification services.
trators of detoxification programs; Single State
This TIP provides medical information on
Agency directors; psychiatrists and other
detoxification protocols for specific sub
physicians working in the field; primary care
stances, as well as considerations for individ
providers such as physicians, nurse practition
uals with cooccurring medical conditions
ers, physician assistants, nurses, psychologists,
including mental disorders. While the TIP is
and other clinical staff members; staff of man
not intended to take the place of medical
aged care and insurance carriers; policymak
texts, it provides the practitioner with an
ers; and others involved in planning, evaluat
overview of medical considerations.
ing, and delivering services for detoxifying
patients from substances of abuse. Secondary This TIP will also bring clinicians and adminis
audiences include public safety/police and trators uptodate on important aspects of
criminal justice personnel, educational institu detoxification, including how the services are to
tions, those involved with assisting workers be paid for. It is unusual in a clinical treatment
(e.g., Employee Assistance Programs), shel improvement protocol to discuss issues related
ters/feeding programs, and managed care orga to how clinical services are reimbursed.
nizations. The TIP also should prove useful to However, in the field of substance abuse and
providers of other services in comprehensive detoxification services, reimbursement issues
systems of care (vocational counseling, occupa have become so intertwined with the delivery of
tional therapy, and public housing/assisted liv services that the consensus panel deemed it
ing), administrators, and payors (public, pri necessary to address the conflicts and misun
vate, and managed care). derstandings that sometimes arise between the
care systems and the reimbursement systems.
Scope
Among other issues covered in this TIP is the History of
importance of detoxification as one compo Detoxification Services
nent in the continuum of healthcare services
for substancerelated disorders. The TIP Prior to the 1970s, public intoxication was
reinforces the urgent need for nontraditional treated as a criminal offense. People arrested
settings—such as emergency rooms, medical for it were held in the “drunk tanks” of local
and surgical wards in hospitals, acute care jails where they underwent withdrawal with
clinics, and others that do not traditionally little or no medical intervention (Abbott et al.
2 Chapter 1
1995; Sadd and Young 1987). Shifts in the Just as the treatment and the conceptualiza
medical field, in perceptions of addiction, and tion of addiction have changed, so too have
in social policy changed the way that people the patterns of substance use and the accom
with dependency on drugs, including alcohol, panying detoxification needs. The popularity
were viewed and treated. Two notable events of cocaine, heroin, and other substances has
were particularly instrumental in changing led to the need for different kinds of detoxifi
attitudes. In 1958, the American Medical cation services. At
Association (AMA) took the official position the same time, public
that alcoholism is a disease. This declaration health officials have
suggested that alcoholism was a medical prob increased invest The AMA’s
lem requiring medical intervention. In 1971, ments in detoxifica
the National Conference of Commissioners on tion services and position is that sub
Uniform State Laws adopted the Uniform substance abuse
Alcoholism and Intoxication Treatment Act, treatment, especially stance dependence
which recommended that “alcoholics not be after 1985, as a
subjected to criminal prosecution because of means to inhibit the is a disease, and it
their consumption of alcoholic beverages but spread of HIV infec
rather should be afforded a continuum of tion and AIDS encourages physi
treatment in order that they may lead normal among people who
lives as productive members of society” inject drugs. More
(Keller and Rosenberg 1973, p. 2). While this recently, people with
cians and other
recommendation did not carry the weight of substance use disor
law, it made a major change in the legal impli ders are more likely clinicians, health
cations of addiction. With these changes came to abuse more than
more humane treatment of people with addic one drug simultane organizations, and
tions. ously (i.e., polydrug
abuse) (Office of policymakers to
Several methods of detoxification have evolved Applied Studies
that reflect a more humanitarian view of people 2005). base all their activi
with substance use disorders. In the “medical
model,” detoxification is characterized by the The AMA continues
use of physician and nursing staff and the to maintain its posi
ties on this premise.
administration of medication to assist people tion that substance
through withdrawal safely (Sadd and Young dependence is a dis
1987). The “social model” rejects the use of ease, and it encour
medication and the need for routine medical ages physicians and other clinicians, health
care, relying instead on a supportive nonhospi organizations, and policymakers to base all
tal environment to ease the passage through their activities on this premise (AMA 2002).
withdrawal (Sadd and Young 1987). Today, it is As treatment regimens have become more
rare to find a “pure” detoxification model. For sophisticated and polydrug abuse more com
example, some social model programs use medi mon, detoxification has evolved into a com
cation to ease withdrawal but generally employ passionate science.
nonmedical staff to monitor withdrawal and
conduct triage (i.e., sorting patients according
to the severity of their disorders). Likewise, Definitions
medical programs generally have some compo Few clear definitions of detoxification and
nents to address social/personal aspects of related concepts are in general use at this
addiction. time. Criminal justice, health care, substance
abuse, mental health, and many other sys
Overview, Essential Concepts, and Definitions in Detoxification 3
tems all define detoxification differently. This taken special care to note that detoxification
TIP offers a clear and uniform set of defini is not substance abuse treatment and rehabil
tions for the various components of detoxifi itation. For further explanation, see the text
cation and substance abuse treatment that box below.
may prove useful to the field of detoxifica
tion. The consensus panel built on existing defini
tions of detoxification as a broad process with
three essential components that may take
Detoxification place concurrently or as a series of steps:
Detoxification is a set of interventions aimed • Evaluation entails testing for the presence
at managing acute intoxication and withdraw of substances of abuse in the bloodstream,
al. It denotes a clearing of toxins from the measuring their concentration, and screen
body of the patient who is acutely intoxicated ing for cooccurring mental and physical
and/or dependent on substances of abuse. conditions. Evaluation also includes a com
Detoxification seeks to minimize the physical prehensive assessment of the patient’s medi
harm caused by the abuse of substances. The cal and psychological conditions and social
acute medical management of lifethreatening situation to help determine the appropriate
intoxication and related medical problems level of treatment following detoxification.
generally is not included within the term Essentially, the evaluation serves as the
detoxification and is not covered in detail in basis for the initial substance abuse treat
this TIP. ment plan once the patient has been with
drawn successfully.
The Washington Circle Group (WCG), a body
• Stabilization includes the medical and psy
of experts organized to improve the quality
chosocial processes of assisting the patient
and effectiveness of substance abuse preven
through acute intoxication and withdrawal
tion and treatment, defines detoxification as
to the attainment of a medically stable, fully
“a medical intervention that manages an indi
supported, substancefree state. This often
vidual safely through the process of acute
is done with the assistance of medications,
withdrawal” (McCorry et al. 2000a, p. 9).
though in some approaches to detoxification
The WCG makes an important distinction,
no medication is used. Stabilization
however, in noting that “a detoxification pro
includes familiarizing patients with what to
gram is not designed to resolve the long
expect in the treatment milieu and their
standing psychological, social, and behavioral
role in treatment and recovery. During this
problems associated with alcohol and drug
time practitioners also seek the involvement
abuse” (McCorry et al. 2000a, p. 9). The con
of the patient’s family, employers, and
sensus panel supports this statement and has
Detoxification as Distinct From Substance
Abuse Treatment
Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised
detoxification may prevent potentially lifethreatening complications that might appear if the patient
were left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of
a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a
result of hospitalization or legal involvement. Finally, for some patients it represents a point of first con
tact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other
hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery
for substance abuse patients.
4 Chapter 1
other significant people when appropriate stanceinduced disorders. According to the
and with release of confidentiality. DSMIVTR, substance use disorders include
• Fostering the patient’s entry into treatment both “substance dependence” and “substance
involves preparing the patient for entry into abuse.” Substance dependence refers to “a
substance abuse treatment by stressing the cluster of cognitive, behavioral, and physio
importance of following through with the logical symptoms indicating that the individu
complete substance abuse treatment contin al continues use of the substance despite sig
uum of care. For patients who have demon nificant substancerelated problems. There is
strated a pattern of completing detoxifica a pattern of repeated selfadministration that
tion services and then failing to engage in can result in tolerance, withdrawal, and com
substance abuse treatment, a written treat pulsive drugtaking behavior” (APA 2000, p.
ment contract may encourage entrance into 192). Substance abuse refers to “a maladap
a continuum of substance abuse treatment tive pattern of substance use manifested by
and care. This contract, which is not legally recurrent and significant adverse conse
binding, is voluntarily signed by patients quences related to the repeated use of sub
when they are stable enough to do so at the stances” (APA 2000, p. 198). It should be
beginning of treatment. In it, the patient noted that for purposes of this TIP, the term
agrees to participate in a continuing care “substance abuse” is sometimes used to
plan, with details and contacts established denote both substance abuse and substance
prior to the completion of detoxification. dependence as they are defined by the DSM
IVTR.
All three components (evaluation, stabiliza
tion, and fostering a patient’s entry into This TIP also uses the DSMIVTR definitions
treatment) involve treating the patient with for substance intoxication and substance
compassion and understanding. Patients withdrawal. Substance intoxication is “the
undergoing detoxification need to know that development of a reversible substancespecific
someone cares about them, respects them as syndrome due to the recent ingestion of (or
individuals, and has hope for their future. exposure to) a substance” whereas substance
Actions taken during detoxification will withdrawal is “the development of a sub
demonstrate to the patient that the provider’s stancespecific maladaptive behavioral
recommendations can be trusted and fol change, with physiological and cognitive con
lowed. comitants, that is due to the cessation of, or
reduction in, heavy and prolonged substance
use” (APA 2000, pp. 199, 201). Figure 11
Other Relevant Terms (p. 6) defines these and other relevant terms.
As defined by the Diagnostic and Statistical Treatment/rehabilitation includes an ongoing,
Manual of Mental Disorders, 4th edition, continual assessment of the patient’s physical,
Text Revision (DSMIVTR) (American psychological, and social status, as well as an
Psychiatric Association [APA] 2000), a sub analysis of environmental risk factors that
stancerelated disorder is a “disorder related may be contributing to substance use and the
to the taking of a drug of abuse (including identification of immediate relapse triggers as
alcohol), to the side effects of a medication, well as prevention strategies for coping with
and to toxin exposure” (APA 2000, p. 191). them. It also includes the delivery of primary
The term substance “can refer to a drug of medical care and psychiatric care, if neces
abuse, a medication, or a toxin” (APA 2000, sary, to help the patient abstain from sub
p. 191). In this TIP, the term substance refers stance use and minimize the physical harm
to alcohol as well as other drugs of abuse. caused by it. Ultimately, the goal of treat
Substancerelated disorders are divided into ment/rehabilitation is to attain a higher level
two groups: substance use disorders and sub of social functioning by reducing risk factors,
Overview, Essential Concepts, and Definitions in Detoxification 5
Figure 11
DSMIVTR Definitions of Terms
Term Definition
Substance A drug of abuse, a medication, or a toxin.
Substancerelated disorders Disorders related to the taking of a drug of abuse (including
alcohol), to the side effects of a medication, and to toxin expo
sure.
Substance abuse (in this TIP, also A maladaptive (i.e., harmful to a person’s life) pattern of sub
sometimes used to denote “substance stance use marked by recurrent and significant negative conse
dependence”) quences related to the repeated use of substances.
Substance dependence (in this TIP, A cluster of cognitive, behavioral, and physiological symptoms
“substance abuse” is sometimes used indicating that the individual is continuing use of the substance
to include “dependence”) despite significant substancerelated problems. A person experi
encing substance dependence shows a pattern of repeated self
administration that usually results in tolerance, withdrawal, and
compulsive drugtaking behavior.
Substance intoxication The development of a reversible substancespecific syndrome as
the result of the recent ingestion of (or exposure to) a substance.
Substance withdrawal The development of a substancespecific maladaptive behavioral
change, usually with uncomfortable physiological and cognitive
consequences, that is the result of a cessation of, or reduction in,
heavy and prolonged substance use.
Source: APA 2000.
enhancing protective factors, and thus patients to emphasize that these persons are
decreasing the possibility of relapse. coming into contact with physicians, nurses,
physician assistants, and medical social work
Maintenance includes the continuation of ers in a medical setting in which the patient
counseling and support specified in the treat often is physically ill from the effects of with
ment plan, refinement and strengthening of drawal from specific substances. In some
strategies to avoid relapse, and engagement in social setting detoxification programs, the
ongoing relapse prevention, aftercare, and/or terms “client” or “consumer” may be used in
domiciliary care (Lehman et al. 2000). place of “patient.”
As a final note, in this TIP persons in need of
detoxification services and subsequent sub
stance abuse treatment are referred to as
6 Chapter 1
empirically measurable and agreed upon by all
Guiding Principles in parties. The consensus panel developed guide
Detoxification and lines (listed in Figure 12) that serve as the
foundation for the TIP.
Substance Abuse
Treatment
The consensus panel recognizes that the suc
cessful delivery of detoxification services is
dependent on standards that are to some extent
Figure 12
Guiding Principles Recognized by the Consensus Panel
1. Detoxification does not constitute substance abuse treatment but is one part of a continuum of care for
substancerelated disorders.
2. The detoxification process consists of the following three sequential and essential components:
•Evaluation
•Stabilization
•Fostering patient readiness for and entry into treatment
A detoxification process that does not incorporate all three critical components is considered incomplete
and inadequate by the consensus panel.
3. Detoxification can take place in a wide variety of settings and at a number of levels of intensity within
these settings. Placement should be appropriate to the patient’s needs.
4. Persons seeking detoxification should have access to the components of the detoxification process
described above, no matter what the setting or the level of treatment intensity.
5. All persons requiring treatment for substance use disorders should receive treatment of the same
quality and appropriate thoroughness and should be put into contact with a substance abuse treat
ment program after detoxification, if they are not going to be engaged in a treatment service provided
by the same program that provided them with detoxification services. There can be “no wrong door
to treatment” for substance use disorders (CSAT 2000a).
6. Ultimately, insurance coverage for the full range of detoxification services is costeffective. If reim
bursement systems do not provide payment for the complete detoxification process, patients may be
released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical com
plications ultimately drive up the overall cost of health care.
7. Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as
unique health needs and life situations. Organizations that provide detoxification services need to
ensure that they have standard practices in place to address cultural diversity. It also is essential that
care providers possess the special clinical skills necessary to provide culturally competent compre
hensive assessments. Detoxification program administrators have a duty to ensure that appropriate
training is available to staff. (For more information on cultural competency training and specific
competencies that clinicians need to be “culturally competent” see the forthcoming TIP Improving
Cultural Competence in Substance Abuse Treatment [SAMHSA in development a]).
8. A successful detoxification process can be measured, in part, by whether an individual who is sub
stance dependent enters, remains in, and is compliant with the treatment protocol of a substance
abuse treatment/rehabilitation program after detoxification.
Overview, Essential Concepts, and Definitions in Detoxification 7
Finally the average length of stay for people
Challenges to undergoing detoxification and treatment in
Providing Effective 1997 was only 7.7 days (Mark et al. 2002).
Given that “research has shown that patients
Detoxification who receive continuing care have better out
It is an important challenge for detoxification comes in terms of drug abstinence and read
service providers to find the most effective mission rates than those who do not receive
way to foster a patient’s recovery. Effective continuing care,” the report authors conclude
detoxification includes not only the medical that there is a pronounced need for better
stabilization of the patient and the safe and linkage between detoxification services and
humane withdrawal from drugs, including the treatment services that are essential for
alcohol, but also entry into treatment. full recovery (Mark et al. 2002, p. 3).
Successfully linking detoxification with sub
stance abuse treatment reduces the “revolving Reimbursement systems can present another
door” phenomenon of repeated withdrawals, challenge to providing effective detoxification
saves money in the medium and long run, and services (Galanter et al. 2000). Thirdparty
delivers the sound and humane level of care payors sometimes prefer to manage payment
patients need (Kertesz et al. 2003). Studies for detoxification separately from other phas
show that detoxification and its linkage to the es of addiction treatment, thus treating detox
appropriate levels of treatment lead to ification as if it occurred in isolation from
increased recovery and decreased use of addiction treatment. This “unbundling” of
detoxification and treatment services in the services has promoted the separation of all
future. In addition, recovery leads to reduc services into somewhat scattered segments
tions in crime, general healthcare costs, and (Kasser et al. 2000). In other instances, some
expensive acute medical and surgical treat reimbursement and utilization policies dictate
ments consequent to untreated substance that only “detoxification” currently can be
abuse (Abbot et al. 1998; Aszalos et al. 1999). authorized, and “detoxification” for that poli
While detoxification is not treatment per se, cy or insurer does not cover the nonmedical
its effectiveness can be measured, in part, by counseling that is an integral part of sub
the patient’s continued abstinence. stance abuse treatment. Many treatment pro
grams have found substance abuse counselors
Another challenge to providing effective to be of special help with resistant patients,
detoxification occurs when programs try to especially for patients with severe underlying
develop linkages to treatment services. A shame over the fact that their substance use is
study (Mark et al. 2002) conducted for the out of control. Yet some payors will not reim
Substance Abuse and Mental Health Services burse for nonmedical services such as those
Administration highlights the pitfalls of the provided by these counselors, and therefore
service delivery system. According to the the use of such staff by a detoxification or
authors, each year at least 300,000 patients treatment service may be impossible, in spite
with substance use disorders or acute intoxi of the fact that they are widely perceived as
cation obtain inpatient detoxification in gen useful for patients.
eral hospitals while additional numbers
obtain detoxification in other settings. Only Payors are gradually beginning to understand
about onefifth of people discharged from that detoxification is only one component of a
acute care hospitals for detoxification receive comprehensive treatment strategy. Patient
substance abuse treatment during that hospi placement criteria, such as those published
talization. Moreover, only 15 percent of peo by the American Society of Addiction
ple who are admitted through an emergency Medicine (ASAM) in the Patient Placement
room for detoxification and then discharged Criteria, Second Edition, Revised (ASAM
receive any substance abuse treatment. 2001), have come to the fore as clinicians and
8 Chapter 1
insurers try to reach agreements on the level for resolving conflicts as well as clearly defin
of treatment required by a given patient, as ing terms used in patient placement and treat
well as the medically appropriate setting in ment settings as a step toward clearer under
which the treatment services are to be deliv standing among interested parties.
ered. Accordingly, the TIP offers suggestions
Overview, Essential Concepts, and Definitions in Detoxification 9
2 Settings, Levels of
Care, and Patient
Placement
In This
Chapter…
Establishing criteria that take into account all the possible needs of
patients receiving detoxification and treatment services is an extraordi
Role of Various
narily complex task. This chapter discusses the criteria for placing
Settings in the
patients in the appropriate treatment settings and offering the required
Delivery of Services
intensity of services (i.e., level of care).
Other Concerns
Regarding Levels of
Care and Placement
Role of Various Settings in the
Delivery of Services
Addiction medicine has sought to develop an efficient system of care that
matches patients’ clinical needs with the appropriate care setting in the
least restrictive and most costeffective manner. (For an explanation of
least restrictive care, see the text box, p. 12.) Challenges to effective
placement matching for clients arise from a number of factors:
• Deficits in the full range of care settings and levels of care
• Limitations imposed by thirdparty payors (e.g., strict adherence to
standardized admission criteria)
• Clinicians’ lack of authority (and sometimes sufficient knowledge) to
determine the most appropriate care setting and level of care
• Insurance that does not have a substance use disorder benefit available
as part of its patient coverage
• Absence of any health insurance at all (Gastfriend et al. 2000)
No clear solution or formula to meet these challenges has emerged.
11
Least Restrictive Care
Least restrictive refers to patients’ civil rights and their right to choice of care. There are four spe
cific themes of historical and clinical importance:
1. Patients should be treated in those settings that least interfere with their civil rights and freedom to
participate in society.
2. Patients should be able to disagree with clinician recommendations for care. While this includes the
right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as
long as considerations of dangerousness and mental competency are satisfied). It implies a patient’s
right to seek a higher or different level of care than that which the clinician has planned.
3. Patients should be informed participants in defining their care plan. Such planning should be done
in collaboration with their healthcare providers.
4. Careful consideration of State laws and agency policies is required for patients who are unable to
act in their own selfinterests. Because the legal complexities of this issue will vary from State to
State the TIP cannot provide definitive guidance here, but providers need to consider whether or
not the person is “gravely” incapacitated, suicidal, or homicidal; likely to commit grave bodily
injury; or, in some States, likely to cause injury to property. In such cases, State law and/or case
law may hold providers responsible if they do not commit the patient to care, but in other cases
programs may be open to lawsuits for forcibly holding a patient.
In spite of the impediments, some progress has 2. Biomedical Conditions and Complications
been made in developing comprehensive 3. Emotional, Behavioral, or Cognitive
patient placement criteria. Because the choice Conditions and Complications
of a treatment setting and intensity of treat
4. Readiness to Change
ment (level of care) are so important, the
American Society of Addiction Medicine 5. Relapse, Continued Use, or Continued
(ASAM) created the Patient Placement Problem Potential
Criteria, Second Edition, Revised (PPC2R) a 6. Recovery/Living Environment
consensusbased clinical tool for matching
patients to the appropriate setting and level of The ASAM PPC2R describes both the settings
care. The ASAM PPC2R represents an effort in which services may take place and the inten
to define how care settings may be matched to sity of services (i.e., level of care) that patients
patient needs and special characteristics. These may receive in particular settings. It is impor
criteria currently define the most broadly tant to reiterate, however, that the ASAM
accepted standard of care for the treatment of PPC2R criteria do not characterize all the
substance use disorders. ASAM criteria are details that may be essential to the success of
intended to provide flexible clinical guidelines; treatment (Gastfriend et al. 2000). Moreover,
these criteria may not be appropriate for par traditional assumptions that certain treatment
ticular patients or specific care settings. can be delivered only in a particular setting
may not be applicable or valuable to patients.
The PPC2R identifies six “assessment dimen Clinical judgment and consideration of the
sions to be evaluated in making placement patient’s particular situation are required for
decisions” (ASAM 2001, p. 4). They are as appropriate detoxification and treatment.
follows:
In addition to the general placement criteria
1. Acute Intoxication and/or Withdrawal
for treatment for substancerelated disorders,
Potential
ASAM also has developed a second set of place
12 Chapter 2
ment criteria, which are more important for should increase the patient’s readiness for
the purposes of this TIP—the five “Adult and commitment to substance abuse treat
Detoxification” placement levels of care within ment and foster a solid therapeutic alliance
Dimension 1 (ASAM 2001). These “Adult between the patient and care provider.
Detoxification” levels of care are
It is important to note that ASAM PPC2R
1. Level ID: Ambulatory Detoxification criteria are only guidelines, and that there
Without Extended Onsite Monitoring (e.g., are no uniform protocols for determining
physician’s office, home health care agen which patients are placed in which level of
cy). This level of care is an organized out care. For further information on patient
patient service monitored at predeter placement, readers are advised to consult
mined intervals. TIP 13, The Role and Current Status of
2. Level IID: Ambulatory Detoxification Patient Placement Criteria in the Treatment
With Extended Onsite Monitoring (e.g., of Substance Use Disorders (Center for
day hospital service). This level of care is Substance Abuse Treatment [CSAT] 1995h).
monitored by appropriately credentialed Because this TIP is geared to audiences that
and licensed nurses. may or may not be familiar with the ASAM
3. Level III.2D: Clinically Managed PPC2R levels of care, this section discusses
Residential Detoxification (e.g., nonmedi the services and staffing specific to the care
cal or social detoxification setting). This settings that are familiar to a broad audience.
level emphasizes peer and social support
and is intended for patients whose intoxi
cation and/or withdrawal is sufficient to Physician’s Office
warrant 24hour support. It has been estimated that nearly one half of
4. Level III.7D: Medically Monitored the patients who visit a primary care provider
Inpatient Detoxification (e.g., freestanding have some type of problem related to sub
detoxification center). Unlike Level stance use (Miller and Gold 1998). Indeed,
III.2.D, this level provides 24hour medi because the physician may be the first point
cally supervised detoxification services. of contact for these people, initiation of treat
5. Level IVD: Medically Managed Intensive ment often begins in the family physician’s
Inpatient Detoxification (e.g., psychiatric office (Prater et al. 1999). Physicians should
hospital inpatient center). This level pro use prudence in determining which patients
vides 24hour care in an acute care inpa may undergo detoxification safely on an out
tient settings. patient basis. As a general rule, outpatient
treatment is just as effective as inpatient
As described by the ASAM PPC2R, the treatment for patients with mild to moderate
domain of detoxification refers not only to the withdrawal symptoms (Hayashida 1998).
reduction of the physiological and psychologi
cal features of withdrawal syndromes, but For physicians treating patients with sub
also to the process of interrupting the momen stance use disorders, preparing the patient to
tum of compulsive use in persons diagnosed enter treatment and developing a therapeutic
with substance dependence (ASAM 2001). alliance between patient and clinician should
Because of the force of this momentum and begin as soon as possible. This includes pro
the inherent difficulties in overcoming it even viding the patient and his family with infor
when there is no clear withdrawal syndrome, mation on the detoxification process and sub
this phase of treatment frequently requires a sequent substance abuse treatment, in addi
greater intensity of services initially to estab tion to providing medical care or referrals if
lish participation in treatment activities and necessary. Staffing should include certified
patient role induction. That is, this phase interpreters for the deaf and other language
Settings, Levels of Care, and Patient Placement 13
interpreters if the program is serving patients under a defined set of policies and procedures
in need of those services. Physicians should or medical protocols. Outpatient services are
be able to accommodate frequent followup designed to treat the patient’s level of clinical
visits during the management of acute with severity and to achieve safe and comfortable
drawal. Medications should be dispensed in withdrawal from moodaltering drugs, includ
limited amounts. ing alcohol, and to effectively facilitate the
patient’s entry into ongoing treatment and
recovery (ASAM 2001).
Level of care
Ambulatory detoxification without
extended onsite monitoring Staffing
This level of detoxification (ASAM’s Level I Although they need not be present in the
D) is an organized outpatient service, which treatment setting at all times, physicians and
may be delivered in an office setting, health nurses are essential to officebased detoxifica
care or addiction treatment facility, or in a tion. In States where physician assistants,
patient’s home by trained clinicians who pro nurse practitioners, or advance practice clini
vide medically supervised evaluation, detoxi cal nurse specialists are licensed as physician
fication, and referral services according to a extenders, they may perform the duties ordi
predetermined schedule. Such services are narily carried out by a physician (ASAM
provided in regularly scheduled sessions. 2001).
These services should be delivered under a Because detoxification is conducted on an
defined set of policies and procedures or med outpatient basis in these settings, it is impor
ical protocols (ASAM 2001). Ambulatory tant for medical and nursing personnel to be
detoxification is considered appropriate only readily available to evaluate and confirm that
when a positive and helpful social support detoxification in the less supervised setting is
network is available to the patient. In this safe. All clinicians who assess and treat
level of care, outpatient detoxification ser patients should be able to obtain and inter
vices should be designed to treat the patient’s pret information regarding the needs of these
level of clinical severity, to achieve safe and persons, and all should be knowledgeable
comfortable withdrawal from moodaltering about the biomedical and psychosocial dimen
drugs, and to effectively facilitate the sions of alcohol and illicit drug dependence.
patient’s transition into treatment and recov Requisite skills and knowledge base include
ery. the following:
Ambulatory detoxification with • Understanding how to interpret the signs and
extended onsite monitoring symptoms of alcohol and other drug intoxica
Essential to this level of care—and distin tion and withdrawal
guishing it from Ambulatory Detoxification • Understanding the appropriate treatment
Without Extended Onsite Monitoring—is the and monitoring of these conditions
availability of appropriately credentialed and • The ability to facilitate the individual’s entry
licensed nurses (such as registered nurses into treatment
[RNs] or licensed practical nurses [LPNs])
who monitor patients over a period of several It is essential that medical consultation is
hours each day of service (ASAM 2001). readily available in emergencies. It is desir
Otherwise, this level of detoxification able that medical staff link patients to treat
(ASAM’s Level IID) also is an organized out ment services, although this may be an unrea
patient service. Like Level ID, in this level of sonable expectation that cannot be met in a
care detoxification services are provided in busy office setting. Linkage to treatment ser
regularly scheduled sessions and delivered vices may be provided by the physician or by
14 Chapter 2
designated counselors, psychologists, social only when there are serious concerns about a
workers, and acupuncturists who are avail patient’s safety.
able either onsite or through the healthcare
system (ASAM 2001). A timely and accurate assessment in an emer
gency department is of the highest impor
tance. This will permit the rapid transfer of
Freestanding Urgent Care the patient to a setting where complete care
Center or Emergency can be provided.
Ideally, personnel in
Department the emergency Although they
There are several distinctions between urgent department will have
care facilities and emergency rooms (ERs). at least a small
Urgent care often is used by patients who amount of experi
need not be
cannot or do not want to wait until they see ence and expertise in
their doctor in his or her office, whereas identifying critically present in the
emergency rooms are utilized more often by ill substanceusing
patients who perceive themselves to be in a patients who may be treatment setting
crisis situation. Unlike emergency depart about to experience
ments, which are required to operate 24 or are already expe at all times,
hours a day, freestanding urgent care centers riencing withdrawal
usually have specific hours of operation. symptoms. Three physicians and
Staffing for urgent care centers generally is essential rules apply
more limited than for an ER. Standard to emergency depart nurses are
staffing includes only a physician, an RN, a ments and their han
technician, and a secretary. Despite these dis dling of intoxicated
essential to
tinctions, in actual practice there is consider patients and patients
able overlap between the two—the ER will see who have begun to
medical problems that could be handled by experience with officebased
visits to offices, and urgent care facilities will drawal:
handle some cases of emergency medicine. detoxification.
• Emergency depart
A freestanding urgent care center or emergen ments and their
cy department reasonably can be expected to clinicians should
provide assessment and acute biomedical never simply
(including psychiatric) care. However, these administer medications to intoxicated persons
settings often are unable to provide satisfacto and then send them home.
ry psychosocial stabilization or complete • No intoxicated patient should ever be allowed
biomedical stabilization (which includes both to leave a hospital setting. All such persons
the initiation and taper of medications used in should be referred to the appropriate detoxi
the treatment of substance withdrawal syn fication setting if possible, although there are
dromes). Appropriate triage and successful legal restrictions that forbid holding persons
linkage to ongoing detoxification services is against their will under certain conditions
essential. The ongoing detoxification services (Armenian et al. 1999).
may be provided in an inpatient, residential, • A clear distinction must be made between
or outpatient setting. Patients with more than acute intoxication on the one hand and with
moderate biomedical or psychosocial compli drawal on the other. Acute intoxication, it
cations are more likely to require treatment must be remembered, creates special issues
in an inpatient setting. Care in these settings and challenges that need to be addressed.
can be quite costly and should be accessed The risk of suicidality in patients who pre
sent in a state of intoxication needs to be
Settings, Levels of Care, and Patient Placement 15
carefully assessed. Because of their volatility biomedical issues, is recommended wherever
and often risky behavior, patients who are possible.
intoxicated, as well as those patients who
have begun to experience withdrawal, merit Appreciation of the value of multidimensional
special attention. For more on treating intox patient assessment is central to the clinician’s
icated patients, see chapter 3. ability to decide which triage (linkage) options
are least restrictive and most costeffective
for a given patient.
Level of care
Care is provided to
Inpatient patients whose with Staffing
drawal signs and Both emergency departments and freestanding
detoxification symptoms are suffi urgent care units are staffed by physicians.
ciently severe to The same rules regarding who may provide
provides 24hour require primary care apply here as they did in the discussion of
medical and nursing staffing of officebased detoxification (ASAM
supervision, care services. The 2001). An RN or other licensed and creden
services are deliv tialed nurse is available for primary nursing
observation, and ered under a care and observation. Psychologists, social
defined set of physi workers, addiction counselors, and acupunc
cianmanaged pro turists usually are not available in these set
support for cedures or medical tings. The physician or attending nurse usually
protocols. Both set facilitates linkage to substance abuse treat
patients who are tings provide medi ment.
cally directed assess
intoxicated or ment and acute care
that includes the ini
Freestanding Substance Abuse
experiencing tiation of detoxifica
Treatment or Mental Health
tion for substance Facility
withdrawal. use withdrawal.
Neither setting is Freestanding substance abuse treatment facili
likely to offer satis ties may or may not be equipped to provide
factory biomedical adequate assessment and treatment of co
stabilization or 24 occurring psychiatric conditions and biopsy
hour observation. Generally speaking, triage to chosocial problems, as the range of services
inpatient care can easily be facilitated from varies considerably from one facility to anoth
either setting. er. Inpatient mental health facilities, on the
other hand, are able generally to provide treat
Freestanding urgent care centers and emer ment for substance use disorders and cooccur
gency departments are outpatient settings ring psychiatric conditions. Nonetheless, like
that are uniquely designed to address the substance abuse treatment facilities, the range
needs of patients in biomedical crisis. For of available services varies from one mental
patients with substance use disorders, care in health facility to another.
these settings is not complete until successful
linkage is made to treatment that is focused General guidelines for considering patient
specifically on the substance use disorder. To placement in either of these settings are pro
accomplish this, a comprehensive assessment, vided below; however, it should be empha
taking into account psychosocial as well as sized that a clear understanding of the specif
ic services that a given setting provides is
16 Chapter 2
indispensable to identifying the least restric Clinically Managed Residential
tive and most costeffective treatment option Detoxification
that may be available. Concern for safety is Residential settings vary greatly in the level of
of primary importance, and the final decision care that they provide. Those with intensive
regarding placement always rests with the medical supervision involving physicians, nurse
treating physician. practitioners, physician assistants, and nurses
can handle all but the most demanding compli
Level of care cations of intoxication and withdrawal. On the
other hand, some residential settings have min
Medically Monitored Inpatient imally intensive medical oversight. Residential
Detoxification detoxification in settings with limited medical
Inpatient detoxification provides 24hour oversight often is referred to as “social detoxifi
supervision, observation, and support for cation.” (Though the “social detoxification”
patients who are intoxicated or experiencing model is not limited to residential facilities.)
withdrawal. Since this level of care is relatively Facilities with lower levels of care should have
more restrictive and more costly than a resi clear procedures in place for implementing and
dential treatment option, the treatment mission pursuing appropriate medical referral and
in this setting should be clearly focused and linkage, especially in the case of emergencies.
limited in scope. Primary emphasis should be For example, a patient who is in danger of
placed on ensuring that the patient is medically seizures or delirium tremens needs to be
stable (including the initiation and tapering of referred to the appropriate medical facility for
medications used for the treatment of sub acute care of presenting symptoms, possibly
stance use withdrawal); assessing for adequate medicated, and then returned to a social detox
biopsychosocial stability, quickly intervening to ification setting for continuing monitoring and
establish this adequately; and facilitating effec observation. The establishment of this kind of
tive linkage to and engagement in other appro collaborative relationship between institutions
priate inpatient and outpatient services. provides a good example of a costeffective way
to provide adequate care to patients.
Inpatient settings provide medically managed
intensive inpatient detoxification. At this level Residential detoxification programs provide
of care, physicians are available 24 hours per 24hour supervision, observation, and sup
day by telephone. A physician should be port for patients who are intoxicated or expe
available to assess the patient within 24 hours riencing withdrawal. They are characterized
of admission (or sooner, if medically neces by an emphasis on peer and social support
sary) and should be available to provide (ASAM 2001). Standards published by such
onsite monitoring of care and further evalua groups as the Joint Commission on
tion on a daily basis. An RN or other quali Accreditation of Healthcare Organizations
fied nursing specialist should be present to (JCAHO) and the Commission on
administer an initial assessment. A nurse will Accreditation of Rehabilitation Facilities
be responsible for overseeing the monitoring (CARF) provide further information on quali
of the patient’s progress and medication ty measures for residential detoxification.
administration on an hourly basis, if needed.
Appropriately licensed and credentialed staff
should be available to administer medications
in accordance with physician orders.
Settings, Levels of Care, and Patient Placement 17
Staffing have biomedical needs that exceed the capaci
ty of the facility and to identify which pro
Inpatient detoxification programs employ
grams will likely have a need for transferring
licensed, certified, or registered clinicians who
such patients to more appropriate treatment
provide a planned regimen of 24hour, profes
settings.
sionally directed evaluation, care, and treat
ment services for patients and their families.
An interdisciplinary team of appropriately Intensive Outpatient and
trained clinicians (such as physicians, RNs and Partial Hospitalization
LPNs, counselors, social workers, and psychol
ogists) should be available to assess and treat Programs
the patient and to obtain and interpret infor An intensive outpatient program (IOP) or par
mation regarding the patient’s needs. The num tial hospitalization program (PHP) is appropri
ber and disciplines of team members should be ate for patients with mild to moderate with
appropriate to the range and severity of the drawal symptoms. Thorough psychosocial
patient’s problems (ASAM 2001). assessment and intervention should be avail
able in addition to biomedical assessment and
Residential detoxification programs are stabilization. Many of these programs have
staffed by appropriately credentialed person close clinical and/or administrative ties to hos
nel who are trained and competent to imple pital centers. When needed, triage to a higher
ment physicianapproved protocols for level of care should be easy to accomplish.
patient observation and supervision. These Outpatient treatment should be delivered in
persons also are responsible for determining conjunction with all components of detoxifica
the appropriate level of care and facilitating tion.
the patient’s transition to ongoing care.
Medical evaluation and consultation should
be available 24 hours a day, in accordance Level of care
with treatment/transfer practice guidelines.
This level of detoxification is an organized out
All clinicians who assess and treat patients
patient service that requires patients to be pre
should be able to obtain and interpret infor
sent onsite for several hours a day. It is thus
mation regarding the needs of these persons
similar to a physician’s office in that ambulato
and should be knowledgeable about the
ry detoxification with extended onsite monitor
biomedical and psychosocial dimensions of
ing is provided. Unlike the physician’s office, in
alcohol and other drug dependence. Such
the IOP and PHP it is standard practice to
knowledge includes awareness of the signs
have a multidisciplinary team available to pro
and symptoms of alcohol and other drug
vide or facilitate linkage to a range of medically
intoxication and withdrawal, as well as the
supervised evaluation, detoxification, and
appropriate treatment and monitoring of
referral services.
those conditions and how to facilitate the
individual’s entry into ongoing care. Staff Detoxification services also are provided in
should ensure that patients are taking medi regularly scheduled sessions and delivered
cations according to their physician’s orders under a defined set of policies and procedures
and legal requirements (ASAM 2001). or medical protocols. These outpatient ser
vices are designed to treat the patient’s level
Some residential detoxification programs are
of clinical severity, to achieve safe and com
staffed to supervise selfadministered medica
fortable withdrawal from moodaltering drugs
tions for the management of withdrawal. All
(including alcohol), and to effectively facili
such programs should rely on established
clinical protocols to identify patients who
18 Chapter 2
tate the patient’s engagement in ongoing treat as an interdisciplinary team to assess and
ment and recovery (ASAM 2001). care for the patient with a substancerelated
disorder, as well as patients with both a sub
A partial hospitalization program may occupy stance use disorder and a cooccurring
the same setting (i.e., physical space) as an biomedical, emotional, or behavioral condi
acute care inpatient treatment program. tion. Successful linkage to treatment for the
Although occupying the same space, the levels substance use disorder (in addition to
of care provided by these two programs are biomedical stabilization) is central to the mis
distinct yet complementary. Acute care inpa sion of an intensive
tient programs provide detoxification services outpatient or partial
to patients in danger of severe withdrawal hospitalization pro
and who therefore need the highest level of gram (ASAM 2001). Successful linkage
medically managed intensive care, including For more informa
access to life support equipment and 24hour tion, see the TIP to treatment for
medical support. In contrast, partial hospital Substance Abuse:
ization programs provide services to patients Clinical Issues in the substance use
with mild to moderate symptoms of withdraw Intensive Outpatient
al that are not likely to be severe or life Treatment [SAMHSA
threatening and that do not require 24hour disorder (in
in development d].
medical support. The transition from an
acute care inpatient program to either a par addition to
tial hospitalization or intensive outpatient Acute Care
program sometimes is referred to as a “step Inpatient biomedical
down.” Typically, whether these programs
share space and staff with an acute care inpa Settings stabilization) is
tient program or are physically distinct from There are several
a hospital structure, they have close clinical types of acute care central to the
and/or administrative ties to hospital centers. inpatient settings.
Collaborative working relationships are indis They include mission of an
pensable in pursuing the goal of providing • Acute care general
patients with the most appropriate level of hospitals
care in the most costeffective setting.
intensive out
• Acute care addic
tion treatment units patient or partial
Staffing in acute care gener
al hospitals hospitalization
IOPs and PHPs should be staffed by physi
cians who are available daily as active mem • Acute care psychi
bers of an interdisciplinary team of appropri atric hospitals program.
ately trained professionals and who medically • Other appropriately
manage the care of the patient. An RN or licensed chemical
other licensed and credentialed nurse should dependency special
be available for primary nursing care and ty hospitals
observation during the treatment day.
Addiction counselors or licensed or registered These settings share the ready availability of
addiction clinicians should be available to acute care medical and nursing staff, life sup
administer planned interventions according to port equipment, and ready access to the full
the assessed needs of the patient. The multi resources of an acute care general hospital or
disciplinary professionals (such as physicians, its psychiatric unit. This level of care provides
nurses, counselors, social workers, psycholo medically managed intensive inpatient detoxifi
gists, and acupuncturists) should be available cation (ASAM 2001).
Settings, Levels of Care, and Patient Placement 19
Level of care in the field, outpatient detoxification is becom
ing the standard for treatment of symptoms of
Acute inpatient care is an organized service withdrawal from substance dependence in
that provides medically monitored inpatient many locales. Most alcohol treatment programs
detoxification that is delivered by medical and have found that more than 90 percent of
nursing professionals. Medically supervised patients with withdrawal symptoms can be
evaluation and withdrawal management in a treated as outpatients (Abbott et al. 1995).
permanent facility with inpatient beds is pro Careful screening of these patients is essential
vided for patients whose withdrawal signs and to reserve for inpatient treatment those clients
symptoms are sufficiently severe to require 24 with possibly complicated withdrawal; for
hour inpatient care. Services should be deliv example, patients with subacute medical or
ered under a set of policies and procedures or psychiatric conditions (that in and of them
clinical protocols designated and approved by a selves would not require hospitalization) and
qualified physician (ASAM 2001). those in danger of seizures or delirium tremens
should receive inpatient care. Inpatient addic
Staffing tion treatment programs will vary in the level
of acute medical or psychiatric care that can be
Acute care inpatient detoxification programs provided. Figure 21 presents an overview of
typically are staffed by physicians who are issues to consider in deciding between inpatient
available 24 hours a day as active members of and outpatient detoxification.
an interdisciplinary team of appropriately
trained professionals and who medically man ASAM criteria are being adopted extensively
age the care of the patient. In some States, on the basis of their “face validity,” though
these duties may be performed by an RN or their outcome validity has yet to be clinically
physician assistant. An RN or LPN, as usual, is proven. Early studies of more versus less
available for primary nursing care and obser restrictive and intensive treatment settings on
vation 24 hours a day. Facilityapproved addic randomized samples generally have failed to
tion counselors or licensed or registered addic show group differences, and studies continue
tion clinicians should be available 8 hours a to show this pattern (Gastfriend et al. 2000).
day to administer planned interventions Whether patients undergoing detoxification
according to the assessed needs of the patient. will have better results as outpatients rather
An interdisciplinary team of appropriately than as inpatients remains to be established
trained clinicians (such as physicians, nurses, (Hayashida 1998).
counselors, social workers, and psychologists)
should be available to assess and treat the Another consideration is that ASAM place
patient with a substancerelated disorder, or a ment guidelines are not always the best guide
patient with cooccurring substance use, to placing a patient in the proper setting at
biomedical, psychological, or behavioral condi the proper level. For example, what is the
tions (ASAM 2001). clinician to do with the patient who qualifies
for outpatient treatment according to the
ASAM guidelines but is homeless in subzero
Other Concerns temperatures? No provision is made for such
cases. The ASAM guidelines are to be regard
Regarding Levels of ed as a “work in progress,” as their authors
Care and Placement readily admit (ASAM 2001, p. 19).
Nevertheless, they are an important set of
In part because of the need to keep costs to a guidelines that are of great help to clinicians.
minimum and in part as the result of research For administrators, the standards published
20 Chapter 2
Figure 21
Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred
Considerations Indications
Ability to arrive at clinic on a daily basis Necessary if outpatient detoxification is to be car
ried out
History of previous delirium tremens or withdraw Contraindication to outpatient detoxification:
al seizures recurrence likely; specific situation may suggest
that an attempt at outpatient detoxification is pos
sible
No capacity for informed consent Protective environment (inpatient) indicated
Suicidal/homicidal/psychotic condition Protective environment (inpatient) indicated
Able/willing to follow treatment recommendations Protective environment (inpatient) indicated if
unable to follow recommendations
Cooccurring medical conditions Unstable medical conditions such as diabetes,
hypertension, or pregnancy: all relatively strong
contraindications to outpatient detoxification
Supportive person to assist Not essential but advisable for outpatient detoxifi
cation
Source: Consensus Panelist Sylvia Dennison, M.D.
by such groups as JCAHO and CARF offer episode should provide an opportunity for
guidance for overall program operations. biomedical (including psychiatric) assess
ment, referral for appropriate services, and
It has become clear that detoxification linkage to treatment services. Chapter 3 pro
involves much more than simply medically vides an overview of the psychosocial and
withdrawing a patient from alcohol or other biomedical issues relevant to detoxification,
drugs. Detoxification, whether done on an strategies to engage the patient, and an
inpatient, residential, or outpatient basis, fre overview of providing adequate linkage to fol
quently is the initial therapeutic encounter low up treatment and services.
between patient and clinician. Irrespective of
the substance involved, a detoxification
Settings, Levels of Care, and Patient Placement 21
3 An Overview of
Psychosocial and
Biomedical Issues
In This
During Detoxification
Chapter…
Evaluating and
Addressing
Regardless of setting or level of care, the goals of detoxification are to
provide safe and humane withdrawal from substances and to foster
Psychosocial and
the patient’s entry into longterm treatment and recovery.
Biomedical Issues
Detoxification presents a unique opportunity to intervene during a
Strategies for
period of crisis and move a client to make changes in the direction of
Engaging and
health and recovery. Hence, a primary goal of the detoxification staff
should be to build the therapeutic alliance and motivate the patient to
Retaining Patients
enter treatment. This process should begin even as the patient is being
in Detoxification
medically stabilized (Onken et al. 1997).
Referrals and
Psychological dependence, cooccurring psychiatric and medical con
Linkages
ditions, social supports, and environmental conditions critically influ
ence the probability of successful and sustained abstinence from sub
stances. Research indicates that addressing psychosocial issues during
detoxification significantly increases the likelihood that the patient
will experience a safe detoxification and go on to participate in sub
stance abuse treatment. Staff members’ ability to respond to patients’
needs in a compassionate manner can make the difference between a
return to substance abuse and the beginning of a new (and more posi
tive) way of life.
This chapter addresses the psychosocial and biomedical issues that may
affect detoxification and ensuing treatment. It highlights evaluation pro
cedures for patients undergoing detoxification, discusses strategies for
engaging and retaining patients in detoxification and preparing them for
treatment, and presents an overview for providing linkages to other
services.
23
Overarching Principles for Care During
Detoxification Services
• Detoxification services do not offer a “cure” for substance use disorders. They often are a first step
toward recovery and the “first door” through which patients pass to treatment.
• Substance use disorders are treatable, and there is hope for recovery.
• Substance use disorders are brain disorders and not evidence of moral weaknesses.
• Patients are treated with respect and dignity at all times.
• Patients are treated in a nonjudgmental and supportive manner.
• Services planning is completed in partnership with the patient and his or her social support network,
including such persons as family, significant others, or employers.
• All health professionals involved in the care of the patient will maximize opportunities to promote rehabili
tation and maintenance activities and to link her or him to appropriate substance abuse treatment imme
diately after the detoxification phase.
• Active involvement of the family and other support systems while respecting the patient’s rights to privacy
and confidentiality is encouraged.
• Patients are treated with due consideration for individual background, culture, preferences, sexual orien
tation, disability status, vulnerabilities, and strengths.
Evaluating and General Guidelines for
Addressing Addressing Immediate
Medical Concerns
Psychosocial and Because substance abuse affects all systems of
Biomedical Issues the body and is associated with lack of self
Patients entering detoxification are undergoing care, it is not unusual for detoxification to be
profound personal and medical crisis. complicated by medical problems. Health pro
Withdrawal itself can cause or exacerbate cur fessionals should screen for medical problems
rent emotional, psychological, or mental prob that may put the client at risk for a medical cri
lems. The detoxification staff needs to be sis or expose other clients or staff to contagious
equipped to identify and address potential diseases. This section outlines important con
problems. siderations for both nonmedical and medical
staff. Chapter 5 provides a clinical overview of
cooccurring medical conditions and is geared
Considerations for Conducting primarily toward medical personnel.
the Initial Evaluation
An initial evaluation will help detoxification Cooccurring medical
staff foresee any variables that might compli conditions
cate a safe and effective withdrawal. Figure 31
lists the biomedical and psychosocial domains The initial consultation should include an eval
that can affect the stabilization of the patient. uation of the expected signs, symptoms, and
severity of the withdrawal. Detoxification is not
The following sections include some general an exact science, but any significant deviation
guidelines and important considerations to from the expected course of withdrawal should
follow when providing detoxification services. be observed closely. Figure 32 (p. 26) provides
24 Chapter 3
Figure 31
Initial Biomedical and Psychosocial Evaluation Domains
Biomedical Domains
• General health history—What is the patient’s medical and surgical history? Are there any psychi
atric or medical conditions? Are there known medication allergies? Is there a history of seizures?
• Mental status—Is the patient oriented, alert, cooperative? Are thoughts coherent? Are there signs of
psychosis or destructive thoughts?
• General physical assessment with neurological exam—This will ascertain the patient’s general health
and identify any medical or psychiatric disorders of immediate concern.
• Temperature, pulse, blood pressure—These are important indicators and should be monitored
throughout detoxification.
• Patterns of substance abuse—When did the patient last use? What were the substances of abuse?
How much of these substances was used and how frequently?
• Urine toxicology screen for commonly abused substances.
• Past substance abuse treatments or detoxification—This should include the course and number of
previous withdrawals, as well as any complications that may have occurred.
Psychosocial Domains
• Demographic features—Gather information on gender, age, ethnicity, culture, language, and educa
tional level.
• Living conditions—Is the patient homeless or living in a shelter? What is the living situation? Are sig
nificant others in the home (and, if so, can they safely supervise)?
• Violence, suicide risk—Is the patient aggressive, depressed, or hopeless? Is there a history of vio
lence?
• Transportation—Does the patient have adequate means to get to appointments? Do other arrange
ments need to be made?
• Financial situation—Is the patient able to purchase medications and food? Does the patient have
adequate employment and income?
• Dependent children—Is the patient able to care for children, provide adequate child care, and
ensure the safety of children?
• Legal status—Is the patient a legal resident? Are there pending legal matters? Is treatment court
ordered?
• Physical, sensory, or cognitive disabilities—Does the client have disabilities that require considera
tion?
a list of signs and symptoms of conditions that Seizures are of special concern. Practitioners
require immediate medical attention. All staff should interview the patient and family about
members who work with patients should be seizure disorders and seizure history. In addi
aware of these and seek medical consultation tion, nonmedical staff should be aware of signs
for the patients as necessary. of impending seizures such as tremors,
An Overview of Psychosocial and Biomedical Issues During Detoxification 25
Figure 32
Symptoms and Signs of Conditions That Require Immediate
Medical Attention
• Change in mental status
• Increasing anxiety and panic
• Hallucinations
• Seizures
• Temperature greater than 100.4° F (these patients should be considered potentially infectious)
• Significant increases and/or decreases in blood pressure and heart rate
• Insomnia
• Abdominal pain
• Upper and lower gastrointestinal bleeding
• Changes in responsiveness of pupils
• Heightened deep tendon reflexes and ankle clonus, a reflex beating of the foot when pressed rostrally
(i.e., toward the mouth of the patient), indicating profound central nervous system irritability and the
potential for seizures
increased blood pressure, overactive reflexes, HIV, viral hepatitis, abscesses, and sepsis (the
and high temperature and pulse. It is essential spreading of infection from its original site in
that nonmedical staff be trained in protocols to the body). Intrapulmonary (within the lungs)
prevent injury in the event of a seizure. administration can cause lung disorders
Competence in carrying out these protocols (Dackis and Gold 1991). Nonmedical detoxifi
should be evaluated by a physician or nurse cation staff also should be aware of the medi
clinician. For more information on seizures, cations used in detoxification, medications for
see chapter 4. common medical and psychiatric disorders,
and signs of common medication reactions
All staff working with patients should be and interactions.
familiar with medical disorders that are asso
ciated with various addictive substances or
routes of administration. Alcoholism has mul Infectious disease
tiple organ effects involving the liver, pan Standard precautions should be used with all
creas, central nervous system, cardiovascular patients to protect the staff and patients against
system, and endocrine system. Cocaine pro the transmission of infectious diseases, includ
duces many of its medical complications ing HIV and hepatitis A, B, and C. All open
through vasoconstriction (i.e., narrowing of wounds should be cultured and treated to pre
the blood vessels), including myocardial vent the spread of infections. Providers should
infarction (heart attack), stroke, renal dis use HIV/blood and respiratory infection pre
ease, spontaneous abortion, and even bowel cautions until HIV and respiratory infectious
infarction (death of tissue). Cocaine also can status are known. Patients with respiratory
cause seizures and cardiac arrhythmia (irreg infections should be carefully evaluated. The
ular heartbeat). A heroin overdose can lead panel suggests that tuberculin testing be per
to a fatal respiratory depression. Intravenous formed or recent test results obtained on all
drug use is particularly likely to increase the patients to screen for active tuberculosis. A
risk of infectious complications, including chest xray is recommended if indicated by the
26 Chapter 3
patient’s history and physical assessments. important, when interacting with patients at
Nonmedical detoxification staff should be risk for suicide, staff should avoid harsh con
trained to watch for the signs of common infec frontation and judgment and instead focus on
tious diseases passed through casual contact, the treatable nature of substance use disor
including infestation with scabies and lice. ders and the rehabilitation options available.
These interactions offer an opportunity to
start a dialog with the patient regarding the
General Guidelines for impact of substance use on mental illness and
Addressing Immediate Mental vice versa.
Health Needs
The following section provides general guide Anger and aggression
lines for treating patients who have immediate Alcohol, cocaine, amphetamine, and hallu
mental health needs. For more detailed infor cinogen intoxication may be associated with
mation on the treatment of patients with co increased risk of violence. Symptoms associ
occurring psychiatric conditions see TIP 42, ated with this increased risk for violence
Substance Abuse Treatment for Persons With include hallucinations, paranoia, anxiety, and
CoOccurring Disorders (Center for depression. As a precaution, all patients who
Substance Abuse Treatment [CSAT] 2005c). are intoxicated should be considered poten
tially violent (Miller et al. 1994). Programs
Suicide should have in place welldeveloped plans to
promote staff and patient safety, including
Those who are users of multiple illicit sub protocols for response by local law enforce
stance are more likely to experience psychiatric ment agencies or security contractors. Staff
disorders, and the risk is highest among those working in detoxification programs should be
who use both opiates and benzodiazepines trained in techniques to deescalate anger and
and/or alcohol (Marsden et al. 2000). aggression. In many cases, aggressive behav
Depression is more common among those who iors can be defused through verbal and envi
abuse a combination of these substances, and ronmental means (Reilly and Shopshire
women are at higher risk than men. Among 2002). For the protection of the staff and the
those patients who are positive for depression, patient, physical restraint should be used as a
the risk of suicide is high. Marsden and col last resort and programs should be aware of
leagues’ 2000 study of 1,075 clients entering local laws and regulations pertaining to physi
treatment showed that 29 percent reported sui cal restraint. Figure 33 (p. 28) lists some use
cidal ideation in the past 3 months. ful ways of managing patients who are angry
During acute intoxication and withdrawal, it and aggressive. Readers may refer to the
is important to provide an environment that standards published by such groups as the
minimizes the opportunities for suicide Joint Commission on Accreditation of
attempts. As a precaution, locations not Healthcare Organizations (JCAHO) and the
clearly visible to staff should be free of items Commission on Accreditation of
that might be used for suicide attempts. Rehabilitation Facilities (CARF) for further
Frequent safety checks should be implement guidance. The Substance Abuse and Mental
ed; the frequency of these checks should be Health Services Administration (SAMHSA)
increased when signs of depression, shame, also has published guidelines on the use of
guilt, helplessness, worthlessness, and hope seclusion and restraint, which call for the
lessness are present. When feasible, patients reduction and possible elimination of their
at risk for suicide should be placed in areas use (SAMHSA 2002).
that are easily monitored by staff. Most
An Overview of Psychosocial and Biomedical Issues During Detoxification 27
Figure 33
Strategies for Deescalating Aggressive Behaviors
• Speak in a soft voice.
• Isolate the individual from loud noises or distractions.
• Provide reassurance and avoid confrontation, judgments, or angry tones.
• Enlist the assistance of family members or others who have a relationship of trust.
• Offer medication when appropriate.
• Separate the individual from others who may encourage or support the aggressive behaviors.
• Enlist additional staff members to serve as visible backup if the situation escalates.
• Have a clearly developed plan to enlist the support of law enforcement or security staff if necessary.
• Establish clear admission protocols in order to help screen for potentially aggressive/violent patients.
• Determine one’s own level of comfort during interaction with the patient and respect personal limits.
• Ensure that neither the clinician’s nor the patient’s exit from the examination room is blocked.
Cooccurring mental General Guidelines for
disorders Addressing Nutritional
With the patient’s consent, a review of the Concerns
patient’s mental health history with the patient Malnutrition is a major concern for patients
and family is useful in identifying cooccurring entering detoxification because the nutrient
psychiatric conditions. Mental health profes deficiencies associated with substance abuse
sionals caring for the client should be consult can interfere with or even prolong the detoxifi
ed. If a pharmacy profile on the patient is cation process (Nazrul Islam et al. 2001).
available, it should be copied for review (within Longstanding irregular eating habits and poor
the confines of State and Federal confidentiali dietary intake only exacerbate the problem
ty laws). (Pelican et al. 1994). The detoxification process
Diagnosis of cooccurring substancerelated itself is stressful to the body and may result in
disorders and mental conditions is difficult increased nutrient requirements. Proper nutri
during acute intoxication and withdrawal tion during recovery improves to a significant
because it often is impossible to be precise until extent the adverse effects of the substance
the clinical picture allows for the full assess abuse (Nazrul Islam et al. 2001).
ment of both the effects of substance use and of
the symptoms of mental disorders. As the indi Nutritional evaluation
vidual moves from severe to moderate with
drawal symptoms, attention to differential An evaluation of nutritional status should be a
diagnosis of substance use disorders and other core component of detoxification. It should be
psychiatric disorders becomes a priority (First noted, however, that for patients who abuse
et al. 2002). The American Psychiatric alcohol, the administration of fluids to address
Association (APA) and the American Society of dehydration should be the first step, with
Addiction Medicine (ASAM) guidelines recom nutritional evaluation occurring after the
mend a period of 2 to 4 weeks of abstinence patient is adequately hydrated.
before attempting to diagnose a psychiatric dis
order (APA 2000; ASAM 2001).
28 Chapter 3
The nutritional evaluation should consist of with a substance use disorder may lead to dras
laboratory and anthropometric indices, a tic mood changes. When blood glucose levels
detailed nutritional history, and nutrition drop below a certain threshold, these patients
counseling (Simko et al. 1995). The interven usually feel depressed, anxious, or moody and
tion begins in the initial acute phase of with may experience cravings for their drug of
drawal and continues through detoxification choice.
and subsequent substance abuse treatment. If
the patient consents, family members or signifi
cant others may be included in the nutritional Nutritional deficits
evaluation and counseling. associated with specific
Weight is an important consideration in deter substances
mining the nutritional status of the person with As noted, the abuse of drugs can interfere with
a substance use disorder. Substance abuse may nutrient utilization and storage. Detoxification
result in a reduction in food intake and disrup personnel should be familiar with the nutrition
tion in the patient’s metabolism that may in al deficits associated with specific substances.
turn have caused an eating disorder, weight Opioids are known to decrease calcium absorp
loss, and malnutrition. Conversely, weight gain tion and to increase cholesterol and body
may be related to inactivity and an excessive potassium levels. Magnesium deficiency often is
intake of highly refined carbohydrates (Zador seen in chronic alcohol dependence. Other
et al. 1996). Patients should be asked whether nutrient deficiencies seen in alcohol abuse
there have been any recent changes in their include protein, fat, zinc, calcium, iron, vita
weight. While a patient may appear to be ade mins A and E, and the watersoluble vitamins
quately nourished, a skinfold caliper (an pyridoxine, thiamine, folate, and vitamin B12
instrument that measures the thickness of a (Nazrul Islam et al. 2001). Alcohol also con
fold of skin with its underlying layer of fat) can tains calories (7 kcal/gm) that when consumed
determine body density (the relationship of the in excessive amounts may displace nutrient
body’s mass to its volume), though the body dense foods. Cocaine is an appetite suppressant
mass index may be a better indicator of nutri and may interfere with the absorption of calci
tional status (Simko et al. 1995). um and vitamin D. Laboratory tests for pro
tein, vitamins, and iron and the other elec
Other questions to ask during the initial evalu trolytes are recommended to determine the
ation concern appetite, eating patterns, food extent of liver function as well as supplementa
preferences, snacking habits, food allergies, tion (Fontaine et al. 2001). Caution should be
food intolerance, special diets, and foods to be exercised when using supplements because of
avoided because of cultural or religious beliefs. their potential interactions with other drugs
A food frequency questionnaire, food diary, or and treatments.
24hour food recall may be of use.
Many drug addictions are associated with Addressing nutritional
abnormal glucose (sugar) metabolism. This
abnormality means that the body is unable to
deficits
maintain a stable concentration of glucose in Detoxification should include efforts to address
the blood. Abnormally high or low blood sugar nutritional deficits and to begin the patient on
levels easily can be confused with the signs and a course of improved eating habits. It is crucial
symptoms of alcohol intoxication or withdraw to switch the paradigm from ingesting sub
al; consequently, a check of blood glucose level stances harmful to the body to taking in foods
is particularly important in patients with a his that heal the body (Nebelkopf 1981, 1987,
tory of blood sugar abnormalities. Hypogly 1988). The regularity of meal times, taste, and
cemia (low levels of blood sugar) in the person presentation are important considerations.
An Overview of Psychosocial and Biomedical Issues During Detoxification 29
Attractively arranged, pleasanttasting food milk products and eggs). If a vegan enters
may inspire the patient to consume vital nutri detoxification with marginal or low nutrient
ents and adequate calories. It is important that stores, his or her diet should be augmented
during the detoxification process, the patient with legumes, meat analogs, textured vegetable
avoid substituting one addiction for another. protein, nuts, and seeds. Many other medical
Consuming excessive amounts of caffeine or conditions (e.g., ulcers, heart disease, food
sugar can compromise the process and lead to allergies, etc.) may require special diets. At
relapse. Patients should be offered only decaf intake, any special dietary considerations
feinated beverages and healthful snacks instead should be noted.
of refined carbohydrates such as sugarbased
sweets like candy, cookies, or donuts. Fresh
fruits, vegetables, and other whole foods can Considerations for
contribute to the individual’s health and well Intoxication and Withdrawal
ness. in Adolescents
Gastrointestinal disturbances (i.e., nausea, Generally, detoxification is the same for adoles
vomiting, and diarrhea) may accompany the cents as it is for adult clients. However, there
first phase of detoxification. Such distur are a few important and unique considerations
bances can worsen dehydration and may dis for adolescent patients. For one, adolescents
turb blood chemistry balance, which in turn are more likely than adults to drink large
can lead to mental status changes, neurologi quantities of alcohol in a short period of time,
cal or heart problems, and other potentially making it is especially important that detoxifi
dangerous medical conditions. Patients with cation providers be alert to escalating blood
gastrointestinal disturbances may only be alcohol levels in these patients. Moreover, ado
able to tolerate clear liquids. When solid lescents are more likely than adults to use
foods are tolerated, balanced meals consisting drugs they cannot identify, to combine multiple
of lowfat foods, with an increased intake of substances with alcohol, to ingest unidentified
protein (meat, dairy products, legumes), com substances, and to be unwilling to disclose drug
plex carbohydrates (whole grain bread and use (Westermeyer 1997). As a result, the con
cereals), and dietary fiber are recommended sensus panel recommends routinely screening
(Duyff 1996). Patients undergoing detoxifica adolescent patients for illicit drug intoxication.
tion may also experience constipation. It also is important for staff to be trained in
Increasing the fiber content of the diet will how to assess for the use of PCP, which can
help to alleviate this discomfort. present with psychosislike symptoms. Staff
should ask the adolescent directly whether he
has used PCP within the 12hour period before
Considerations for patients entering the clinic or treatment center.
with special dietary
Adolescents should be placed in a secure,
requirements clean environment with observation and sup
Patients with special dietary requirements need portive care. If alcohol, heroin, or other
additional nutrition therapy. A person with drugs associated with vomiting are suspected,
diabetes, for example, should follow the dietary protecting the individual’s airway and posi
guidelines of the American Diabetes tioning the patient on his or her side to avoid
Association, which emphasizes individualized aspiration (inhaling) of stomach contents are
meal planning (American Diabetes Association critical. In severe cases of ingestion of respi
2004). A patient who is a vegetarian may have ratory depressants, respiratory support may
additional nutritional deficiencies, especially if be needed. If the individual is severely com
she or he is a vegan (i.e., a person who avoids bative or belligerent, physical restraint may
eating all foods derived from animals, including be needed as a last resort when allowed and
30 Chapter 3
appropriate. In milder cases, observation in a Considerations for Victims of
quiet, secure room with compassionate reas
surance may be sufficient. Additionally, ado
Domestic Violence
lescents served in adult settings should be While both men and women are victims of
separated from the adult population and domestic abuse, women’s substance use is asso
observed closely to ensure that they are not ciated with increased risk of intimate partner
victimized (i.e., verbally, physically, or sexu violence (Cunradi et al. 2002). Staff should
ally) by adult clients. Finally, adolescents in know the signs of domestic violence and be pre
detoxification settings should always be pared to follow proce
screened carefully for suicide potential and dures to ensure the
cooccurring psychiatric problems. safety of the patient.
It sometimes is challenging to establish rap If a patient discloses
port with adolescents, as their experience a history of domestic
Ensuring that
with adults may be marked by adverse conse violence, trained
quences. Asking openended questions and staff can help the
children have a
using street terminology for drugs and other victim create a long
expressions commonly used by teenagers can term safety plan or
be helpful both in establishing rapport and in make a proper refer safe place to stay
obtaining an accurate substance use history. ral. If a safety plan
For more information on working with ado is made or phone while their
lescents, see TIP 31, Screening and Assessing numbers for domes
Adolescents for Substance Use Disorders tic violence help are mothers are in
(CSAT 1999d), and TIP 32, Treatment of provided, related
Adolescents With Substance Use Disorders information should detoxificaton is of
(CSAT 1999f). be labeled carefully
so as not to disclose vital importance.
its purpose (e.g., list
Considerations for Patients ed as women’s health
Who Are Parents With resources) since the
Dependent Children abuser may go
through all personal
For parents—especially women—entering belongings. All print
detoxification programs, the safety of children ed information about domestic violence also
often is a concern and one of the biggest barri should be disguised and none should be kept
ers to retention. Even if women do not have by the patient when she leaves the safe facili
custody of their children they often are the ty. If the victim needs to press charges or
ones who continue to care for them. Some chil obtain a restraining order, this should be
dren may show extreme need for their mother done from a safe setting (e.g., inpatient detox
while separated from her, and their demands ification). If at all possible, the victim should
could trigger unauthorized leave from detoxifi be escorted to a safety shelter. It may be
cation. Thus, ensuring that children have a important that the abused person, whether
safe place to stay while their mothers are in male or female, not be allowed to talk to the
detoxification is of vital importance. Working abuser while in detoxification. Parents who
with women and men to identify supportive are victims of domestic violence may need
family or friends may identify temporary child help with parenting skills and securing coun
care resources. A consult or referral to the seling and childcare. Therefore, it is impor
treatment facility’s social services while the tant for detoxification providers to be famil
patient is being detoxified is indicated when the iar with local childcare resources. For more
care of children is uncertain.
An Overview of Psychosocial and Biomedical Issues During Detoxification 31
information see TIP 25, Substance Abuse of detoxification, their feelings about the
Treatment and Domestic Violence (CSAT healthcare system generally, and their social
1997b). and community support structures vary
according to their cultural backgrounds. In
working with any specific population, the prac
Considerations for Culturally titioner should avoid defining the patient in
Diverse Patients terms of his culture, since over or underem
In providing psychosocial supports for cultur phasizing the patient’s race or ethnicity can be
ally diverse patients, cultural sensitivity is of detrimental (Clark et al. 1998). Figure 34 pro
tremendous importance. Clients’ expectations
Figure 34
Questions To Guide Practitioners To Better Understand the Patient’s
Cultural Framework
• What language do you prefer we use?
• Therapists and clients sometimes have different ideas about diseases, can you tell me more about
your idea of why you are in detoxification now?
• Do you require assistance for daily living activities (such as personal hygiene, shopping, paying bills,
etc.)?
• What do you call your present condition/situation (as it relates to substance use)? How does your
family view your present condition/situation (as it relates to substance use)?
• What is the role of alcohol or drugs in your family?
• How does your community view your present condition/situation (as it relates to substance use)? Or
what is the role of alcohol or drugs in your community?
• How has your present condition/situation (as it relates to substance use) altered your status in the
community?
• What experiences have you had with the healthcare system?
• Do you think your substance use is a problem for you?
• What do you think caused your present condition/situation (as it relates to substance use)?
• Why do you think it started?
• What is going on in your body?
• How has your present condition/situation (as it relates to substance use) altered your life?
• How have you tried to solve the problem(s) associated with substance use in the past? Was it helpful?
What worked/didn’t work?
• Why are you coming now?
• Are you on any herbal medications or special foods for this problem?
• What concerns or fears do you have about your present condition/situation (as it relates to substance
use)?
• What concerns or fears do you have about this treatment?
Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.
32 Chapter 3
vides clinicians with some helpful questions to Educate the Patient on the
guide their discussions.
Withdrawal Process
During intoxication and withdrawal, it is useful
Considerations for Chronic to provide information on the typical with
Relapsers drawal process based on the particular drug of
abuse. Usually withdrawal includes symptoms
A patient who recently relapsed after a period
that are the opposite of the effects of the partic
of extended abstinence may feel especially
ular drug. This rebound effect can cause anxi
hopeless and vulnerable (an abstinence viola
ety and concern for patients. Providing infor
tion effect). In this situation, clinicians can
mation about the common withdrawal symp
acknowledge progress that had been made
toms of the specific drugs of abuse may reduce
prior to relapse and reassure the patient that
discomfort and the likelihood that the individu
the internal gains from past recovery work
al will leave detoxification services prematurely
have not all been lost (despite the feeling at the
(for a list of withdrawal symptoms, see chapter
moment that they have), perhaps reframing the
4). Settings that routinely encounter individu
severity of emotional pain as an indicator of
als in withdrawal should have written materials
how important recovery is to the patient.
available on drug effects and withdrawal from
specific drugs, and have staff who are well
Strategies for versed in the signs and symptoms of withdraw
al. An additional consideration is providing
Engaging and such information to non–Englishspeaking
patients and their families.
Retaining Patients in
Detoxification Interventions that assist the client in identify
ing and managing urges to use also may be
It is essential to keep patients who enter detoxi helpful in retaining the client in detoxification
fication from “falling through the cracks” and ensuring initiation of rehabilitation.
(Kertesz et al. 2003). Successful providers These interventions may include cognitive–
acknowledge and show respect for the patient’s behavioral approaches that help the individu
pain, needs, and joys, and validate the al identify thoughts or urges to use, the devel
patient’s fears, ambivalence, expectation of opment of an individualized plan to resist
recovery, and positive life changes. It is essen these urges, and use of medications such as
tial that all clinicians who have contact with naltrexone to reduce craving (Anton 1999;
patients in withdrawal continually offer hope Miller and Gold 1994).
and the expectation of recovery. An atmo
sphere that conveys comfort, relaxation, clean
liness, availability of medical attention, and Use Support Systems
security is beneficial to patients experiencing The use of client advocates to intervene with
the discomforts of the withdrawal process. clients wishing to leave early often can be an
Throughout the detoxification experience, effective strategy for promoting retention in
detoxification staff should be unified in their detoxification. Visitors should be instructed
message that detoxification is only the begin about the importance of supporting the individ
ning of the substance abuse treatment process ual in both detoxification and substance abuse
and that rehabilitation and maintenance activi treatment. If available, and if the patient is sta
ties are critical to sustained recovery. ble, he or she can attend onsite 12Step or
other support group meetings while receiving
detoxification services. These activities rein
force the need for substance abuse treatment
An Overview of Psychosocial and Biomedical Issues During Detoxification 33
and maintenance activities and may provide a services goal of promoting initiation in reha
critical recoveryoriented support system once bilitation and maintenance activities. Use of
detoxification services are completed. these techniques in the detoxification setting
increases the likelihood that patients will seek
treatment by helping them understand the
Maintain a DrugFree adverse consequences of continued substance
Environment use. It also establishes a supportive and non
Maintaining a safe and drugfree environment judgmental relationship between the sub
is essential to retaining clients in detoxifica stance abuse counselor and the patient—this
tion. Providers should be alert to drugseek therapeutic alliance is an important factor in
ing behaviors, including bringing alcohol or the patient’s choice to seek treatment services
other drugs into the facility. Visiting areas (Miller and Rollnick 2002). TIP 35,
should be easy for the staff to monitor closely, Enhancing Motivation for Change in
and staff may want to search visiting areas Substance Abuse Treatment (CSAT 1999c),
and other public areas periodically to reduce covers specific interventions and techniques
the opportunities for acquiring substances. It to increase motivation to change substance
is important to note, however, that personnel related behaviors. TIP 35 also includes some
should be respectful in their efforts to main basic principles common to motivational
tain a drugfree environment. It is important interventions (CSAT 1999c, p. xvii):
to explain to patients (prior to treatment) and • Focus on the patient’s strengths.
visitors why substances are not allowed in the • Show respect for a patient’s decisions and
facility. autonomy; respect should be maintained
at all times, even when the patient is
intoxicated.
Consider Alternative
• Avoid confrontation.
Approaches
• Individualize treatment.
Alternative approaches such as acupuncture
are safe, inexpensive, and increasingly popular • Do not use labels that depersonalize the
in both detoxification and substance abuse patient, such as “addict” or “alcoholic.”
treatment. Although the effectiveness of alter • Empathize with the patient, making an
native treatments in detoxification and treat attempt to understand the patient’s perspec
ment has not been validated in wellcontrolled tive and accept his or her feelings.
clinical trials, if an alternative therapy brings • Accept treatment goals that involve small
patients into detoxification and keeps them steps toward ultimate goals.
there, it may have utility beyond whatever spe
• Assist the patient in developing an awareness
cific therapeutic value it may have
of discrepancies between her or his goals or
(Trachtenberg 2000). Other treatments that
values and current behavior.
reside outside the Western biomedical system,
typically grouped together under the heading of • Listen reflectively to the patient’s immediate
Complementary or Alternative Medicine, also concerns and ask openended questions.
may be useful for retaining patients. Indeed,
In addition, the detoxification team can lever
given the great cultural diversity in the United
age the relationship the patient has with sig
States, other culturally appropriate practices
nificant others. Using interventions such as
should be considered.
Community Reinforcement and Family
Training (CRAFT) (Miller et al. 1999), the
Enhancing Motivation detoxification team can help significant others
in the patient’s life capitalize on moments
Motivational enhancements are particularly
when the patient is ready for change and
wellsuited to accomplishing the detoxification
34 Chapter 3
assist the patient in preparing for change in a transtheoretical model, also known as the
nonthreatening, nonconfrontational manner. stages of change model (DiClemente and
The consensus panel does not recommend Prochaska 1998). The interventions to
that clinicians use direct confrontation in increase patient motivation for substance
helping a person with a substance use disor abuse treatment described in TIP 35,
der begin the process of detoxification and Enhancing Motivation for Change in
subsequent substance abuse treatment. Substance Abuse
Techniques that involve purposefully con Treatment (CSAT
fronting patients about their substance use 1999c) are based on
behavior, such as the Johnson Intervention, this model.
where significant others are taught to con
front the individuals using substances According to the
Clinicians,
(Liepman 1993), have been shown to be high model, a client is
ly effective when significant others implement considered to be at
one of five stages of groups, and
them. However, subsequent studies of clini
cians, groups, and programs that rely on con readiness to change
his substanceabus programs that
frontational techniques have yielded poor
outcomes (Miller et al. 1995). Moreover, the ing behavior, each
vast majority of significant others do not wish stage being progres rely on
to use these techniques, and for that reason sively closer to sus
these techniques are not recommended (Miller tained recovery. confrontational
et al. 1999). Those stages are pre
contemplation, con techniques have
Care should be taken to ensure that any sig templation, prepara
nificant other who is involved in motivating tion, action, and yielded poor
the patient for therapy is appropriate for this maintenance. The
task. Only significant others who have been model assumes that
appropriately introduced to the intervention individuals may
outcomes.
by a clinician should participate. The pres move back and forth
ence of a trained facilitator is recommended, between different
either for coaching or for facilitating the stages over time. A
intervention. It also is important to have the corollary to this
recommended treatment option readily avail assumption is that an
able so if the patient agrees, admission can be individual’s level of motivation is definitely
swift and seamless. Those individuals selected not a permanent characteristic. Rather, moti
to intervene should support the patient’s vation to change can be influenced by others,
abstinence from substances of abuse. including detoxification treatment staff.
Furthermore, if the patient places consider
able value on her or his relationships with In general, the basic concept is to try to move
these significant others, success is more likely patients to the next stage of change. The clini
(Longabaugh et al. 1993). cian needs to identify any potential obstacles
that might hinder the patient’s progress
through the stages of change. The transtheo
Tailoring Motivational retical model is illustrated in Figure 35
Intervention to Stage of (p. 36) and the details of each stage are
described in the text below.
Change
Perhaps the most wellknown and empirically
validated model of “readiness to change” that
has been applied to substance abuse is the
An Overview of Psychosocial and Biomedical Issues During Detoxification 35
Figure 35
The Transtheoretical Model (Stages of Change)
Source: DiClemente and Prochaska 1998.
36 Chapter 3
spective, and keep the door open for further cal that the clinician respond quickly to any
communication regarding treatment options. requests for treatment to capitalize on this
motivation before it wanes. One of the most
In the contemplation stage, the individual has critically important roles the clinician can
some awareness that substance use presents a play in this stage is to assist the patient in
problem. In this stage, the patient may developing a plan of action or a behavioral
express a desire or willingness to change, but contract, taking into account the individual
has no definite plans to do so in the near needs of the patient. As part of this process
future, which generally is considered to be the clinician should help the patient enlist
the next 2 to 6 months. Whether it is explicit social support. Exploring the patient’s expec
ly stated or not, it is thought that most indi tations regarding treatment and her role in it
viduals in this stage are ambivalent about is important. Finally, because of the common
changing. That is, sidebyside with any ly experienced difficulty in accessing treat
desire to change is a desire to continue the ment, the clinician should discuss with the
current behavior. For patients in the contem patient ways of maintaining motivation for
plation stage, clinicians are advised to use change during a possible wait for entry into a
“decisional balancing strategies” to help the treatment program, should the patient be
patient move to the action stage (Carey et al. placed, for example, on a waiting list.
1999). In this approach, the clinician helps
the patient to consider the positive and nega In the action stage, the patient is taking
tive aspects of her substance abuse and has active steps to change substance use behav
the patient weigh them against each other iors. This includes making modifications to
with the expectation that the scale of balance his habits and environment, such as not
tips in favor of adopting new behavior. spending time in places or with people associ
Psychoeducation on the interaction of sub ated with drug taking behavior. These
stance abuse with other problems, including changes may even continue to be made 3 to 6
health, legal, employment, parenting, and months after substance abuse has ceased.
mental illness, can be part of this procedure.
Helping the patient understand that ambiva In the maintenance stage, the patient is work
lent feelings about changing substance use ing to maintain the changes initiated in the
behaviors are normal and expected can be action phase.
particularly useful at this stage.
In the preparation stage, the patient is aware Fostering a Therapeutic
that his substance use presents a significant Alliance
problem and desires change. Moreover, the The therapeutic alliance refers to the quality of
patient has made a conscious decision to com the relationship between a patient and his care
mit himself to a behavior change. This stage is providers and is the “nonspecific factor” that
defined as one in which the individual pre predicts successful therapy outcomes across a
pares for the upcoming change in specific variety of different therapies (Horvath and
ways, such as deciding whether a formal Luborsky 1993). A therapeutic alliance should
treatment program is needed and, if so, which be developed in the context of an ability to
one. This stage is characterized by goal set form an alliance to a group of helping individu
ting and making commitments to stop using, als—such as a healthy support network or
such as informing coworkers, friends, and therapeutic community. A clinically appropri
family of treatment plans. For patients in the ate relationship between the clinician and
preparation stage, clinicians should elicit the patient that is supportive, empathic, and non
patient’s goals and strategies for change and judgmental is the hallmark of a strong thera
be on the alert for signs that the patient is peutic alliance.
ready to move into the action stage. It is criti
An Overview of Psychosocial and Biomedical Issues During Detoxification 37
Readiness to change predicts a positive thera recovery is difficult. He also advises being
peutic alliance (Connors et al. 2000). Strong consistent, dependable, trustworthy, and
alliances, in turn, have been associated with available, even when the patient is not. The
positive outcomes in patients who are depen clinician should remain calm and cool even if
dent on alcohol (Connors et al. 1997), as well the patient becomes noticeably upset.
as patients involved in methadone mainte Practitioners should be confident yet humble
nance, on such measures as illicit drug use, and should set limits in a respectful manner
employment status, and psychological func without engaging in a power struggle. See
tioning. In addition, the practitioner’s exper Figure 36 for a list of characteristics most
tise and competence instill confidence in the valuable to a clinician in strengthening the
treatment and strengthen the therapeutic therapeutic alliance.
alliance. Emphasis also should be given to the
alliance with a social support network, which
can be a powerful predictor of whether the Referrals and Linkages
patient stays in treatment (Luborsky 2000). Once an individual passes through the most
Given the importance of the therapeutic severe of the withdrawal symptoms and is safe
alliance and the fact that detoxification often and medically stable, the focus of the psychoso
is the entry point for patients into substance cial interventions shifts toward actively prepar
abuse treatment services, work on establish ing her for substance abuse treatment and
ing a therapeutic alliance ideally will begin maintenance activities. These interventions
upon admission. Many of the guidelines listed include (1) assessment of the patient’s charac
above for enhancing motivation apply to teristics, strengths, and vulnerabilities that will
establishing this rapport. Newman (1997) influence recommendations for substance
makes some additional recommendations for abuse treatment; (2) preparing the patient to
developing the therapeutic alliance, such as participate in treatment; and (3) successfully
discussing the issue of confidentiality with linking the patient to treatment as well as other
patients and acknowledging that the road to needed services and resources.
Figure 36
Clinician’s Characteristics Most Important to the Therapeutic Alliance
• Is supportive, empathic, and nonjudgmental
• Knows which patients can be engaged and which should be referred to another treatment provider
• Can establish rapport with any client
• Remembers to discuss confidentiality issues
• Acknowledges challenges on the road to recovery
• Is consistent, trustworthy, and reliable
• Remains calm and cool even when a client is upset
• Is confident but humble
• Sets limits without engaging in a power struggle
• Recognizes the client’s progress toward a goal
• Encourages selfexpression on the part of the client
38 Chapter 3
Ensuring that patients with substance use dis 5. Relapse, Continued Use, or Continued
orders enter substance abuse treatment fol Problem Potential
lowing detoxification often is difficult. Many 6. Recovery/Living Environment
patients believe that once they have eliminat
ed the substance or substances of abuse from Due to the limited time patients stay in detoxifi
their bodies, they have achieved abstinence. cation settings, it is challenging for programs to
Moreover, some insurance policies may not conduct a complete assessment of the rehabili
cover treatment, or only offer partial cover tation needs of the individual. With this in
age. The patient may have to go through cum mind, detoxification programs should focus on
bersome channels to determine if treatment is those areas that are essential to make an
covered, and if so, how much. appropriate linkage to substance abuse treat
ment services. The assessment of the psychoso
Preparation should focus on eliminating cial needs affecting the rehabilitation process
administrative barriers to entering substance itself may have to be left to the professionals
abuse treatment prior to discussing treatment providing substance abuse treatment. Other
options with the patient. Discussions with the assessment considerations include
patient should be consistent with the patient’s
• Special needs, such as cooccurring psychi
improving ability to process and assess infor
atric and medical conditions that may com
mation in such a way that the patient appears
plicate treatment or limit access to available
to be acting with his or her own interests in
rehabilitation services
mind.
• Pregnancy, physical limitations, and cogni
tive impairments that limit the settings suit
Evaluation of the Patient’s able for the individual
Rehabilitation Needs • Support system issues such as family sup
To make appropriate recommendations for port, domestic violence, and isolation that
ongoing treatment and recovery activities, influence recommendations about residen
detoxification staff need to determine the tial versus outpatient settings
individual characteristics of clients and their • The needs of dependent children
environments that are likely to influence the • The need for genderspecific treatment (for
level of care, setting, and specialized services more information see the forthcoming TIPs
needed for recovery. ASAM’s Patient Substance Abuse Treatment: Addressing
Placement Criteria, Second Edition, Revised the Specific Needs of Women [SAMHSA in
(PPC2R) (ASAM 2001) provides one widely development e] and Substance Abuse
used model for determining the level of ser Treatment: Men’s Issues [SAMHSA in
vices needed to address substancerelated dis development g]).
orders. The levels of treatment services range
from communitybased early intervention Figure 37 (p. 40) outlines the areas the consen
groups to medically managed intensive inpa sus panel recommends for assessment to deter
tient services. As noted in chapter 2, mine the most appropriate rehabilitation plan.
providers need to make a placement decision
based on six dimensions: Appendix C lists a variety of instruments use
ful in characterizing the addiction and related
1. Acute Intoxication and/or Withdrawal disorders (for example, the Addiction
Potential Severity Index [ASI]), measuring motivation
2. Biomedical Conditions and Complications al willingness to change (Stages of Change
3. Emotional, Behavioral, or Cognitive Readiness and Treatment Eagerness Scale
Conditions or Complications [SOCRATES] and University of Rhode Island
4. Readiness to Change Change Assessment [URICA]), and evaluating
cooccurring psychiatric conditions and social
An Overview of Psychosocial and Biomedical Issues During Detoxification 39
Figure 37
Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans
Domain Description
Medical Conditions and Infectious illnesses, chronic illnesses requiring intensive or specialized treat
Complications ment, pregnancy, and chronic pain
Motivation/Readiness to Degree to which the client acknowledges that substance use behaviors are a
Change problem and is willing to confront them honestly
Physical, Sensory, or Physical conditions that may require specially designed facilities or staffing
Mobility Limitations
Relapse History and Historical relapse patterns, periods of abstinence, and predictors of absti
Potential nence; client awareness of relapse triggers and craving
Substance Frequency, amount, and duration of use; chronicity of problems; indicators of
Abuse/Dependence abuse or dependence
Developmental and Ability to participate in confrontational treatment settings, and benefit from
Cognitive Issues cognitive interventions and group therapy
Family and Social Degree of support from family and significant others, substancefree friends,
Support involvement in support groups
CoOccurring Psychiatric Other psychiatric symptoms that are likely to complicate the treatment of the
Disorders substance use disorder and require treatment themselves, concerns about
safety in certain settings (note that assessment for cooccurring disorders
should include a determination of any psychiatric medications that the patient
may be taking for the condition)
Dependent Children Custody of dependent children or caring for noncustodial children and
options for care of these children during rehabilitation
Trauma and Violence Current domestic violence that affects the safety of the living environment, co
occurring posttraumatic stress disorder or trauma history that might compli
cate rehabilitation
Treatment History Prior successful and unsuccessful rehabilitation experiences that might influ
ence decision about type of setting indicated
Cultural Background Cultural identity, issues, and strengths that might influence the decision to
seek culturally specific rehabilitation programs, culturally driven strengths or
obstacles that might dictate level of care or setting
Strengths and Resources Unique strengths and resources of the client and his or her environment
Language Language or speech issues that make it difficult to communicate or require an
interpreter familiar with substance abuse
40 Chapter 3
and family factors. Administering these highly intensive substance abuse counseling
instruments requires varying degrees of and clients may participate in the upkeep of
sophistication on the part of the clinician. All facilities. Peer support is critical to the
instruments should be considered for their treatment delivered. As a general rule,
cultural, linguistic, level of cognitive compre patients will stay at a residential treatment
hension, and developmental appropriateness facility for 7 to 30 days.
for each patient. For further information on • Therapeutic communities (TCs) usually
patient placement see TIP 13, The Role and have 24hour supervision by nonmedical
Current Status of Patient Placement Criteria staff or clients who have sustained recov
in the Treatment of Substance Use Disorders ery. They tend to provide highly intensive
(CSAT 1995h). counseling services and rely on peer sup
port and confrontation to shape behaviors
Settings for Treatment of clients. The TC is based on concepts of
selfhelp. Residence in a TC is longer than a
Just as with settings for detoxification, set patient’s stay in a residential program—
tings where substance abuse treatment is pro patients usually stay for a period of at least
vided often are confused with the level of 30 days and often 6 months to a year. In
intensity of the services. It is increasingly some special situations, such as a criminal
clear that although level of intensity of ser justice setting, TC residence can last 2
vices and setting are both critical to success years or more.
ful recovery, they are two separate dimen
• Transitional residential programs and
sions to be considered when linking clients to
halfway houses ordinarily have 24hour
treatment. This process has been called “de
supervision from nonmedical staff or clients
linking” or “unbundling” and generally
who have sustained recovery. Patients in
involves determining the need for social ser
these programs often are working and par
vices independently from the clinical intensity
ticipate in counseling and peer support dur
(Gastfriend and McLellan 1997; McGee and
ing the evening and weekend hours.
MeeLee 1997).
• Partial hospitalization and day treatment
Treatment and maintenance activities are programs use a combination of medical and
offered in a variety of settings. These include nonmedical staff to deliver a high intensity
settings specifically designed to deliver sub of counseling services during daytime
stance abuse treatment, such as freestanding hours. Patients return home in the
substance abuse treatment centers, as well as evenings.
settings operating for other purposes, includ • Intensive outpatient programs usually are
ing mental health centers, jails and prisons, delivered by nonmedical staff in a clinic
and community corrections facilities. location. Patients receive 6 to 9 hours of
Descriptions of these settings appear below: counseling services each week in two or
• Inpatient programs for treatment of sub three contacts.
stance abuse generally are delivered in hos • Traditional outpatient services typically are
pitals and freestanding clinics and provide delivered by counselors in a clinic or office
24hour nursing care in addition to inten setting and provide fewer hours of services
sive treatment for substancerelated prob than the “intensive outpatient” programs.
lems.
• Recovery maintenance activities are not
• Residential treatment programs normally treatment but are highly valuable for ongo
provide 24hour supervision by nonmedical ing sobriety maintenance. They include 12
staff and the availability of medical staff Step and other support groups aimed at
may be limited. These programs deliver maintaining the gains accomplished in treat
An Overview of Psychosocial and Biomedical Issues During Detoxification 41
ment settings. Oxford House establishments behavioral health carveout and lower cost
and other “clean and sober” living environ sharing requirements are more likely to enter
ments are among the resources that clini treatment than those who do not (Mark et al.
cians should explore and perhaps incorpo 2003b). Kleinman and associates (2002) fol
rate in maintenance activities. lowed 279 opioid and cocainedependent
patients who had been in detoxification pro
Provide Linkage to Treatment grams to determine how many had entered
substance abuse treatment 30 days after leav
and Maintenance Activities ing the detoxification program. They found
Approximately half of those making an that those who were on parole, homeless, or
appointment for treatment do not appear for who had been using drugs for less than 20
their first appointment and another 20 per years were more likely than others to have
cent or more fail to appear for the second entered treatment.
appointment (Gottheil et al. 1997; Parker
2002). As patients near completion of detoxi Research indicates that patients are more
fication, whether they take the next step and likely to initiate and remain in rehabilitation
enter treatment is dependent on a number of if they believe the services will help them with
variables. Patients who are employed, are specific life problems (Fiorentine et al. 1999).
motivated beyond the precontemplation stage, Figure 38 suggests strategies that detoxifica
and have family and social support, as well as tion personnel can use with their patients to
those with cooccurring psychiatric condi promote the initiation of treatment and main
tions, are more likely to initiate treatment. tenance activities.
Conversely, those who have severe drug
dependence and those who are older are less
Provide Access to Wraparound
likely to follow through and enter treatment
(Kirchner et al. 2000; Weisner et al. 2001). Services
Women are more likely to initiate treatment Patients are more likely to engage in treatment
after detoxification than men, and individuals if they believe the full array of their problems
who have health insurance that features a
Figure 38
Strategies To Promote Initiation of Treatment and
Maintenance Activities
• Perform assessment of urgency for treatment.
• Reduce time between initial call and appointment.
• Call to reschedule missed appointments.
• Provide information about what to expect at the first session.
• Provide information about confidentiality.
• Offer tangible incentives.
• Engage the support of family members.
• Introduce the client to the counselor who will deliver rehabilitation services.
• Offer services that address basic needs, such as housing, employment, and childcare.
Source: Carroll 1997; Fehr et al. 1991.
42 Chapter 3
will be addressed, including those needs typi these programs includes more than a phone
cally addressed by wraparound services (e.g., number; detoxification staff should assist
housing, vocational assistance, childcare, patients in scheduling initial appointments
transportation) (Fiorentine et al. 1999). and arranging for transportation.
Moreover, patients receiving needed
wraparound services remain in substance Linkage to primary health and prenatal care
abuse treatment longer and improve more than as well as to community resources is essential
people who do not receive such services (Hser for individuals with substance use disorders.
et al. 1999). Linkages can be an effective mechanism to
assist the patient in accessing these services if
As the individual passes through acute intoxi they are not available as a part of the detoxi
cation and withdrawal, it is important to fication program. Formalized referral
ensure that the basic needs of the patient are arrangements through contracts or memoran
met after discharge. These needs include da of understanding can be useful to specify
access to a safe, stable, and drugfree living organizational obligations (D’Aunno 1997).
environment if possible; physical safety; food
and clothing; ongoing health and prenatal
care; financial assistance; and childcare. Minimize Access Barriers
Ensuring access to these basic needs may be An integral part of the process of linking an
problematic, and staff must be flexible and individual with rehabilitation and treatment
creative in finding the means to meet the resources is to address access barriers.
basic needs of the patient. Transportation, child care during treatment,
the potential for relapse between detoxification
Clearly, services planning should extend discharge and treatment admission, housing
beyond the issues of substance dependence to needs, and safety issues such as possible
other areas that may affect compliance with domestic violence should be addressed through
rehabilitation. Detoxification providers an individualized plan prior to discharge.
should be familiar with available resources
for legal assistance, dental care, support The problem of a patient’s placement on a
groups, interpreters, housing assistance, waiting list presents a special barrier to treat
trauma treatment, recoverysensitive parent ment. The solution lies in developing strate
ing groups, spiritual and cultural support, gies to maintain motivation for treatment dur
employment assistance, and other assistance ing the waiting period.
programs for basic needs. Family and other
support systems also can be helpful to the For pregnant women and patients with depen
patient in accessing services and should take dent children, the threat of Child Protective
part in the services planning as often as possi Services removing their children for abuse
ble, always with the patient’s consent. and neglect due to drug use can be a barrier
to entering a treatment program.
To address the needs of homeless and indigent
patients, detoxification providers should be Additionally, interacting with hostile or
familiar with emergency shelters, cash assis unfriendly practitioners and encountering
tance, and food programs in their communi resistance from family, partners, or friends
ties and should have established referral rela can be barriers to treatment entry.
tionships. Assessing women, teenagers, older
Detoxification staff should be knowledgeable
adults, and other vulnerable individuals for
about State laws regarding drug use during
victimization by another member of the
pregnancy and definitions of child abuse and
household also is important. Patients should
neglect in order to be able to reassure and
be linked with prenatal and primary health
encourage women to enter treatment.
care for domestic violence. Ideally, linkage to
An Overview of Psychosocial and Biomedical Issues During Detoxification 43
People who identify as having a physical or mental health and substance abuse treatment
cognitive disability also face special barriers for those with cooccurring conditions (Drake
to treatment. The reader is referred to TIP and Mueser 2000).
29, Substance Use Disorder Treatment for
People With Physical and Cognitive
Disabilities (CSAT 1998g) and TIP 36, Linkage to Ongoing
Substance Abuse Treatment for Persons With Psychiatric Services
Child Abuse and Neglect Issues (CSAT Although it is important to make referrals for
2000d), for more information on these topics. ongoing psychiatric attention, the presence of
For racial/ethnic minorities, access barriers psychological symptoms should not prevent
can be compounded by language, cultural, detoxification staff from referring patients to
and financial factors. The ability of programs substance abuse treatment. Individuals with
to develop culturally specific interventions, cooccurring psychiatric conditions appear to
train staff and interpreters to respond to the be able to initiate and benefit from substance
specific needs of these individuals, and be abuse treatment like individuals without psy
aware of cultural differences in the manifesta chiatric conditions (Joe et al. 1995).
tion of symptoms is critical to improving Since some psychiatric illnesses may affect
access to care. Supervision of staff and train drug cravings in patients who are substance
ing in crosscultural issues is equally impor dependent, it is important to ensure that both
tant to all programs serving diverse patient the psychiatric condition and the substance
populations. The forthcoming TIP Improving use disorder are addressed in rehabilitation
Cultural Competence in Substance Abuse (Anton 1999). Individuals who are taking psy
Treatment (SAMHSA in development a) con chotropic medications should be counseled
tains more information on this topic. about the importance of continuing on these
medications. Whenever possible, discharge
Use Case Management from the detoxification services should be
coordinated with the patient’s mental health
Case management presents an opportunity to provider in the community, and the patient
tailor services to individual client needs and should have an appointment scheduled at the
to minimize barriers to these services time of discharge from the detoxification
(Gastfriend and McLellan 1997). Case man facility. Detoxification providers should
agement is a set of services managed to assist request that the patient sign appropriate
the client in accessing needed resources. It is releases of information to provide assessment
a useful strategy to ensure that access to and other material to the mental health
wraparound services such as employment, provider to promote continuity of care. This
housing, health care, and basic needs are met should only occur when the patient is medi
along with minimizing barriers to accessing cally stabilized and is in such a state of mind
substance abuse treatment. As outlined in that he or she can make coherent decisions in
TIP 27, Comprehensive Case Management for this regard (e.g., while intoxicated, patients
Substance Abuse Treatment (CSAT 1998a), should not be permitted to sign releases).
the common functions of case management
are defined as assessment, planning, linkage, For individuals with serious cooccurring psy
monitoring, and advocacy. Case managers chiatric conditions, integrated treatment for
can facilitate the critical linkage between substance use disorders and mental illness is
detoxification services and rehabilitation by recommended. Case management services as
providing transportation to the rehabilitation described above may be especially important
facility, arranging for childcare, or assisting for individuals with severe mental illness
with housing needs. Additionally, case man impeding their ability to access services on
agement is a widely used strategy to integrate their own. Increasingly, substance abuse and
44 Chapter 3
mental health providers are implementing approaches may not be effective. In some
models using clinicians trained to deliver both cases, addressing other needs may provide an
substance abuse and mental health treatment avenue to engage the individual with chronic
concurrently (Drake and Mueser 2000). For substance dependence in treatment. Case
more information, see TIP 42, Substance management approaches can be successful at
Abuse Treatment for Persons With Co addressing the need for housing, health care,
Occurring Disorders (CSAT 2005c). and basic needs even though the individual is
not yet willing to confront the issue of drink
ing or other drug use (Cox et al. 1998). TIP
Linkage to Followup 27, Comprehensive Case Management for
Medical Care Substance Abuse Treatment (CSAT 1998a),
The patient’s consent should be sought to provides additional information about deliv
involve her or his primary healthcare provider ery of case management services to homeless
in the coordination of care. Patients with individuals with substance use disorders and
chronic medical conditions and those in need of those with other complex problems.
followup care should have an appointment Documentation of repetitive inappropriate
made for followup medical care before leaving use of voluntary detoxification services may
the detoxification setting (Luborsky et al. help pave the way for civil commitment to
1997). involuntary treatment where this is an option,
and, where detoxification resources are limit
ed, treatment systems need to be creative in
Considerations for Individuals designing care plans for patients seeking fre
With Chronic Substance quent detoxification without evidence of any
therapeutic benefit.
Dependence
For individuals with substance abuse prob
lems who detoxify regularly but have limited
periods of abstinence, traditional treatment
An Overview of Psychosocial and Biomedical Issues During Detoxification 45
In This
4 Physical
Chapter…
Detoxification
Psychosocial and
Biomedical
Services for
Screening and
Assessment
Withdrawal From
Alcohol
Intoxication and
Specific Substances
Withdrawal
Opioids
This chapter highlights specific treatment regimens for specific sub
Benzodiazepines
stances and provides guidance on the medical, nursing, and social ser
and Other
vices aspects of these treatments. It also includes considerations for spe
Sedative
cific populations. Although it is written principally for healthcare profes
Hypnotics
sionals, some professionals without medical training may find it of use.
Stimulants
To accommodate a broad audience, the chapter includes definitions for
Inhalants/Solvents
technical terms that may be unfamiliar to some readers—for example,
“the patient was afebrile (without fever).”
Nicotine
Marijuana and
Other Drugs
Psychosocial and Biomedical
Containing THC
Screening and Assessment
Anabolic Steroids
This section covers more complex psychosocial and biomedical assess
Club Drugs
ments that may occur after initial contact as an individual undergoes
Management of
detoxification. Psychosocial and biomedical screening and services are
Polydrug Abuse:
closely associated: neither is likely to succeed without the other, as the
An Integrated
case study below illustrates.
Approach
Although the medical issues in this case indicate that the patient could
Alternative
successfully be managed as an outpatient, careful assessment of psy
Approaches
chosocial and biomedical aspects of the patient’s condition, including
lack of transportation, the risk of violence, and his inability to carry out
Considerations for
routine medical instructions, strongly indicated that the patient remain
Specific
in a 24hour supervised setting such as a residential detoxification or
Populations
treatment program. For an illustration of some of the fundamental
47
Case Study
A 44yearold Caucasian male with a fifthgrade education presented to an emergency clinic in mild alcohol
withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia;
blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical
Institute Withdrawal Assessment for Alcohol (CIWAAr) (see below) score = 12, indicating mild withdrawal.
A treatment plan was recommended that called for an outpatient 3day fixeddose taper of lorazepam (a
benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return
daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that
there was no reliable transportation to the clinic, there had been domestic violence on the parts of both
spouses, and the patient’s ability to carry out routine medical instructions was questionable.
aspects of the patient’s health and psychosocial rehabilitation, and treatment are being
status that should be covered in screening and promoted.
assessment, see Figure 31, p. 25.
Clinicians also can use the presentation of
Figure 41 lists several instruments useful in information from biochemical markers to
characterizing the intensity of specific with patients as an effective tool in motivational
drawal states (see appendix C for more infor enhancement. For example, information
mation on these instruments and how to obtain regarding liver transaminases (specific kinds
them). of enzymes that perform chemical reactions
within the liver) helps provide the patient
with objective information on the level of
Biochemical Markers and recent alcohol use and potential acute hepatic
Their Use damage. This may help the patient move from
This section focuses on biochemical laborato contemplating treatment to actually beginning
ry tests that detect the presence or absence of treatment. For a more detailed discussion of
alcohol or another substance of abuse, may biological markers in substance abuse, see
be able to quantify the level of present use, or Javors and colleagues (1997).
may be able to quantify cumulative use over
the past few weeks. Tests in all of these areas Blood alcohol content
are reasonably well developed and validated
for alcohol. This is not the case for most Blood alcohol content (BAC) can be determined
other substances of abuse. Biochemical mark by highly sensitive laboratory procedures that
ers are not adequate screening or assessment generally are available in most emergency
instruments alone, but rather are used to departments, hospitals, and clinical chemistry
support a more comprehensive clinical assess laboratories. Alcohol elimination undergoes,
ment. Common uses of these biochemical for the most part, zeroorder kinetics (decreas
markers are: ing a set amount per unit of time rather than a
set percentage), so the concept of halflife is not
1. In the initial screening setting to support really accurate. However, firstorder kinetics
or refute other information that leads to and halflife do occur when BAC is low (i.e.,
proper diagnosis, assessment, and manage below 10mg percent), and the halflife is on the
ment. order of about 15 minutes at that point.
2. For forensic purposes (e.g., evaluating a Though disappearance rates of 15mg percent
driver after an automobile accident). per hour are probably average for moderate
3. In detecting occult (secretive or hidden) drinkers, higher values were seen in a group of
use of alcohol and other substances in Swedish drivers apprehended for driving while
therapeutic settings where abstinence, intoxicated (19mg/dL/hr) (Jones and Andersson
48 Chapter 4
Figure 41
Assessment Instruments for Dependence and Withdrawal From Alcohol
and Specific Illicit Drugs
1996). The rate of metabolism of alcohol range (about 15 or higher), the clinician can
increases with dependence—some alcoholics reasonably predict that the withdrawal will be
can metabolize 20–25mg/dL/hr (Jones and relatively severe. As noted, however, the rate
Andersson 1996), and Jones and Sternebring of metabolism of alcohol increases with
(1992) have found that alcoholdependent dependence. The diagnosis of alcohol intoxi
patients may metabolize 22mg/dL/hr during cation is a clinical diagnosis and not based
detoxification. simply on a BAC. A person with a BAC of
200mg percent could be in withdrawal, intoxi
When knowledge of BAC is combined with cated (showing related signs and symptoms),
clinical information, the healthcare provider or showing no signs and symptoms of either
can make some predictions regarding the intoxication or withdrawal. A BAC above
acuteness of withdrawal. For example, in an 100mg percent does not necessarily indicate
individual whose blood alcohol level is 200mg clinical intoxication. Like all laboratory pro
percent but who is already showing tremu cedures, the blood alcohol levels test has limi
lousness (shakiness of the hands), brisk tations. Usually, patient permission must be
reflexes, tachycardia (rapid heart rate), obtained prior to testing, the testing itself can
diaphoresis (excessive sweating), and perhaps be expensive, and forensic testing may be
a CIWAAr score in the moderate or high subject to specific legal procedures.
Physical Detoxification Services for Withdrawal From Specific Substances 49
Reading Blood Alcohol Concentrations
Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. This
figure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BAC
of .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.
Source: Center for Substance Abuse Treatment (CSAT) 1995a.
Breath alcohol levels chromatography, urine alcohol concentration,
and gas chromatographymass spectrometry.
Although the initial cost of small breath alcohol
instruments may be relatively high, the recur Informed clinicians also should be aware of
ring costs (of disposable mouthpieces and peri which drugs are screened for by the laboratory
odic recalibration) are low. The technique is they use, the relative time window of detection
less invasive than blood testing and health (a substance’s metabolic halflife, or approxi
providers can follow breath alcohol levels mately how long a drug can be detected once
repeatedly at low expense during the course of ingested), and whether crossreactivity with
assessment and detoxification. The detection of other interfering substances may alter out
rapidly rising, high levels of alcohol over a comes. Many laboratories perform more specif
short period of time may indicate alcohol poi ic confirmation testing on positive screening
soning overdose. Breath alcohol levels provide tests, which can largely eliminate falseposi
useful guidance in determining whether to hos tives. It is important to clarify which type of
pitalize these patients. test result is being reported. Interfering and
crossreactive substances leading to falseposi
Limitations on breath alcohol determinations tive tests frequently are discussed in bulletins
are that patient cooperation is required and and publications periodically published by the
that some patients with lung diseases are not National Institute on Drug Abuse (NIDA) and
able to muster a sufficient tidal volume (force the Centers for Disease Control and Prevention
ful breath) to give an accurate reading to the (CDC). Usually, the senior laboratory supervi
machine. On occasion, patients whose breath sor has uptodate information in this area and
alcohol levels indicate recent alcohol use will often can be consulted via email or telephone
assert that they have recently gargled with in an emergency. Limitations of urine drug
mouthwash that contained alcohol. Having the screening include consent and privacy issues,
patient rinse his mouth with water several expense, the inability to screen for some drugs
times and then making another breath alcohol of abuse, and the inability of urine drug
determination in 15 to 30 minutes usually will screens to provide information on the current
resolve whether the patient’s assertion is valid. level of intoxication.
Urine testing should at a minimum test for the
Urine drug screens presence of
Urine drug screens vary widely in their meth • Benzodiazepines
ods of detection, sensitivity and specificity,
expense, and availability. The healthcare • Barbiturates
provider assessing patients for detoxification • Cocaine
should be familiar with the type of assay (test • Amphetamines
measurement) being used; some examples are
• Opioids
enzyme multiple assay techniques, thin layer
chromatography, high performance liquid • PCP
50 Chapter 4
It also should be noted that current testing for insults to the liver from toxins (such as chemi
opioids primarily refers to “organic” drugs that cals, alcohol, prescribed or overthecounter
are derived from opium (i.e., heroin, codeine, medications). In any form of hepatitis, GGT
and morphine). Synthetic opioids like may be elevated, indicating damage to liver
hydrocodone and methadone are not detected cells. Therefore, GGT elevation does not
by the usual tests; this is true of oxycodone as automatically mean liver damage from alcohol
well. If the use of these drugs is suspected, spe use, although this is certainly one of the most
cial tests can be ordered. Most important, each common reasons for elevated GGT levels in
program should tailor its urine screening tests patients hospitalized in North America. The
to reflect the substance use patterns prevalent use of GGT levels along with carbohydrate
in the community. deficient transferrin (CDT) levels is a rela
tively sensitive and specific indicator of alco
hol use. The CDT test is discussed below.
Gammaglutamyltransferase
(GGT)
Carbohydratedeficient
GGT has been measured in serum (the portion
of the blood that has neither red nor white transferrin
blood cells) for many years as a marker for CDT has been developed over the past 20 years
liver damage. More recently, GGT has been as a marker of cumulative alcohol consumption
advocated as a measure of cumulative alcohol but is just now becoming widely available as a
use (Dackis 2001). Sensitivity of the test is in clinical tool. Sensitivities appear to be in the 70
the 60 to 70 percent range and specificity (its to 80 percent range, and specificities of greater
ability not to misidentify or confuse alcohol use than 90 percent have been found. Sensitivity
with other disorders) is in the 40 to 50 percent and specificity are somewhat lower among
range. In general, both sensitivity and specifici females than males. Most therapeutic drugs or
ty are lower in females than males. GGT does drugs of abuse do not appear to affect CDT
correlate with alcohol intake but often requires levels. When CDT and GGT levels are com
heavy drinking (more than six drinks per day) bined, sensitivity and specificity rise to more
to elevate it, and only about half of individuals than 90 percent (Anton 2001). CDT testing is
will show elevations. The halflife of elevated limited by its relatively high cost, lack of clini
serum GGT after the onset of abstinence is said cal availability in some laboratories, and false
to be 2 to 3 weeks with alcoholic liver disease. positive results in abstaining individuals who
Chlorpromazine, phenobarbital, and have endstage liver disease from causes other
acetaminophen can all raise serum GGT levels. than alcohol use (DiMartini et al. 2001).
GGT is limited by its expense and its relative
ly low specificity, which sometimes leads to Mean corpuscular
falsepositive evaluations. GGT is helpful as a volume (MCV)
motivational enhancer in patients with a high
degree of denial during detoxification. Erythrocyte (red blood cell) size is measured in
Evidence of liver damage, as measured by the a Coulter counter and often is part of a com
GGT, provides patients with objective feed plete blood count; therefore, it is widely avail
back concerning the consequences of their able to clinicians. Sensitivity and specificity are
alcohol use and thus plays a very important in the 30 to 50 percent range. Hence, caution
role in enhancing motivation. should be exercised when interpreting an ele
vated MCV in relation to drinking behavior.
Hepatitis is a general term that refers to This lab test should be considered complemen
inflammation of the liver with damage to liver tary to other biological markers that are more
cells (hepatocytes). Hepatitis may be due to specific and sensitive, such as GGT or CDT.
viruses (such as in hepatitis A, B, C) or Advanced age, nutritional status, cigarette
Physical Detoxification Services for Withdrawal From Specific Substances 51
smoking, and cooccurring disease states with in monitoring vital functions, protecting respi
out the presence of alcoholism may make test ration, and observing aspiration, hypo
results abnormal. glycemia, and thiamin deficiency. Screening for
other drugs that may contribute to the coma,
as well as other sources of coma induction,
Alcohol Intoxication should be done. Agitation is best managed with
interpersonal and nursing approaches rather
and Withdrawal than additional medications, which may only
complicate and delay the elimination of the
Intoxication Signs and alcohol.
Symptoms
The clinical presentation of intoxication from Withdrawal Signs and
alcohol varies widely depending in part on
blood alcohol level and level of previously
Symptoms
developed tolerance. At alcohol concentrations Hippocrates, writing around 400 B.C., gave us
between 20mg percent and 80mg percent, loss our first written clinical picture of alcohol with
of muscular coordination, changes in mood, drawal when he wrote that if the patient is “in
personality alteration, and [increases in motor the prime of life and if from drinking he has
activity] begin. At levels from 80 to 200mg per trembling hands,” it may well be the case that
cent, more progressive neurologic impairment the patient is showing withdrawal signs and
occurs with ataxia (inability to coordinate mus symptoms. To this day, alcohol withdrawal
cular activity) and slurring of speech being remains underrecognized and undertreated.
prominent. A variety of cognitive functions also The signs and symptoms of acute alcohol with
are impaired. At blood alcohol levels between drawal generally start 6 to 24 hours after the
200 and 300mg percent nausea and vomiting patient takes his last drink. Alcohol withdrawal
may occur, which along with sedation may may begin when the patient still has significant
place patients at grave risk for aspiration of blood alcohol concentrations. The signs and
stomach contents. At levels greater than 300mg symptoms may include the following:
percent, hypothermia (low body temperature) • Restlessness, irritability, anxiety, agitation
with impairment of level of consciousness is • Anorexia (lack of appetite), nausea, vomiting
likely except in all but the most tolerant indi
viduals. Coma begins to be seen at levels of 400 • Tremor (shakiness), elevated heart rate,
to 600mg percent, but this is variable, again increased blood pressure
depending on tolerance. Although exceptions • Insomnia, intense dreaming, nightmares
are found, BACs between 600 and 800mg per • Poor concentration, impaired memory and
cent are fatal. At this point, respiratory, car judgment
diovascular, and body temperature controls
• Increased sensitivity to sound, light, and tac
fail. See Figure 42 for more symptoms of alco
tile sensations
hol intoxication.
• Hallucinations (auditory, visual, or tactile)
Since the elimination rate of alcohol from the • Delusions, usually of paranoid or persecutory
body generally is 10 to 30mg percent per hour, varieties
the goals for the treatment of alcohol intoxica
tion are to preserve respiration and cardiovas • Grand mal seizures (grand mal seizures rep
cular function until alcohol levels fall into a resent a severe, generalized, abnormal elec
safe range. Patients who are severely intoxicat trical discharge of the major portions of the
ed and comatose as the result of alcohol use brain, resulting in loss of consciousness, brief
should be managed in the same manner as all cessation of breathing, and muscle rigidity
comatose patients, with particular care taken followed by muscle jerking; a brief period of
52 Chapter 4
Figure 42
Symptoms of Alcohol Intoxication*
Blood Alcohol Level Clinical Picture
20–100mg percent • Mood and behavioral changes
•Reduced coordination
•Impairment of ability to drive a car or operate machinery
101–200mg percent •Reduced coordination of most activities
•Speech impairment
•Trouble walking
•General impairment of thinking and judgment
201–300mg percent •Marked impairment of thinking, memory, and coordination
•Marked reduction in level of alertness
•Memory blackouts
•Nausea and vomiting
301–400mg percent •Worsening of above symptoms with reduction of body temperature and blood
pressure
•Excessive sleepiness
•Amnesia
401–800mg percent •Difficulty waking the patient (coma)
•Serious decreases in pulse, temperature, blood pressure, and rate of breath
ing
•Urinary and bowel incontinence
•Death
*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood
alcohol level).
Source: Consensus Panelist Robert Malcolm, M.D.
sleep, awakening later with some mild to even the heading Management of Delirium and
severe confusion, generally occurs) Seizures (p. 63).
• Hyperthermia (high fever) Mild alcohol withdrawal generally consists of
• Delirium with disorientation with regard to anxiety, irritability, difficulty sleeping, and
time, place, person, and situation; fluctua decreased appetite. Severe alcohol withdrawal
tion in level of consciousness usually is characterized by obvious trembling
of the hands and arms, sweating, elevation of
For a discussion of seizures and delirium,
pulse (above 100) and blood pressure (greater
including delirium tremens, see below under
Physical Detoxification Services for Withdrawal From Specific Substances 53
than 140/90), nausea (sometimes with vomit the number of previous withdrawals (treated
ing), and hypersensitivity to noises (which seem or untreated) experienced, with three or four
louder than usual) and light (which appears being a particularly significant number for
brighter than usual). Brief periods of hearing the appearance of severe withdrawal reac
and seeing things that are not present (auditory tions unless adequate medical care is provid
and visual hallucinations) also may occur. A ed. This assumption that this phenomenon
fever greater than 101° F also may be seen, will manifest itself, which has been referred
though care should be taken to determine to as the “kindling hypothesis,” is wellestab
whether the fever is the result of an infection. lished in the research literature (Booth and
Seizures and true delirium tremens, as dis Blow 1993; Wojnar et al. 1999).
cussed elsewhere, represent the most extreme Uncomplicated or mild to moderate with
forms of severe alcohol withdrawal. Moderate drawal is characterized by restlessness, irri
alcohol withdrawal is defined more vaguely, tability, anorexia (lack of appetite), tremor
but represents some features of both mild and (shakiness), insomnia, impaired cognitive
severe withdrawal. functions, and mild perceptual changes.
Complicated or severe medical withdrawal
The course of these symptoms is extremely has one or more elements of delirium, halluci
variable. An individual may progress partial nations, delusions, seizures, and disturbances
ly through some of the symptoms noted above of body temperature, pulse, and blood pres
and then have a slow improvement. Other sure.
individuals may have mild to moderate symp
toms with almost abrupt resolution. Yet
another group may present with a grand mal Medical Complications of
seizure or with hallucinations. Some people Alcohol Withdrawal: Possible
with alcohol dependence, regardless of their
pattern of drinking or the extent of drinking, Fatal Outcomes
appear to develop minor symptoms or show Seizures; delirium tremens (severe delirium
no symptoms of withdrawal. Infrequent binge with trembling); and dysregulation of body
drinkers seem less likely to have withdrawal temperature, pulse, and blood pressure are
symptoms than individuals who are heavy outcomes in severe alcohol dependence that can
regular users of alcohol who then abruptly lead to fatal consequences. Other medical com
cease their alcohol use, but this is not well plications of alcohol withdrawal include infec
substantiated. As previously discussed in the tions, hypoglycemia, gastrointestinal (GI)
assessment section, the use of a standardized bleeding, undetected trauma, hepatic failure,
clinical rating instrument for withdrawal such cardiomyopathy (dilation of the heart with
as the CIWAAr is valuable because it guides ineffective pumping), pancreatitis (inflamma
the clinician through multiple domains of tion of the pancreas), and encephalopathy
alcohol withdrawal and allows for semiquan (generalized impaired brain functioning). The
titative assessment of nausea, tremor, auto suspicion of impending complications or their
nomic hyperactivity, anxiety, agitation, per appearance will require hospitalization of the
ceptual disturbances, headache, and disorien client and possible intensive care unit level of
tation. Age, general health, nutritional fac management. Consultation with internists spe
tors, and possible cooccurring medical or cializing in infectious disease, pulmonary care,
psychiatric conditions all appear to play a and hepatology; surgeons; neurologists; psychi
role in increasing the severity of the symp atrists; anesthesiologists; and other specialists
toms of alcohol withdrawal. also may be warranted, depending on the
nature of the complications.
The most useful clinical factors to assess the
likelihood and the extent of a current with
drawal is the patient’s last withdrawal and
54 Chapter 4
Management of Withdrawal withdrawal. The consensus panel has found
that in actual practice, social detoxification
Without Medication programs vary greatly in their approach and
The management of an individual in alcohol scope. Some programs offer some medical and
withdrawal without medication is a difficult nursing onsite supervision, while others pro
matter because the indications for this have not vide access to medical
been established firmly through scientific stud and nursing evalua
Furthermore, the course of alcohol withdrawal urgent care pro
is unpredictable and currently available tech grams, and emergen
sedativehypnotic,
niques of screening and assessment do not cy departments.
allow us to predict with confidence who will or Some social detoxifi
will not experience lifethreatening complica
and opioid with
cation programs only
tions. Severe alcohol withdrawal may be associ offer basic room and
ated with seizures due to relative impairment of board for a “cold drawal syndromes,
gammaaminobutyric acid (GABA) and relative turkey” detoxifica
overactivity of NmethylDaspartate systems tion, while other pro hospitalization (or
(a subtype of the excitatory glutamate receptor grams offer super
system) (Moak and Anton 1996). The failure to vised use of medica some form of
treat incipient convulsions is a deviation from tions. Sometimes
the established general standard of care. medications are pre 24hour medical
scribed at the onset of
Positive aspects of the nonmedication withdrawal by health
approach are that it is highly costeffective care) is generally the
care professionals in
and provides inexpensive access to detoxifica an outpatient setting,
tion for individuals seeking aid. Observation preferred setting for
while the staff in the
is generally better than no treatment, but social detoxification
people in moderate to severe withdrawal will program supervises
detoxification, based
be best served at a higher level of care. Young the administration of
individuals in good health, with no history of these medications.
on principles of
previous withdrawal reactions, may be well Whatever the partic
medication. However, personnel supervising be, there should
ties and be able to summon help through the surveillance, includ
emergency medical system. Methods of with ing monitoring of
drawal management without medication vital signs, as part of every social detoxification
include frequent interpersonal support, pro program.
vision of adequate fluids and food, attention
to hygiene, adequate sleep, and the mainte The consensus panel agrees that for alcohol,
nance of a noalcohol/nodrug environment. sedativehypnotic, and opioid withdrawal syn
dromes, hospitalization (or some form of 24
hour medical care) is generally the preferred
Social Detoxification setting for detoxification, based on principles of
Social detoxification programs are defined as safety and humanitarian concerns. When hos
shortterm, nonmedical treatment services for pitalization cannot be provided, a setting that
individuals with substance use disorders. A provides a high level of nursing and medical
social detoxification program offers room, backup 24 hours a day, 7 days a week is desir
board, and interpersonal support to intoxicat able. The panel readily acknowledges that
ed individuals and individuals in substance use social detoxification programs are, for some
Physical Detoxification Services for Withdrawal From Specific Substances 55
communities, the only available resources for The consensus panel acknowledges that, for a
uninsured, homeless individuals. Social detoxi substantial group of individuals, substance
fication is preferable to detoxification in unsu use withdrawal syndromes do not lead to fatal
pervised settings such as the street, shelters, or outcomes or even significant morbidity.
jails. The panel also notes that in some large Determining which individuals will have
urban areas, social detoxification programs benign outcomes often is difficult, and in fact
have longstanding, excellent reputations of pro this determination prior to social detoxifica
viding highquality supervision and nurturance tion referral frequently is not made. Some
for their clients. incorrect beliefs have sprung up in the con
Social detoxification text of social detoxification: Individuals
programs are orga undergoing opioid withdrawal often are con
For a substantial nized and funded by sidered to require hospitalization to alleviate
a variety of sources, suffering, while individuals undergoing alco
group of including faithbased hol withdrawal sometimes are, for a variety of
organizations, com reasons, denied hospitallevel treatment for
individuals, munity charities, detoxification, even though alcohol withdraw
and municipal and al produces suffering and may have fatal con
substance use other local govern sequences.
ments.
The consensus panel agreed on several guide
withdrawal The genesis of social lines for social detoxification programs:
detoxification is • Such programs should follow local govern
syndromes do not complex. Often, mental regulations regarding their licensing
these programs grew and inspection.
lead to fatal out of community
• It is highly desirable that individuals entering
needs when no other
social detoxification be assessed by primary
outcomes or even alternatives were
care practitioners (physicians, physician
available. Early
assistants, nurse practitioners) with some
significant reports (Whitfield et
experience in substance abuse treatment.
al. 1978) indicated
that many individu • Such an assessment should determine
morbidity. whether the patient currently is intoxicated
als in alcohol with
drawal could be and the degree of intoxication, the type of
managed successful withdrawal syndrome, severity of the with
ly without medications in a social detoxification drawal, information regarding past with
setting. Subsequent reviews that have revisited drawals, and the presence of cooccurring
the topic (Lapham et al. 1996) have reached psychiatric, medical, and surgical conditions
similar conclusions. Critical analysis of these that might well require specialized care (see
reports by the consensus panel indicates that chapter 3, Figure 31, p. 25).
some of the scientific issues were oversimplified • Particular attention should be paid to those
and misleading. A number of these studies, in individuals who have undergone multiple
fact, excluded many seriously ill clients from withdrawals in the past and for whom each
their surveys prior to referral to social detoxifi withdrawal appears to be worse than previ
cation. Some of these surveys had a very high ous ones—this is the socalled “kindling
stafftoclient ratio during social detoxification, effect” (Ballenger and Post 1978; Booth and
thus providing an unusually high level of psy Blow 1993; Malcolm et al. 2000; Shaw et al.
chological support. This level of staffing is not 1998; Wojnar et al. 1999; Worner 1996).
frequently found today in social detoxification Subjects with a history of severe with
programs. drawals, multiple withdrawals, delirium
56 Chapter 4
tremens, or seizures are not good candidates sion, been abstinent for a few hours and have
for social detoxification programs. not developed signs or symptoms of withdraw
• All social detoxification programs should al. A decision regarding medication for this
have an alcohol and drugfree environment, group should be in part based on age, num
have personnel who are familiar with the fea ber of years of alcohol dependence, and the
tures of substance use withdrawal syn number of previously treated or untreated
dromes, have training in basic life support, severe withdrawals (three or four appears to
and have access to an emergency medical sys be a significant threshold in predicting future
tem that can provide transportation to emer serious withdrawal) (Shaw 1995). If there is
gency departments and other sites of clinical an opportunity to observe the patient in the
care. emergency department of the clinic or similar
setting over the next 6 to 8 hours, then it is
possible to delay a decision regarding treat
Management of Withdrawal ment and periodically reevaluate a client of
With Medications this category. If this is not possible, then the
Over the last 15 years several reviews and posi return of the patient to a setting in which
tion papers (Fuller and Gordis 1994; Lejoyeux there is some supervision by family, signifi
et al. 1998; MayoSmith 1997; Nutt et al. 1989; cant others, or in a social detoxification pro
Shaw 1995) have asserted that only a minority gram is desirable.
of patients with alcoholism will in fact go into
The decision as to whether to give the patient
significant alcohol withdrawal requiring medi
a single medication dose prior to discharge
cations. Identifying that significant minority
and perhaps provide one or two additional
sometimes is problematic, but there are signs
medication doses to be administered in the
and symptoms of impending problems that can
referral setting rests on adequacy of supervi
alert the caretaker to seek medical attention.
sion, the probability of whether the patient
Deciding on whether to use medical manage will drink while undergoing treatment, and
ment for the treatment of alcohol withdrawal whether the patient can or will return for
requires that patients be separated into three assessments the following day. In some cir
groups. The first and most obvious group cumstances, no treatment may be safer than
comprises those clients who have had a previ treatment with medication. MayoSmith
ous history of the most extreme forms of with (1997) has shown that benzodiazepines confer
drawal, that of seizures and/or delirium. This protection against alcohol withdrawal seizures
group is discussed in more detail below, but and thus patients with previous seizures
in general, the medication treatment of this should be treated early. The same applies to
group in early abstinence, whether or not delirium. Both of these topics will be explored
they have had the initiation of withdrawal in greater detail in the next section.
symptoms, should proceed as quickly as pos Extremely heavy drinking in the weeks prior
sible. to complete cessation also predicts more
severe withdrawal (Lejoyeux et al. 1998), but
The second group of patients requiring imme confirming such a history often is difficult.
diate medication treatment includes those
patients who are already in withdrawal and A less accepted and more controversial posi
demonstrating moderate symptoms of with tion on the indications for medication treat
drawal. ment for alcohol withdrawal springs from
studies that attempt to measure oxidative
The third group of patients includes those stress, which is the formation of oxidative
who may still be intoxicated and therefore free radicals (chemicals that damage pro
have not had time to develop withdrawal teins), and stress hormones during alcohol
symptoms or who have, at the time of admis withdrawal (Dupont et al. 2000; Tsai et al.
Physical Detoxification Services for Withdrawal From Specific Substances 57
1998). These studies have asserted that indi benzodiazepines have side effects and limita
viduals who are undergoing mild withdrawal tions. These limitations are far more prominent
without treatment still have the formation of when treating alcohol withdrawal in an outpa
toxic oxidative products which have the hypo tient setting.
thetical potential of producing neuronal dam
age and perhaps some cell death. Lending Loading dose of a benzodiazepine
support to this argument is the fact that alco Medical or nursing administration of a slowly
hol withdrawal appears to be progressive in metabolized benzodiazepine, frequently intra
that it worsens with each successive episode venously, but sometimes orally, may be carried
(Malcolm et al. 2000) and that some patients out every 1 to 2 hours until significant clinical
dependent on alcohol develop evidence of improvement occurs (such as reducing the
dementia over time. On the other hand, age, CIWAAr score to 10 or less) or the patient
nutritional status, trauma, cooccurring con becomes sedated (Sellers and Naranjo 1985).
ditions, and other unspecified events also Patients at grave risk for the most severe com
probably contribute to this process. plications of alcohol withdrawal or who are
already experiencing severe withdrawal should
The decision to treat a patient in alcohol be hospitalized and can be treated with this
withdrawal or at potential risk for alcohol regimen. In general, patients with severe with
withdrawal will in great part rest on the clini drawal may receive 20mg of diazepam or
cal judgment of the practitioner, relying on 100mg of chlordiazepoxide every 2 to 3 hours
the factors noted above in addition to the until improvement or sedation prevails.
issue of whether treatment may in fact actual Oversedation, ataxia (lack of muscular coordi
ly do more harm than good. This topic is dis nation), and confusion, particularly in elderly
cussed below under the heading Limitations patients, may occur with this protocol. The
of Benzodiazepines in Outpatient Treatment treatment staff should closely monitor hemody
(p. 60). For more information about medica namic (blood pressure and pulse) and respira
tionassisted treatment, see TIP 43, tory features. They should particularly be pre
MedicationAssisted Treatment for Opioid pared to detect and rapidly treat apnea (no
Addiction in Opioid Treatment Programs breathing) with assisted ventilation. Having
(CSAT 2005d). experienced staff with adequate time to fre
quently monitor the patient and provide intra
Benzodiazepine treatment of venous medication is necessary.
alcohol withdrawal Symptomtriggered therapy
Depending upon the clinical setting and the Using the CIWAAr or similar alcohol with
patient circumstances, there are several accept drawal rating scales, medical personnel can be
able regimens for treating alcohol withdrawal trained to recognize signs and symptoms of
that make use of benzodiazepines. These drugs alcohol withdrawal, make a rating, and based
remain the medication class of choice for treat on that rating administer benzodiazepines to
ing alcohol withdrawal. The early recognition their patients only when signs and symptoms
of alcohol withdrawal and prompt administra reach a particular threshold score. Studies
tion of a suitable benzodiazepine usually will have demonstrated that appropriate training of
prevent the withdrawal reaction from proceed nurses in the application of the CIWAAr dra
ing to serious consequences. Patients suspected matically reduces the number of patients who
of alcohol withdrawal should be seen promptly need to receive symptomtriggered medication
by a primary care provider (physician, nurse (Saitz et al. 1994; Wartenberg et al. 1990). This
practitioner, physician assistant) who has expe regimen has been used successfully with short,
rience in diagnosing and managing alcohol intermediate, and long halflife benzodi
withdrawal. Practitioners are reminded that azepines.
58 Chapter 4
The training of staff in a standardized proce drug response) according to severity of symp
dure of administering rating scales is impor toms. An alternative regimen might be the
tant and periodic retraining to ensure contin administration of 1 to 2mg lorazepam two or
ued reliability among raters is essential. A three times a day the first day, followed by
typical routine of administration of symptom gradual reduction over the next 3 to 5 days.
triggered therapy is as follows: Administer The general approach to tapering is to estab
50mg of chlordiazepoxide (Librium) for lish an acute dose in the first 24 hours, then
CIWAAr > 9 and reassess in 1 hour. to reduce it over the next three days: for
Continue administering 50mg chlordiazepox example, 400 chlordiazepoxide total on day 1,
ide every hour until CIWAAr is < 10. Dosage then 300, 200, 100,
amount and frequency can be modified and off on day 5.
depending on the individual clinical situation This has to be
as determined by the medical provider. extended if
Patients with a history of withdrawal seizures lorazepam is used.
should receive scheduled doses of a longact Doses of withdrawal Benzodiazepines
ing benzodiazepine (e.g., diazepam [Valium], medication are omit
20mg every 6 hours for 3 days) regardless of ted if the patient is remain the
CIWAAr score, and should receive addition sleeping soundly,
al doses if indicated by elevated CIWAAr showing signs of medication class
score. It must be noted here that symptom oversedation, or
triggered therapy is not recommended for exhibiting marked
of choice for
outpatient detoxification. Symptomtriggered ataxia.
therapy requires monitoring and decision
making by a healthcare professional. The use of gradual, treating alcohol
tapering doses is
Gradual, tapering doses appealing in settings withdrawal.
Before beginning any tapering regimen, the where trained nurs
patient must be fully stabilized; that is, all signs ing or medical
and symptoms of withdrawal must be observations cannot
improved. Without proper stabilization, no be made frequently;
tapering scheme will succeed. Once the patient however, this in
has been stabilized, oral benzodiazepines can itself is a pitfall.
be administered on a predetermined dosing Under or overmedication with this regimen
schedule for several days and gradually can occur depending on benzodiazepine toler
tapered over time. This is a commonly used ance; the presence of chronic cigarette smok
regimen. ing, which induces benzodiazepine
metabolism; liver function; age; and the pres
Dosing protocols vary widely among treat ence of cooccurring medical or psychiatric
ment facilities based on the needs of the conditions. The use of this regimen may be
patient population. One example is that problematic in the outpatient settings in
patients might receive 50mg of chlordiazepox which it frequently is applied. Supplying the
ide or 10mg of diazepam every 6 hours during patient with 4 to 5 days of a benzodiazepine
the first day of treatment and 25mg of chlor and facing the probability that the patient
diazepoxide or 5mg of diazepam every 6 may drink and take the benzodiazepine is a
hours on the second and third days. This hazard. It is important to enforce strict limi
approach to dosing, that is, every 6 hours, is tations on driving automobiles, climbing, or
not as accurate in tailoring medications to operating hazardous machinery.
counter symptoms; a more precise dosing reg
imen is titrating (adjusting dosage in light of
Physical Detoxification Services for Withdrawal From Specific Substances 59
Single daily dosing protocol ataxia, and on rare occasions, confusion may
Jauhar and Anderson (2000) compared single ensue.
daily dosing of diazepam to multiple daily dos
Lorazepam
ing of chlordiazepoxide in inpatients being
treated for alcohol withdrawal. Patients in the Lorazepam (Ativan) has an intermediate half
diazepam single daily dose group did as well as life of about 8–15 hours, and although it usual
the chlordiazepoxide multiple dosing group. ly is administered in multiple doses each day, it
The authors suggest that this regimen might be can be given approximately twice per day.
attractive in community or social detoxification Lorazepam, with its shorter halflife and lack
settings, particularly if patients could be moni of storage in adipose (fatty) tissue, actually has
tored between administered doses. Further to be given more frequently than the longact
study with a larger group of patients is needed. ing preparations, not less. It is absorbed easily
orally, intramuscularly, and intravenously.
The choice of the specific benzodiazepine for Older patients and patients with severe liver
any particular regimen depends on a number disease tolerate it well and it is an effective
of factors, but the most significant factor is that anticonvulsant in blocking a second alcohol
the clinician administer one that she has the withdrawal seizure (D’Onofrio et al. 1999).
most experience using. Despite 30 years of However, it has been suggested that seizures
research, no single benzodiazepine has emerged may occur late in detoxification with shortact
as the number one drug of choice in treating ing benzodiazepines such as lorazepam and
alcohol withdrawal. All benzodiazepines stud oxazepam (Shaw 1995).
ied have worked better than placebo but have
been roughly equivalent with each other. Many Oxazepam
clinicians prefer long halflife benzodiazepines Oxazepam (Serax) often is favored by internists
such as chlordiazepoxide and diazepam, desir and hepatologists treating alcohol withdrawal
ing less frequent daily dosing, relatively steady in patients with severe liver failure. It has a rel
serum levels, and the ability of these drugs to atively short halflife of 6 to 8 hours. Its
selftaper based on their long halflives. metabolism is very simple and it has no
metabolites. The agent is relatively limited in
Diazepam and chlordiazepoxide that its oral absorption is quite slow compared
Both diazepam and chlordiazepoxide have to other benzodiazepines, it must be given
excellent rapid oral absorption and are avail three to four times a day, and is only available
able for intravenous (IV) use. Intramuscular in the United States in an oral form.
use of these drugs is to be discouraged since
muscle absorption is erratic. One study sug Ultimately, the experience of the treating clini
gests that if chlordiazepoxide (Librium) is cian, characteristics of the patient, and the set
taken in overdose with alcohol, it is less likely ting in which he will be treated will determine
to be fatal than diazepam (Valium) (Serfaty the choice of drug. Although all benzodi
and Masterton 1993). Detractors of the use of azepines are now generic in the United States,
these two drugs point out that they have long costs vary and this too may be a factor in
halflives (although some clinicians see this as choice.
an advantage because it prevents the emer
Limitations of benzodiazepines in
gence of withdrawal symptoms between doses),
outpatient treatment
have multiple active metabolites, and go
through many oxidative metabolic steps in the Although benzodiazepines remain the mainstay
liver. Older patients or patients with liver dis of treatment for alcohol withdrawal, they have
ease are likely to accumulate these medications limitations that are particularly pronounced
quickly without being able to metabolize them. when treating outpatients. Benzodiazepines’
Possible consequences include oversedation or potential interactions with alcohol can lead to
coma and respiratory suppression, motor inco
60 Chapter 4
ordination (leading to falls and automobile the majority of these studies, patients were
accidents), and abuse of the medications. treated with benzodiazepines, although in a
Abuse usually is in the context of the concur few, phenobarbital was used.
rent use of alcohol, opioids, or stimulants.
A second, and at present more hypothetical,
There are two other limitations of benzodi concern about benzodiazepine use to treat out
azepines that may be relevant in some clinical patients in alcohol withdrawal is that they may
settings for some patients. First, although ben “prime” or reinstate alcohol use during their
zodiazepines have been studied for more than administration. Two preclinical studies support
30 years and are effective for suppressing alco this premise (Deutsch and Walton 1977;
hol withdrawal symptoms at any one episode, Hedlund and Wahlstrom 1998). A recent ran
their ability to halt the progressive worsening domized, blinded, clinical trial comparing car
of each successive alcohol withdrawal reaction bamazepine to lorazepam for the outpatient
is in question. There are now at least nine stud treatment of alcohol withdrawal found that the
ies that have found that an everincreasing outpatients on lorazepam were three times as
number of previous alcohol withdrawals likely to drink as those on carbamazepine. The
increases the severity of withdrawal, particu lorazepam group drank about twice as much
larly seizures and delirium tremens, and alcohol in the immediate postdetoxification
decreases responsiveness to benzodiazepines period than the carbamazepine group (Malcolm
(Ballenger and Post 1978; Booth and Blow et al. 2002).
1993; Brown et al. 1988; Gross et al. 1972;
Lechtenberg and Worner 1990, 1992; Malcolm For a list of potential contraindications to using
et al. 2000; Shaw et al. 1998; Worner 1996). A benzodiazepines to treat alcohol withdrawal in
tenth study (Wojnar et al. 1999) found that certain patients, see Figure 43.
increasing severity of alcohol withdrawal symp
toms was observed only in a minority (22 per Other medications
cent) of 418 repeatedly treated clients.
However, within this group of one in five indi Barbiturates
viduals, seizures were three times more com Barbiturates have been used for nearly a cen
mon than in the larger, nonprogressive group tury for the treatment of alcohol withdrawal.
and premature age of death was 7 years Most barbiturates, other than phenobarbital,
younger than for the nonprogressive group. In have fallen into disfavor because of severe
Figure 43
Potential Contraindications To Using Benzodiazepines To Treat
Alcohol Withdrawal
• Previous allergic reaction
• Previous paradoxical disinhibition (e.g., violence, agitation, selfharm)
• Previous serious adverse outcomes that could have medicolegal consequences if they reoccur (e.g.,
fractured hip, status epilepticus [continuous seizures of several minutes])
• Severe alterations in mental status with low dose of benzodiazepines (e.g., confusion, delirium)
• An outpatient setting where benzodiazepine use with alcohol has occurred previously with extreme intox
ication leading to injuries, coma, or apnea
Source: Consensus Panelist Robert Malcolm, M.D.
Physical Detoxification Services for Withdrawal From Specific Substances 61
lethal interactions Other agents
with alcohol, death Beta blockers and alpha adrenergic agonists
Delirium and from overdose of the such as clonidine have been used in the treat
agents alone, rapid ment of alcohol withdrawal. They do not pre
seizures are the tolerance, and high vent seizures in delirium and have only modest
abuse potential. benefits for ameliorating symptoms of with
two most Barbiturates are drawal. However, some patients will have
highly addictive. In tachycardia (rapid heartbeat) and hyperten
pathological clinical practice, the sion (high blood pressure) that will not be con
medication is effec trolled by benzodiazepines, and beta blockers
responses seen in tive both for the and alpha adrenergic agonists can be of use in
treatment of alcohol these patients. Calcium channel antagonists will
alcohol withdrawal and also ameliorate some symptoms of alcohol with
sedativehypnotic drawal. As with beta blockers and clonidine,
withdrawal although calcium channel antagonists should be consid
withdrawal.
few controlled trials ered adjunctive therapy primarily to manage
have been conduct extreme hypertension during withdrawal.
ed with it (Wilbur
and Kulik 1981). Phenobarbital has a long Antipsychotics
halflife and may rapidly accumulate. Antipsychotics have long been used to control
Overdoses with phenobarbital also can be fatal. extreme agitation, hallucinations, delusions,
Members of the consensus panel recommend its and delirium during alcohol withdrawal. Older,
use only in highly supervised settings. lowpotency drugs such as chlorpromazine gen
erally are avoided since they can reduce the
Anticonvulsants
seizure threshold. Highpotency drugs such as
Anticonvulsants have been used in Europe for haloperidol (Haldol) also can reduce the
a quarter of a century for the treatment of seizure threshold, but less commonly.
alcohol withdrawal. Carbamazepine (Atretol, Haloperidol and related agents are available
Tegretol) has been shown in at least three trials for oral, intramuscular, and IV administration.
to be as effective as various benzodiazepines in Clinicians should note that since antipsychotics
mild to moderate alcohol withdrawal (Malcolm can lower the seizure threshold, their use dur
et al. 2001). Although less well studied, val ing alcohol withdrawal should be undertaken
proic acid also has been shown to be effective with great care and close supervision of the
(Reoux et al. 2001). Older, firstgeneration patient is required.
anticonvulsants have limitations in that they
only have been studied in mild to moderate Relapse prevention agents
withdrawal, can on rare occasions have serious Relapse prevention agents such as naltrexone
hepatic and bone marrow toxicities, interact and acamprosate are under consideration as
with several other classes of medication, and additional therapies during late withdrawal
are only available in oral forms. They are not, treatment, although they are not effective for
however, controlled substances, are not alcohol detoxification. Since onethird to one
abused, and as previously noted, carba half of outpatients detoxifying with benzodi
mazepine may have the propensity to reduce azepines will either drink or leave treatment
some of the indices of drinking behavior imme prematurely, naltrexone and acamprosate may
diately in the postwithdrawal treatment of out be valuable in assisting in reducing the proba
patients. Newer drugs such as tiagabine, oxcar bility of the individual drinking during late
bazepine, and gabapentin do not appear to detoxification. Highdose naltrexone therapy
have these liabilities, but sufficient studies have has been associated with some liver toxicity,
not been done to confirm their effectiveness but this has not been reported in individuals
and safety. taking therapeutic doses to enhance relapse
62 Chapter 4
prevention. Acamprosate may produce diar weeks prior to treatment, the severity of the
rhea and this may be already present in some last withdrawal episodes, and the number of
individuals in alcohol withdrawal. Thus far no previously treated or untreated withdrawal
wellcontrolled studies have been conducted to episodes. Other factors such as increasing age;
provide guidelines as to when these medications the patient’s general health, including nutri
should be introduced during detoxification or tional status; the presence of cooccurring med
whether it would be better to wait until the ical, surgical, and psychiatric disorders; and
early phase of rehabilitation. For an extended the use of medications (prescription, overthe
review, see Kranzler and Jaffe (2003). counter, or herbal) also can amplify severity of
withdrawal symptoms. Early proper medical
Other medications management of alcohol withdrawal reduces the
Abecarnil (Anton et al. 1997), and more recent probability of these complications, assuming
ly baclofen (Addolorato et al. 2002), have both early recognition.
shown promise in the treatment of alcohol with
drawal. However, insufficient information has For patients with a history of DTs or seizures,
been accumulated on these drugs, and there early benzodiazepine treatment is indicated at
fore they are not recommended for use in clini the first clinical contact setting (e.g., doctor’s
cal patient settings. Their use in alcohol with office, clinic, urgent care, emergency depart
drawal should be considered experimental and ment). Patients with severe withdrawal symp
premature for the present. toms, multiple past detoxifications (more than
three), and cooccurring unstable medical and
psychiatric conditions should be managed simi
Management of Delirium and larly.
Seizures Once an initial clinical screening and assess
Delirium and seizures are the two most patho ment have been made, and the diagnosis is rea
logic responses seen in alcohol withdrawal. The sonably certain, medication should be given.
major goal of medical management is to avoid Giving the patient a benzodiazepine should not
seizures and a special state of delirium called be delayed by waiting for the return of labora
delirium tremens (DTs) with aggressive use of tory studies, transportation problems, or the
the primary detoxification drug (e.g., higher availability of a hospital bed. Early thiamine
doses of a benzodiazepine). Prevention is and multivitamin administration also should be
essential where DTs are concerned. DTs do not done at this time. Once full DTs have devel
develop suddenly but instead progress from oped, they tend to run their course despite
earlier withdrawal symptoms. Properly admin medication management, and there is little evi
istered symptomtriggered medication dence in the medical literature to suggest that
approaches will prevent DTs and limit over any medication treatment can immediately
medication that can occur when highdose ben abort DTs.
zodiazepines are administered without regard
to clinical response. It can be challenging clini Patients presenting in severe DTs should have
cally to differentiate impending DTs versus emergency medical transport to a qualified
benzodiazepine toxicity on day 3 of detoxifica emergency department and generally will
tion. When in doubt, in most cases it is safer to require hospitalization. If the DTs are severe,
overmedicate than to undertreat and allow DTs patients may need to be placed in an intensive
to develop. Flumazenil (Romazicon) can be care unit (ICU), and in such settings continu
used to reverse benzodiazepine overdose. ous monitoring of cardiac rhythm, pulse, blood
pressure, oxygen saturation, temperature, and
Death and disability may result from DTs or respiration rates begins with the emergency
seizures without medical care. Several factors medical system and continues in the emergency
are related to severity of alcohol withdrawal: department and ICU.
high amounts of alcohol being consumed in the
Physical Detoxification Services for Withdrawal From Specific Substances 63
Early care will depend on medical and surgical sists of jerking of head, neck, arms, and legs.
complications and may involve protocols from Breathing resumes during this clonic phase of
advanced cardiac life support (ACLS) and/or the seizure but may be irregular. During the
advanced trauma life support. Correction of clonic phase, the lips, tongue, or inside of the
fluids and electrolytes (salts in the blood), cheeks may be bitten. Involuntary urination or
hyperthermia (high fever), and hypertension a bowel movement may occur. Immediately
are vital. Loading doses (rapid administration after the jerking ceases, the patient generally
of initial high doses) of IV diazepam or has a period of what appears to be sleep with
lorazepam are recommended, as are IV thi more regular breathing. Vomiting may occur at
amine (prior to IV glucose) and multiple vita this time. The period of sleep may be a few sec
mins. The physician should consider intramus onds with awakening or a few minutes. Rarely,
cular or intravenous haloperidol (Haldol and the patient may appear not to waken at all and
others) to treat agitation and hallucinations. have a second period of rigidity followed by
Nursing care is vital, with particular attention muscle jerking. This is known as status epilep
to medication administration, patient comfort, ticus. Upon awakening, the individual usually
soft restraints, and frequent contact with ori is mildly confused as to what has happened and
enting responses and clarification of environ may be disoriented as to where she or he is.
mental misperceptions. This period of postseizure confusion generally
lasts only for a few minutes but may persist for
Alcohol withdrawal seizures represent another several hours in some patients. Headache,
management challenge (Ahmed et al. 2000), sleepiness, nausea, and sore muscles may per
since no largescale clinical studies have been sist in some individuals for a few hours. See the
conducted to establish firmly best treatment text box on the next page for what to do in the
practices. The majority of alcohol withdrawal event of a seizure.
seizures occur within the first 48 hours after
cessation or reduction of alcohol, with peak Patients who start to retch or vomit should be
incidence around 24 hours (Victor and Adams gently placed on their side so that the vomitus
1953). Most alcohol withdrawal seizures are (stomach contents vomited) may exit the mouth
singular, but if more than one occurs they tend and not be taken into the lungs. Vomitus taken
to be within several hours of each other. While into the lungs is a severe medical condition
alcohol withdrawal seizures can occur several leading to immediate difficulty breathing and,
days out, a higher index of suspicion for other within hours, severe pneumonia.
causes is prudent. Someone experiencing an
alcohol withdrawal seizure is at greater risk for Predicting who will have a seizure during alco
progressing to DTs, whereas it is extremely hol withdrawal cannot be accomplished with
unlikely that a patient already in DTs will also any great certainty. There are some factors
then experience a seizure. that clearly increase the risk of a seizure, but
even in individuals with all of these factors,
The occurrence of an alcohol withdrawal most patients will not have a seizure. Out of
seizure happens quickly, usually without warn 100 people experiencing alcohol withdrawal
ing to the individual experiencing the seizure or only two or three of them will have a seizure.
anyone around him. The patient loses con The best single predictor of a future alcohol
sciousness, and if seated usually slumps over, withdrawal seizure is a previous alcohol with
but if standing will immediately fall to the floor. drawal seizure. Individuals who have had three
The patient’s body is rigid, and breathing ceas or more documented withdrawal episodes in
es. This part of the seizure is called the tonic the past are much more likely to have a seizure
phase, which usually lasts for a few seconds regardless of other factors including age, gen
and rarely more than a minute. der, or overall medical health. However, cer
tain other factors may increase the risk of
The next part of the seizure (more dramatic seizures for all patients:
and generally remembered by witnesses) con
64 Chapter 4
What To Do in the Event of a Seizure
• At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel.
• Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for
the clinic or hospital unit.
• While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt
to prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s head
and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen
by anyone.
• In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from
extreme headbanging by placing a soft object under the head and neck. Sometimes placing one’s hand or
shoe under the head is adequate.
• No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades).
Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially
swallowed and obstruct the airway.
• Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach
contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a
severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia.
• Even if the individual appears to become fully awake, alert, and oriented without any harm following a
seizure, it is strongly recommended that he be referred for medical evaluation.
• Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages
to reorient them as to what happened and where they are.
• Having drunk for more than two decades preferably with IV administration. The study
• Having poor general medical health and poor by D’Onofrio and colleagues (1999) indicated
nutritional status that a single dose of 1mg of IV lorazepam
reduced recurrent seizure risk, reduced rates
• Having had previous head injuries
of return to emergency departments, and low
• Having had disturbances of serum calcium, ered hospitalization rates. Despite this
sodium, potassium, or magnesium report, the consensus panel agrees that hospi
talization for further detoxification treatment
Patients having a witnessed seizure can be
is strongly advised to monitor and ameliorate
treated with IV diazepam or lorazepam and
other withdrawal symptoms, reduce suffering,
ACLS protocol procedures. This reduces but
and stabilize the patient for rehabilitation
does not completely prevent the likelihood of a
treatment.
second seizure (D’Onofrio et al. 1999). In the
rare patient with recurrent multiple seizures or The addition of antiepileptic drugs (AEDs)
status epilepticus (continuous seizures of sever has not been established as effective (Chance
al minutes) an anesthesiology consultation may 1991; Hillbom and HjelmJager 1984; Rathlev
be required for general anesthesia. Evaluation et al. 1994). This is primarily based on evalu
of electrolyte disturbances, central nervous sys ations of phenytoin (Dilantin and others).
tem (CNS) trauma, and consideration of seda Newer AEDs have not been studied extensive
tivehypnotic withdrawal should be reviewed. ly for preventing alcohol withdrawal seizures.
The consensus panel suggests that AED thera
Patients who have had a single witnessed or
py should be considered in alcohol withdraw
suspected alcohol withdrawal seizure should
al patients with multiple past seizures (of any
be immediately given a benzodiazepine,
cause), a history of recent head injury, past
Physical Detoxification Services for Withdrawal From Specific Substances 65
meningitis, encephalitis, or family history of mine whether the patient is using aspirin or
seizures. Further evaluation of a first seizure nonsteroidal antiinflammatory medications
often warrants neurologic evaluation (com (for example, Motrin or Advil, both containing
puterized tomography and electroencephalo ibuprofen) in conjunction with alcohol use.
gram), even if the seizure may be suspected to Antidiabetic agents in concert with alcohol may
have been due to alcohol withdrawal. produce hypoglycemia (low blood sugar) and
lactic acidosis (blood that has become too
acidic). The therapeutic efficacy and margin of
Patient Care and Comfort safety for the use of antianxiety medications,
Interpersonal support and hygienic care along antidepressants, and antipsychotic medication
with adequate nutrition should be provided. is thought by some to be lessened by alcohol
Staff assisting patients in detoxification should use, but this is based largely on anecdotal
provide whatever assistance is necessary to information. Alcohol interacts with numerous
help get patients cleaned up after entering the other classes of medications that lead to less
facility and bathed thoroughly as soon as they serious results. Some important examples are
have been medically stabilized. Attention to the sedatives, tranquilizers, antiseizure medica
treatment of scabies, body lice, and other skin tions, and anticoagulants (blood thinners) such
conditions should be given. Screening for as Coumadin. Patients who may be taking such
tuberculosis should be done. Dental and oral medications need to be carefully observed and
care should be made available. The patient have their medications carefully monitored.
should be screened for physical trauma,
including bruises and lacerations. Tetanus
immunization may be necessary. Patients with Opioids
an altered mental status or altered level of con Opioids are highly addicting, and their chronic
sciousness should be seen in emergency depart use leads to withdrawal symptoms that,
ments, evaluated, and possibly hospitalized. although not medically dangerous, can be high
Staff should continue to observe patients for ly unpleasant and produce intense discomfort.
head injuries after admission because some All opioids (e.g., heroin, morphine, hydromor
head injuries, such as subdural hematomas, phone, oxycodone, codeine, and methadone)
may not immediately be evident and cost con produce similar effects by interacting with
siderations may preclude obtaining a brain endogenous (produced by the body itself) opi
scan in some settings. oid (:, *, and 6) receptors (that is, specific sites
on cells where these substances bind to the
cell). Opioid agonists stimulate these receptors
Other Immediate Concerns
and opioid antagonists block them, preventing
Alcohol may interact with several classes of their action.
medicine to produce serious CNS depression.
Some examples include benzodiazepines, barbi
turates, meprobamate, and other sedative hyp Opioid Withdrawal Symptoms
notic groups. Metoclopramide and sedating All opioid agents produce similar withdrawal
antipsychotic medicines such as phenothiazines signs and symptoms with some variance in
also can produce CNS suppression. A disulfi severity, time of onset, and duration of symp
ramlike (Antabuse) reaction characterized by tomatology, depending on the agent used, the
flushing, sweating, tachycardia, nausea, and duration of use, the daily dose, and the interval
chest pain has been reported for metronidazole between doses. For instance, heroin withdrawal
and several antibiotics including, but not limit typically begins 8 to 12 hours after the last
ed to, cefamandole, cefoperazone, and cefote heroin dose and subsides within a period of 3
tan. Acetaminophen in low doses may act to 5 days. Methadone withdrawal typically
acutely with alcohol to produce hepatotoxicity begins 36 to 48 hours after the last dose, peaks
(liver damage). Clinicians also should deter
66 Chapter 4
after about 3 days, and gradually subsides over the opioid withdrawal syndrome, after which
a period of 3 weeks or longer. Physiological, dose reductions can be made gradually.
genetic, and psychological factors can signifi
cantly affect intoxication and withdrawal sever Medical complications associated with opioid
ity. Figure 44 summarizes many of the com withdrawal can develop and should be quick
mon signs and symptoms of opioid intoxication ly identified and treated. Unlike alcohol and
and withdrawal. sedative withdrawal, uncomplicated opioid
withdrawal is not lifethreatening. Rarely,
The clinician uses intoxication and withdraw severe gastrointestinal symptoms produced by
al measures as guides to avoid under or over opioid withdrawal, such as vomiting or diar
medicating patients during medically super rhea, can lead to dehydration or electrolyte
vised detoxification; the number and intensity imbalance. Most individuals can be treated
of signs determine the severity of opioid with with oral fluids, especially fluids containing
drawal. It is important to appreciate that electrolytes, and some might require intra
untreated opioid withdrawal gradually builds venous therapies. In addition, underlying
in severity of signs and symptoms and then cardiac illness could be made worse in the
diminishes in a selflimited manner. Repeated presence of the autonomic arousal (increased
assessments should be made during detoxifi blood pressure, increased pulse, sweating)
cation to determine whether symptoms are that is characteristic of opioid withdrawal.
improving or worsening. Repeated assess Fever may be present during opioid with
ments also should address the effectiveness of drawal and typically will respond to detoxifi
pharmacological interventions. Detoxification cation. Other causes of fever should be evalu
strategies should aim to establish control over ated, particularly with intravenous users,
Figure 44
Signs and Symptoms of Opioid Intoxication and Withdrawal
Opioid Intoxication Opioid Withdrawal
Signs Signs
Bradycardia (slow pulse) Tachycardia (fast pulse)
Hypotension (low blood pressure) Hypertension (high blood pressure)
Hypothermia (low body temperature) Hyperthermia (high body temperature)
Sedation Insomnia
Meiosis (pinpoint pupils) Mydriasis (enlarged pupils)
Hypokinesis (slowed movement) Hyperreflexia (abnormally heightened reflexes)
Slurred speech Diaphoresis (sweating)
Head nodding Piloerection (gooseflesh)
Increased respiratory rate
Symptoms Lacrimation (tearing), yawning
Euphoria Rhinorrhea (runny nose)
Analgesia (painkilling effects) Muscle spasms
Calmness
Symptoms
Abdominal cramps, nausea, vomiting, diarrhea
Bone and muscle pain
Anxiety
Source: Consensus Panelist Charles Dackis, M.D.
Physical Detoxification Services for Withdrawal From Specific Substances 67
because HIV infec Management of Withdrawal
tion, viral hepati
tis, abscesses,
With Medications
Methadone is the The management of opioid withdrawal with
infected injection
sites, and pneumo medications is most commonly achieved
most frequently nia occur common through the use of methadone (in addition to
ly in this popula adjunctive medications for nausea, vomiting,
used agent tion and always diarrhea, and stomach cramps). Federal regu
require medical lations restrict the use of methadone for opioid
approved for attention. Anxiety withdrawal to specially licensed programs,
disorders, especial except in cases where the patient is hospitalized
detoxification by ly those involving for treatment of another acute medical condi
panic anxiety, also tion. Methadone is the most frequently used
the FDA, and a might show agent approved for detoxification by the Food
increased intensity and Drug Administration (FDA), and a new
during opioid with medication, buprenorphine (discussed below),
new medication,
drawal. Finally, has been approved for use. Methadone can be
any condition used for detoxification from heroin and all opi
buprenorphine, involving pain is oid agonists.
likely to worsen
has been during opioid with Another commonly used agent is clonidine
drawal because of a (Gold et al. 1984), an aadrenergic agonist
approved for use. reduced pain that relieves most opioid withdrawal symp
threshold and the toms without producing opioid intoxication or
lack of analgesia drug reward. However, since clonidine detox
(pain relief) afford ification is less effective against many opioid
ed by opioid use. withdrawal symptoms, adjunctive medicines
This phenomenon is particularly common
often are necessary to treat insomnia, muscle
with dental pain and chronic back pain.
pain, bone pain, and headache. Adjunctive
agents should not be used in the place of an
adequate detoxification dosage. Additional
Management of Withdrawal
opioid agonists could be used theoretically for
Without Medications
detoxification but would have to be adminis
tered “off label,” because the FDA has
It is not recommended that clinicians attempt approved only methadone for this purpose.
to manage significant opioid withdrawal symp Offlabel use (prescribing an agent approved
toms (causing discomfort and lasting several for another condition) could be difficult to
hours) without the effective detoxification justify, given the efficacy of methadone in
agents discussed below. Even mild levels of opi reversing opioid withdrawal.
oid use commonly produce uncomfortable lev
els of withdrawal symptomatology. Detoxification is indicated for treatmentseek
Management of this syndrome without medica ing persons who display signs and symptoms
tions can produce needless suffering in a popu sufficient to warrant treatment with medica
lation that tends to have limited tolerance for tions and for whom maintenance is declined
physical pain. or for some reason is not indicated or practi
cal. In addition, individuals dependent on
opioids sometimes are hospitalized for other
health problems and may require hospital
based detoxification even though they are not
68 Chapter 4
seeking substance abuse treatment. Such and endocrinologic defects caused by longterm
patients also can be maintained on methadone heroin addiction. This is one of many impor
during the course of hospitalization for any tant reasons to consider conversion to mainte
condition other than opioid addiction. The nance during most methadone detoxification
hospital does not have to be a registered opi admissions.
oid treatment program, as long as the patient
was admitted for a detoxification treatment Once the dose requirement for methadone has
for some substance other than opioids. On been established, methadone can be given
the other hand, some persons may not have once daily and generally tapered over 3 to 5
used sufficient amounts of opioids to develop days in 5 to 10mg daily reductions. The initial
withdrawal symptoms, and for others suffi dose requirement is determined by estimating
cient time may have elapsed since their last the amount of opioid use and gauging the
dose to extinguish withdrawal and eliminate patient’s response to administered
the need for detoxification. methadone. Clinicians should take care not to
underdose patients with methadone; adequate
dosage is vitally important. Patients some
Methadone times exaggerate their daily consumption to
This section discusses methadone as an agent receive greater dosages of methadone. For
for detoxification. For detailed information this reason, history is no substitute for a
on methadone maintenance, readers are physical examination that screens for signs of
referred to TIP 43 MedicationAssisted opioid withdrawal. Treating clinicians should
Treatment for Opioid Addiction in Opioid not only be familiar with the intoxication and
Treatment Programs (CSAT 2005d). While withdrawal signs that are set forth in Figure
methadone is one of the more common medi 44 (p. 67), but also should be skilled in dis
cations for opioid detoxification, its use is cerning these features of opioid withdrawal.
highly regulated and it can only be prescribed Avoidance of overmedicating is crucial during
for withdrawal by a doctor at a Substance methadone detoxification because excessive
Abuse and Mental Health Services doses of this agent can produce overdose,
Administration (SAMHSA)certified whereas opioid withdrawal does not constitute
methadone clinic or if the patient is being a medical danger in otherwise healthy adults.
hospitalized for another medical condition. For more information on methadone and
(Detoxification programs may become certi other medications used to treat opioid addic
fied to prescribe methadone by undergoing tion, see TIP 43, MedicationAssisted
the process described in TIP 43.) Federal reg Treatment for Opioid Addiction in Opioid
ulations allow for the use of methadone in Treatment Programs (CSAT 2005d).
both a shortterm detoxification treatment of Patients with significant opioid dependence
less than 30 days and a longterm treatment may require a starting dose of 30 to 40mg per
of 30 to 180 days. The regulations also specify day; this dose range should be adequate for
that if a patient has failed two detoxification even the most severe withdrawal. If the
attempts in a 12month period he or she must degree of dependence is unclear, withdrawal
be evaluated for a different course of treat signs and symptoms can be reassessed 1 to 2
ment (e.g., ongoing opioid substitution hours after giving a dose of 10mg of
therapy). methadone. The practice of giving a dose of
Methadone is a longacting agonist at the :opi methadone and later assessing its effect (also
oid receptor site that, in effect, displaces hero termed a challenge dose) is an important
in (or other abused opioids) and restabilizes the intervention of detoxification. Sedation or
site, thereby reversing opioid withdrawal symp intoxication signs after a methadone challenge
toms. If maintained for long enough, this stabi dose indicate a lower starting dose. Similarly,
lizing effect can even reverse the immunologic intoxication at any point of the detoxification
Physical Detoxification Services for Withdrawal From Specific Substances 69
signals the need to hold or more rapidly wean muscle aches, and drug craving. Completion
(reduce to a zero dose) the methadone. Care rates for opioid detoxification using clonidine
should be taken to avoid giving methadone to have been low (ranging from 20 to 40 per
newly admitted patients with signs of opioid cent); those patients who complete the proce
intoxication, since overdose could result. dure are more likely to be dependent on opi
Note that methadone stabilization is the treat oids other than heroin, have private health
ment of choice for patients who are pregnant insurance, and report lower levels of subjec
and opioid dependent. tive withdrawal symptoms than those who do
not complete (Strobbe et al. 2003).
Clonidine (Catapres) An appropriate protocol for clonidine is
Clonidine was originally marketed and 0.1mg administered orally as a test dose. A
approved for the treatment of high blood pres dose of 0.2mg might be used initially for
sure but also has been used for opioid detoxifi patients with severe signs of opioid withdraw
cation since 1978. While clonidine is not FDA al or for those patients weighing more than
approved for treatment of opioid withdrawal, it 200 pounds. The sublingual (under the
is widely used “off label” for this purpose tongue) route of administration also may be
(Alling 1992) because the research literature used. Clinicians should check the patient’s
substantiates its effectiveness for this condition. blood pressure prior to clonidine administra
Advantages of clonidine over methadone in the tion and clonidine should be withheld if sys
treatment of opioid withdrawal are as follows: tolic blood pressure is lower than 90 or dias
tolic blood pressure is below 60. These
• Clonidine does not produce opioid intoxica parameters can be relaxed to 80/50 in some
tion and is not reinforcing. cases if the patient continues to complain of
• The FDA does not classify clonidine as having withdrawal and is not experiencing symptoms
abuse potential. Yet some abuse has been of orthostatic hypotension (a sudden drop in
reported. (See p. 107 under the section on blood pressure caused by standing).
pregnant women and opioids.) Clonidine (0.1 to 0.2mg orally) can then be
• Since clonidine does not interact with the given every 4 to 6 hours on an asneeded
:opioid receptor, detoxification occurs basis. Clonidine detoxification is best con
without opioids. ducted in an inpatient setting, as vital signs
and side effects can be monitored more close
• No special licensing is required for the dis
ly in this environment. In cases of severe
pensing of this medication.
withdrawal, a standing dose (given at regular
One disadvantage to methadone detoxification intervals rather than purely “as needed”) of
with naltrexone (an opioid antagonist), com clonidine might be advantageous (Alling
pared with clonidine, is that naltrexone, when 1992). The daily clonidine requirement is
it is prescribed for abstinence, can precipitate established by tabulating the total amount
opioid withdrawal if given too soon after the administered in the first 24 hours, and divid
last methadone dose. This problem does not ing this into a three or four times per day
exist with clonidine, making this agent particu dosing schedule. Total clonidine should not
larly beneficial in a drugfree treatment pro exceed 1.2mg the first 24 hours and 2.0mg
gram or a therapeutic community. after that, with doses being held in accor
dance with parameters noted above. The
Nevertheless, patients addicted to opioids standing dose is then weaned over several
generally prefer methadone over clonidine days. Clonidine must be tapered to avoid
detoxification. Although clonidine alleviates rebound hypertensions.
some symptoms of opioid withdrawal, it usu
ally is relatively ineffective for insomnia, The clonidine transdermal (administered
through the skin) patch, FDA approved in
70 Chapter 4
1986 for the treatment of hypertension (high Buprenorphine is available in oral form as
blood pressure), also is used in opioid detoxi Subutex, which contains only buprenorphine,
fication. However, the safety of the patch for and is meant for patients who are starting
treatment of opioid withdrawal has not been treatment for drug dependence. Another
sufficiently studied in controlled clinical tri form, Suboxone, contains buprenorphine and
als. The transdermal route of administration naloxone and is intended for persons depen
has the disadvantage of continued clonidine dent on opioids who have already started and
action even after the patch has been removed. are continuing medication therapy.
Blood pressure effects of clonidine can there Buprenorphine has great affinity for the
fore be prolonged, leading to undesirable and :opioid receptor, in
persistent reductions of blood pressure. For spite of being only a
this reason, it has been recommended that the partial agonist, and
patch be used only if the patient’s blood pres can displace other One advantage of
sure is monitored regularly (Alling 1992). opioids such as hero
in. This feature gives buprenorphine is
The clonidine patch is available in three buprenorphine the
sizes that deliver a total daily oral equivalent ability to precipitate
clonidine dose of 0.2mg (3.5 cm2), 0.4mg (7.0 that it can be
opioid withdrawal
cm2), or 0.6mg (10.5 cm2). The patch supplies when administered to
clonidine for up to 7 days and one patch patients who have
dispensed at a
application usually is sufficient. The conve recently used heroin
nience of one application allows the clinician (Kosten and physician’s office,
to avoid the disruption that multiple dosing McCanceKatz 1995).
might have during rehabilitative program unlike methadone,
ming. In particular, patients can focus on An advantage to
rehabilitative treatment without being dis buprenorphine is its which can be
tracted by the need to ask repeatedly for oral safety. Because of
clonidine doses. Vital signs should be moni the partial agonist
dispensed only at
tored at least four times daily to assess persis action, buprenor
tent signs and symptoms of withdrawal or phine has a “ceiling
undesirable effects of clonidine on blood pres effect” with regard to designated treat
sure. overdose potential
(Walsh et al. 1994). ment centers.
That is, unlike
Buprenorphine
Buprenorphine, a partial aopioid agonist that
methadone, which
produces increasing
is FDA approved in an injectable form respiratory suppression with increasing dose,
(Buprenex) for the treatment of pain, has respiratory effects of buprenorphine tend to
recently been approved as a detoxification level off due to its partial agonist action.
agent and for opioid maintenance treatment as Another advantage of buprenorphine is that
an alternative to methadone maintenance. A it can be dispensed at a physician’s office,
number of clinical trials have reported it to be unlike methadone, which can be dispensed
effective for heroin detoxification (Becker et al. only at designated treatment centers. This
2001; Bickel et al. 1988; Diamant et al. 1998), makes access to this medication for opioid
and the medication should play an important dependence much more convenient for both
role in gradually removing patients from patient and clinician. See TIP 40, Clinical
methadone maintenance (Amass et al. 2004; Guidelines for the Use of Buprenorphine in
Banys et al. 1994; Johnson et al. 2000). the Treatment of Opioid Addiction (CSAT
2004a).
Physical Detoxification Services for Withdrawal From Specific Substances 71
Unlike methadone, buprenorphine may be described above for heroin. The methadone
prescribed by physicians who are not con dose should be tapered gradually by 5 to
nected with a certified opioid treatment pro 10mg/week until a daily dose of 30 to 40mg has
gram. However, there is a still a specific been attained. At that time, detoxification with
training and certifi either clonidine or smaller doses of methadone
cation process can be instituted. The use of clonidine has the
Inpatient physicians must advantage of brevity as a complete clonidine
undergo in order to detoxification usually can be conducted within
prescribe the medi 2 to 3 weeks (Gold et al. 1984).
treatment can cation. Information
on the legal aspects Once the daily dose requirement has been
provide additional of prescribing established by using the principles outlined
buprenorphine and above, the patient can be placed on a stand
support, medical rules for carrying ing dose of clonidine. The dose required usu
out detoxification in ally is in the range of 0.2mg, three to four
supervision, and the physician’s times daily, although titration (adjustment of
office can be found dosage in light of drug response) is necessary
at http:// based on the information gathered during the
rehabilitative
www.buprenor clinical examination. Additional doses as
phine.samhsa.gov/. needed (sometimes abbreviated “PRN”) of
treatment that 0.2mg clonidine also can be given and blood
Information given
at the site includes pressure parameters must be followed prior
serve as to the administration of standing and PRN
the following on the
Drug Addiction doses to avoid orthostatic hypotension. The
disincentives to Treatment Act initial standing dose can be reduced to 0.1mg,
(DATA) of 2000: given three to four times daily, after one week
relapse. “[DATA 2000] of detoxification, with PRN doses of 0.1mg
expands the clinical available. After a period of 1 week on this
context of medica reduced dosage, clonidine is given for an
tionassisted opioid addiction treatment by additional week only if needed. Because cloni
allowing qualified physicians to dispense or dine does not reverse all opioid withdrawal
prescribe specifically approved Schedule III, symptoms, especially insomnia, adjunctive
IV, and V narcotic medications for the treat medications for symptom relief of insomnia,
ment of opioid addiction in treatment settings nausea, diarrhea, etc. usually are required.
other than the traditional Opioid Treatment Clonidine detoxification is best conducted on
Program (i.e., methadone clinic). In addition, an inpatient basis to ensure appropriate vital
DATA 2000 reduces the regulatory burden on sign monitoring. Inpatient treatment also
physicians who choose to practice opioid addic reduces the impulse to relapse, especially if
tion therapy by permitting qualified physicians the detoxification is difficult.
to apply for and receive waivers of the special Methadone detoxification can be continued
registration requirements defined in the once a daily dose of 30 to 40mg is achieved, as
Controlled Substances Act” (SAMHSA 2002). described above. The dose can be reduced to
20mg per day by a reduction of 5 to
Terminating Methadone
10mg/week. Once the patient is on 20mg/day,
methadone can be reduced by 1 to 2mg daily,
Maintenance Treatment
depending on clinical measures of withdraw
Individuals seeking the discontinuation of al. As with clonidine detoxification, the final
methadone maintenance require a much more 2 to 3 weeks of methadone detoxification is
lengthy detoxification process than that associated with recidivism (relapsing).
72 Chapter 4
Inpatient treatment, if available, can provide and shortened during the 1980s (Charney et
additional support, medical supervision, and al. 1982, 1986; Kleber et al. 1987; Riordan
rehabilitative treatment that serve as disin and Kleber 1980; Vining et al. 1988) so that a
centives to relapse. blocking dose of naltrexone—at least 25mg—
usually was used by the second or third day
of treatment. The ratelimiting factor of this
Rapid and Ultrarapid rapid clonidinenaltrexone method is its
Detoxification capacity to adequately relieve the precipitat
Although there are few data showing that the ed withdrawal symptoms in the conscious
rapid or ultrarapid methods of opioid detoxifi patient. Golden and Sakhrani (2004) found
cation show a positive correlation with the like that 25 percent of the 20 patients they studied
lihood of a patient’s being abstinent a few who were undergoing rapid detoxification
months later, efforts persist to make the detoxi using clonidine and naltrexone developed
fication process shorter and easier. This stems delirium and had to discontinue the proce
in part from the desire of the person addicted dure after the first day, and another patient
to opioids for a rapid, painless procedure, and dropped out before completion.
in part from an attempt to coax more such per The 1990s witnessed a variety of attempts to
sons into treatment (fewer than one in five peo overcome this barrier by using general anes
ple with substance use disorders in the United thesia or heavy sedation. Although the ultra
States are in treatment at any time) (Office of rapid procedure under anesthesia has
National Drug Control Policy 2002). Another received wide publicity, controlled studies
contributing factor is the American culture’s that would make it possible to evaluate the
search for rapidity in most endeavors. Finally, risk/benefit ratio are absent. The procedure
the desire for rapid opioid detoxification is a is still unproven and controversial. For a
remnant of the belief system of a century ago, brief review of studies done in this area, see
when detoxification often was erroneously Stine and colleagues (2003).
equated with cure.
Rapid methods of detoxification have at their Patient Care and Comfort
core the use of narcotic antagonists; for exam
ple, naloxone, naltrexone, or nalmefene, to Opioid detoxification, when properly conduct
precipitate narcotic withdrawal by displacing ed, usually can be concluded without signifi
exogenous opioids (those not produced by the cant patient discomfort. Aside from the com
body itself) from the receptor sites. The ensu passionate goal of preventing unnecessary suf
ing severe symptoms then are managed by a fering, appropriate opioid detoxification
variety of medications and techniques. This strengthens the therapeutic alliance between
procedure was tried in the mid1970s (Blachly the patient and clinician and prevents patients
et al. 1975; Resnick et al. 1977), using naloxone from leaving treatment prematurely.
combined with benzodiazepines or propranolol Discomfort also can indicate that too low a dose
to ameliorate symptoms, but relief was insuffi of the detoxification agent is being adminis
cient for the technique to be considered useful. tered. Mere symptomatic treatment is not a
substitute for reversing opioid withdrawal
With the discovery of clonidine as a nonopi and care should be taken to avoid masking
oid that could successfully treat much of the symptoms that would better respond to
withdrawal syndrome (Gold et al. 1978), the detoxification.
method became more successful, but was still
problematic. Using combinations of clonidine, Nevertheless, patients receiving adequate
naltrexone, benzodiazepines, and other detoxification doses still may complain of
adjunct medications, the method was refined symptoms that can be treated with adjunctive
Physical Detoxification Services for Withdrawal From Specific Substances 73
medications. Insomnia can be treated with
diphenhydramine (Benadryl) 50 to 100mg,
Benzodiazepines
trazodone (Desyrel) 75 to 200mg, or hydrox and Other Sedative
yzine (Vistaril) 25 to 50mg at bedtime.
Benzodiazepines should be avoided unless
Hypnotics
required for concomitant alcohol or sedative
detoxification. Headache, muscle aches, and Intoxication and Withdrawal
bone pain can be managed with acetamin Symptoms Associated With
ophen (e.g., Tylenol), aspirin, or ibuprofen
(e.g., Motrin) as needed. Abdominal cramps
Benzodiazepines and Other
are rare when the detoxification dose is suffi SedativeHypnotics
cient but can be ameliorated with dicyclomine Patients intoxicated with sedativehypnotics
(e.g., Bentyl) 10 to 20mg every 6 hours. appear similar to individuals intoxicated with
Mylanta or Maalox can be administered for alcohol. Slurred speech, ataxia, and poor phys
epigastric complaints and bismuth subcar ical coordination are prominent. If benzodi
bonate (e.g., PeptoBismol) 30 cc can be given azepines are used alone, breath and blood alco
every 2 to 3 hours for diarrhea. Constipation, hol levels should be zero. It should be remem
a frequent complaint during methadone main bered that benzodiazepines, when ingested
tenance, usually can be managed with milk of alone, intentionally, or accidentally in over
magnesia at 30 cc daily. dose, rarely lead to death by themselves.
Unfortunately, most individuals who ingest
Opioid dependence, particularly intravenous
benzodiazepines also may be using alcohol,
heroin dependence, is associated with a num
other sedativehypnotics, or other drugs of
ber of medical conditions. For this reason, a
abuse, which in combination with benzodi
complete physical examination, review of sys
azepines could be fatal if not managed appro
tems, and laboratory evaluation (when indi
priately.
cated) should be conducted. The patient
should be screened for tuberculosis as well as Management of benzodiazepines and other
for commonly encountered medical complica sedativehypnotics in overdose is in part sup
tions. These include HIV/AIDS, viral hepati ported following principles of ACLS with par
tis (especially B and C), other sexually trans ticular attention to ventilation. Additionally,
mitted diseases, and opportunistic infections. removal of the benzodiazepine from the gas
Injection sites should be examined for infec trointestinal tract using lavage and a cathar
tion or abscess and patients should be tic is generally carried out, particularly if the
queried about night sweats, chills, nutritional overdose is recent. Flumazenil (Romazicon) is
intake, diarrhea and gastrointestinal distress, a competitive antagonist that acts at the ben
fever, and cough. History or evidence of trau zodiazepine receptor. It can reverse the seda
ma also should be elicited as part of a com tive and overdose effects of benzodiazepines
prehensive assessment upon which a full but not of alcohol or other sedativehyp
treatment plan will be based. In general, notics. The medication is administered via IV
patients should be ambulatory and able to by slow push (2 to 3 minutes) and dosage
participate in rehabilitative activities during varies, depending on whether one is treating
detoxification. However, during the first 24 sedation reversal or overdose comareversal.
hours they may require bed rest or reduced Flumazenil is only effective in benzodiazepine
activity. overdose and is not an effective antidote
against other drugs. Clinicians should be
aware that in chronic benzodiazepine users
who are physically dependent, flumazenil
may induce seizures, high blood pressure,
74 Chapter 4
and delirium. So patients who are comatose diazepine are at risk for falls and myocardial
from benzodiazepines and are benzodiazepine infarctions. Delirium without marked auto
dependent may move quickly from coma to nomic hyperactivity (no elevations of pulse,
acute benzodiazepine withdrawal symptoms blood pressure, or temperature) also may be
when flumazenil is administered. seen in the elderly. The management of benzo
diazepine withdrawal is not recommended
Assessing the potential or actual severity of a without medical supervision. All benzodi
benzodiazepine and other sedativehypnotic azepines should be tapered rather than stopped
abstinence syndrome is based primarily on abruptly, regardless of dose or duration of
clinical information obtained from the patient, use—unless it is a
significant others, and physical assessment. matter of use for only
Confirmation of length of benzodiazepine treat a few days (Ashton
ment with significant others, local pharmacies, 2002). Patients
and treating physicians is useful. Specific name
of medication, dose, and duration of therapy
are vital. The presence or absence of alcohol Management intoxicated with
use is also important to know, as with the use of of
other sedativehypnotics, such as medications sedativehypnotics
for sleep. The existence of cooccurring psychi Withdrawal
atric disorders such as panic disorder also are With appear similar to
important factors and should be investigated. Medications
Cigarette smoking tends to induce the individuals
There are a limited
metabolism of some benzodiazepines and this
number of controlled
can be a factor in scheduling a taper. Physical intoxicated with
trials that can pro
assessment, with particular attention to mental
vide guidance regard
status, and neurologic exams are important. alcohol. Slurred
ing the management
Determination of vital signs also provides guid
of benzodiazepine
ance. A urine drug screen may confirm the
and other sedative speech, ataxia,
presence of benzodiazepines but otherwise will
hypnotic withdrawal.
not be particularly helpful. Although sedative
hypnotic withdrawal scales have been used in
For reviews, see and poor physical
Rickels and col
research studies, they are not widely available
leagues (1999) and coordination are
for clinical practice.
Eickelberg and Mayo
Medical complications of withdrawal from ben Smith (1998). One prominent.
zodiazepines include problems similar to those strategy that is appro
seen in alcohol withdrawal. Seizures are partic priate is to begin with
ularly worrisome and may occur without being a slow taper of the
preceded by other evidence of withdrawal. As benzodiazepine that the patient already is tak
in alcohol withdrawal, seizures and delirium ing. This taper may be conducted over several
represent the most extreme pathology seen. weeks or perhaps even months. This may be
Anecdotal reports appearing in the literature effective in cases of longacting benzodiazepines
also have described distortions in taste, smell, but often is not effective in detoxification from
and other perceptions. Since many individuals short halflife benzodiazepines. Sometimes
who take benzodiazepines have underlying switching to another benzodiazepine in a
anxiety disorders, it often is difficult during patient who has had serious loss of control and
periods of withdrawal to determine whether abuse problems with his primary agent is ther
symptomatology is related to withdrawal or the apeutic. Another strategy is to switch the
emergence of panic attack symptoms. Elderly patient to another benzodiazepine with a long
patients who are being withdrawn from benzo halflife. Frequently chlorodiazepoxide and
Physical Detoxification Services for Withdrawal From Specific Substances 75
clonazepam are recommended. Figures 45 and that, in more severe withdrawal syndromes,
46 (p. 78) give the equivalent doses of these they do not decrease symptoms. Imipramine
medicines along with numerous other sedative can lower the seizure threshold and therefore
hypnotics and benzodiazepines. is not recommended. The use of anticonvul
sants is probably best reserved as an adjunc
Another alternative is phenobarbital substitu tive medicine to the longacting benzodi
tion. For patients who have used high doses of azepine or phenobarbital. The use of bus
benzodiazepines for an extended period of pirone for benzodiazepine detoxification is
time, hospitalization is always prudent. ineffective and should not be considered. For
Outpatient detoxification should be reserved patients with major autonomic symptoms dur
for patients whose doses of benzodiazepines ing withdrawal that cannot be controlled by
were mainly in therapeutic ranges, who do not the primary treating agent, consideration of
have polysubstance dependence, and who are the use of a low dose of clonidine or propra
reliable and have reliable significant others to nolol may be helpful.
aid in monitoring and supervising their
progress. In the outpatient setting, patients and Preparing patients and starting detoxification
families need to be informed that even with during a period of low external stressors, with
sound withdrawal treatment, seizures and patient commitment to tapering, and a plan to
delirium are possible. The individual should be manage underlying anxiety disorders, also are
instructed not to drive or operate dangerous important in detoxification. A flexible detoxi
machinery during treatment and perhaps for fication schedule is advised. During periods
several weeks thereafter. Recurring assessment of increased withdrawal symptoms, dosage
will be necessary, particularly around times of should be stabilized or even increased for a
dosage reductions. Pregnant patients will need period of days. Frequent inperson or phone
to be detoxified slowly and in consultation with contact with the patient is vital. Patients
an obstetrician. being detoxified in the outpatient setting may
need to be seen several times per week, espe
A variety of cognitive and behavioral tech cially at times of dosage reductions.
niques have been proposed to assist in the pres
ence of a medication taper. These techniques
alter negative cognitions regarding medication Stimulants
cessation, provide patient education, and pro
Cocaine and amphetamines (such as metham
vide alternative cognitive and behavioral tech
phetamine) are the most frequently abused cen
niques for anxiety reduction and sleep
tral nervous system stimulants. These agents
enhancement during detoxification (Spiegel
are intensely rewarding and are selfadminis
1999).
tered by laboratory animals to the point of
Anticonvulsants such as carbamazepine and death. Individuals dependent on stimulants
valproate, as well as sedating antidepressants experience profound loss of control over stimu
such as trazodone and imipramine, have been lant intake, presumably in response to the
advocated for use in withdrawal (Dickinson et stimulation and disruption of endogenous (orig
al. 2003). Rickels and colleagues (1999) assert inating internally) reward centers (Dackis and
that these drugs have some beneficial effect in O’Brien 2001). They often use stimulants in a
the management of relatively lowdose benzo binge pattern that is followed by periods of
diazepine discontinuation in their ability to withdrawal. It is not clear whether craving
reduce patients’ subjective complaints, but occurs predominantly during stimulant with
76 Chapter 4
Figure 45
Benzodiazepines and Their Phenobarbital Withdrawal Equivalents
Generic name Trade name Therapeutic dose Dose equal to Phenobarbital
range (mg/day) 30mg of pheno conversion
barbital for with constant
drawal (mg)**
Benzodiazepines
* Usual hypnotic dose.
** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal
equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious highdose
withdrawal signs and symptoms.
*** Not applicable.
Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.
Physical Detoxification Services for Withdrawal From Specific Substances 77
Figure 46
Other SedativeHypnotics and Their Phenobarbital
Withdrawal Equivalents
Generic name Trade Common Dose equal Phenobarbital Conversion
name(s) therapeutic to 30mg of for with constants
indication therapeutic drawal (mg)**
dose range
(mg/day)
Barbiturates
Others
* Butalbital usually is available in combination with opioid or nonopioid analgesics.
** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal
equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious highdose
withdrawal signs and symptoms.
*** Not crosstolerant with barbiturates.
Source: APA 1990; Wesson and Smith 1985.
78 Chapter 4
drawal or after these symptoms have largely or amphetamine withdrawal and, in part, a
disappeared. While the processes that govern reaction to individuals’ acute realization of the
addiction to cocaine and amphetamines are devastating psychosocial consequences after a
believed to be similar, recent animal research binge ends. While both cocaine and
suggests that there are also subtle differences in amphetamine users may experience depression
the ways in which these two types of drugs cre during withdrawal, the period of depression
ate sensitization (and perhaps addiction) in reg experienced by amphetamine users is more
ular users (Li et al. 2005). prolonged and may be more intense.
Amphetamine users, in particular, should be
monitored closely during detoxification for
Stimulant Withdrawal signs of suicidality and treated for depression if
Symptoms appropriate.
Stimulants are associated with withdrawal Although the literature on cocaine withdrawal
symptoms that differ markedly from those seen is controversial, reasonable consensus supports
with opioid, alcohol, and sedative dependence the constellation of symptoms depicted in
(see Figure 47). While most clinicians believe Figure 47 (Coffey et al. 2000; Cottler et al.
that alcohol and heroin withdrawal should be 1993). These symptoms often disappear after
treated aggressively with detoxification, there several days of stimulant abstinence but can
has been little emphasis on treating symptoms persist for 3 to 4 weeks (Coffey et al. 2000). In
of stimulant withdrawal. Consequently, no addition, since individuals addicted to stimu
medications have been developed for this pur lants often fail to achieve abstinence, withdraw
pose. This situation is understandable because al symptoms can be a persistent component of
stimulant withdrawal usually does not involve active addiction. In addition, individuals
medical danger or intense patient discomfort. addicted to stimulants may experience impair
However, if stimulant withdrawal predicts poor ment in hedonic function (ability to experience
outcome, it may be a reasonable target for clin pleasure) that has been ascribed to stimulant
ical interventions. induced disruptions of endogenous reward cen
An often overlooked but potentially lethal ters (Dackis and O’Brien 2002). Research on
“medical danger” during stimulant withdrawal animals has found that exposure to high doses
is the risk of a profound dysphoria (depres of methamphetamine results in changes to both
sion, negative thoughts and feelings) that may the dopaminergic and serotonergic systems of
include suicidal ideas or attempts. This may the brain (Nordahl et al. 2005) and dopamine
be, in part, a physiological response to cocaine abnormalities among animals and humans who
had been ingesting cocaine (Schuckit 2000).
Figure 47
Stimulant Withdrawal Symptoms
• Depresion • Poor concentration
• Hypersomnia (or insomnia) • Psychomotor retardation
• Fatigue • Increased appetite
• Anxiety • Paranoia
• Irritability • Drug craving
Source: Consensus Panelist Robert Malcolm, M.D.
Physical Detoxification Services for Withdrawal From Specific Substances 79
Researchers have also observed abnormalities electrocardiogram (between the q wave and the
in regions of the brain that govern attention t wave), while QTc is the relative (or “correct
and memory in animals that were regularly ed”) QT interval. Some conditions and many
administered methamphetamine (Nordahl et al. drugs (LAAM, other opioids, and even antibi
2005). otics) can cause the interval to lengthen and
this can result in cardiac rhythm disturbances.
Although cocaine withdrawal has traditionally Anterior chest pain or cardiac symptoms
been viewed as relatively mild (Satel et al. should therefore be fully evaluated in these
1991; Weddington et al. 1990), evidence sug individuals. Seizures also may be a complica
gests that individuals dependent on cocaine tion of stimulant abuse and can occur during
with severe stimulant withdrawal are more like detoxification. Persistent headaches could rep
ly to have a poor clinical outcome (Kampman resent a subdural, subarachnoid, or intracere
et al. 2001a). The level of withdrawal symp bral bleed (bleeding in or around the brain)
toms, therefore, may be clinically significant and should be appropriately evaluated. It also
and should be monitored and recorded for should be emphasized that people who abuse
future treatment (Kampman et al. 2001b). stimulants usually become addicted to other
Kampman reported significantly higher substances, such as alcohol, sedatives, or opi
dropout rates in individuals dependent on oids, and therefore can experience any of the
cocaine who scored high on the Cocaine complications ascribed to detoxification from
Selective Severity Assessment (CSSA), a reli these substances. Covert (secretive) use of
able and valid structured interview designed to other substances should be suspected and
capture cocaine withdrawal symptoms assessed with urine toxicology.
(Kampman et al. 1998). Patients with high
scores on the CSSA were five times more likely
to leave treatment and four times more likely to Management of Withdrawal
resume cocaine use than those with low scores Without Medications
(Mulvaney et al. 1999). The CSSA is an easily
administered 18item questionnaire. Each item The most effective means of treating stimulant
is a 7point rating scale, so that a person can withdrawal involves establishing a period of
score a number of points on any given ques abstinence from these agents. Access to brief
tion. Scores in excess of 22 indicate the pres hospitalization, a level of care previously avail
ence of significant cocaine withdrawal. See able for those who abuse stimulants, has been
appendix C for more information on the CSSA. largely eliminated by managed care initiatives.
Given the poor prognosis associated with In its place, intensive outpatient treatment can
cocaine withdrawal, it is reasonable that more assist the patient to cease use long enough for
clinical attention be directed toward this phe withdrawal symptoms to abate entirely.
nomenon. Rehabilitative approaches to achieve stimulant
abstinence have been reviewed elsewhere
(Dackis and O’Brien 2001). The avoidance of
Medical Complications of cueinduced craving is particularly important
Stimulant Withdrawal in these individuals, especially in light of
research that shows limbic activation (activity
As previously noted, stimulant withdrawal is in a certain part of the brain) in response to
not usually associated with medical complica cueinduced craving (Childress et al. 1999). It
tions. However, patients with recent cocaine also is important that individuals dependent on
use can experience persistent cardiac complica stimulants abstain from other addictive sub
tions, including prolonged QTc interval and stances.
vulnerability for arrhythmia and myocardial
infarction (Chakko and Myerburg 1995). QT is
an interval of time that can be measured on an
80 Chapter 4
Management of Withdrawal or hydroxyzine (Vistaril) 25 to 50mg at bed
time. Benzodiazepines should be avoided unless
With Medications required for concomitant alcohol or sedative
There are no medications with proven efficacy detoxification. As stimulant withdrawal symp
to treat stimulant withdrawal. However, toms wane, patients are best treated with an
researchers have investigated some medications active rehabilitative approach that combines
for cocaine detoxification. Amantadine may entry into substance abuse treatment with sup
help reduce cocaine use in patients with more port, education, and changes in lifestyle.
severe withdrawal symptoms (Kampman et al.
2000). Modafinil, an antinarcolepsy agent with
stimulantlike action, is currently under inves Other Immediate Concerns
tigation by one research group as a cocaine Central nervous system stimulants exert most
detoxification agent (Dackis and O’Brien of their toxic effects through vasoconstriction
2002). One small study in Thailand found the (constriction of the blood vessels).
antidepressant mirtazapine (Remeron) was Consequently, a number of medical conditions
effective at reducing a number of the symptoms can arise from
associated with amphetamine withdrawal ischemia (lack of
(Kongsakon et al. 2005). None of these medica proper blood supply)
tions, however, are approved for use in treating
Intensive
or infarction (death
stimulant withdrawal and further research is of tissue as the result
needed. Gorelick and colleagues (2004) review of lack of blood sup
outpatient
the full range of clinical literature on pharma ply) as a result of
cological intervention for cocaine addiction. stimulant use. treatment can
Myocardial (heart
muscle) infarction assist the patient
Patient Care and Comfort and stroke are widely
Since stimulant withdrawal is not associated recognized complica to cease use long
with severe physical symptoms, adjunctive tions of stimulant use.
medications are seldom required. These However, other prob enough for
patients often are sleep deprived and might be lems such as sponta
unable to benefit from therapeutic activities neous abortion, bowel withdrawal
during the first 24 to 36 hours of abstinence. necrosis (tissue
They often are hungry and in need of large death), and renal
meal portions initially as their food intake may
symptoms to abate
(kidney) infarction
have been inadequate during active addiction. also have been
Stimulant users also may be irritable and care reported from entirely.
should be taken to avoid needless confrontation cocaineinduced vaso
during the initial withdrawal phase. Headaches constriction. Cardiac
often are reported and can be treated symp arrhythmias also are common. Other medical
tomatically. Persistent headaches should be problems that are associated with stimulant
evaluated, as cocaine can produce cerebrovas dependence include dental disease, neuropsy
cular disease. Similarly, chest pain of possible chiatric abnormalities, and movement distur
cardiac origin should be evaluated medically bances/disorders.
with electrocardiography, cardiac enzymes,
and appropriate medical attention. On occa Antidepressants, such as selective serotonin
sion, patients undergoing withdrawal from reuptake inhibitors, can be prescribed for the
cocaine or amphetamines report insomnia and depression that often accompanies metham
may benefit from diphenhydramine (Benadryl) phetamine or other amphetamine withdrawal.
50 to 100mg, trazodone (Desyrel) 75 to 200mg,
Physical Detoxification Services for Withdrawal From Specific Substances 81
There are no specific assessment instruments
Inhalants/Solvents available to measure inhalant withdrawal
symptoms. A patient who presents with a his
Withdrawal Symptoms tory of inhalant use and symptoms of seda
Associated With tivelike withdrawal should alert the clinician
Inhalants/Solvents to the possibility of inhalant withdrawal.
These patients require a complete history and
The term “inhalants” is used to describe a physical exam. Additionally, a blood alcohol
large and varied group of psychoactive sub level and urine drug screen are helpful in the
stances that all share the common characteris cases of suspected polydrug abuse.
tic of being inhaled for their effects. They are
commonly found in household, industrial, and
medical products. These drugs are used pri Medical Complications of
marily by adolescents, although some, especial Withdrawal From
ly the nitrates, are used by adults as well
(NIDA 2000). Figure 48 presents some of the
Inhalants/Solvents
more commonly abused inhalants. There are a large number of medical complica
tions associated with inhalant abuse and intoxi
Dependence on inhalants and subsequent cation. Many of these complications are not the
withdrawal symptoms are both relatively result of withdrawal but may still be seen when
uncommon phenomena (Balster 2003). There the patient presents to the clinician. Most
is no specific or characteristic withdrawal inhalants produce some neurotoxicity with cog
syndrome that would include all drugs in the nitive, motor, and sensory involvement.
inhalant class. Intoxication with the solvents, Additionally, damage to internal organs includ
aerosols, and gases often produces a syn ing the heart, lungs, kidneys, liver, pancreas,
drome most like that of alcohol intoxication and bone marrow has been reported.
but lasting only 15 to 45 minutes (Miller and
Gold 1990). Rarely, symptoms similar to
sedative withdrawal have been described, Management of Withdrawal
including “fine tremors, irritability, anxiety, Without Medications
insomnia, tingling sensations, seizures and
It is crucial to provide the patient with an envi
muscle cramps” (Miller and Gold 1990, p.
ronment of safety that removes him from access
87). Toluene withdrawal has been reported to
to inhalants. This can pose a challenge due to
cause delirium tremens (Miller and Gold
the almost universal availability of these drugs
1990). Longtime users also may exhibit weak
in society. Many of the medical consequences of
ness, weight loss, inattentive behavior, and
inhalant usage will remit once the patient
depression (NIDA 2005). It has been reported
achieves abstinence (Balster 2003). The patient
that withdrawal symptoms can occur with as
should be monitored for withdrawal symptoms
little as 3 months of regular usage (Ron 1986).
and changes in mental status.
When present, the withdrawal typically lasts
2 to 5 days (Evans and Raistrick 1987). Most patients presenting for treatment of
inhalant dependence will be adolescents.
In addition to their shortterm intoxicating
Ideally, they should be entered into an age
affects, nitrates are used to enhance sexual
appropriate treatment program that meets
pleasure by vasodilation (dilation of blood
their medical and psychosocial needs.
vessels) that produces a rush and sensation of
Supportive care, including helping them to get
warmth. There is no withdrawal syndrome
enough sleep and a wellbalanced diet, usually
that has been associated with nitrate abuse.
will be sufficient to get patients safely through
withdrawal (Frances and Miller 1998).
82 Chapter 4
Figure 48
Commonly Abused Inhalants/Solvents
Type Example Chemicals in Inhalant/Solvent
Degreaser Tetrachloroethylene, trichloroethane, trichloroethylene
Management of Withdrawal has been established, although some clinicians
have found phenobarbital useful (CSAT
With Medications 1995d). The usefulness of benzodiazepines is
Patients presenting with only inhalant with unknown but would seem a reasonable alter
drawal are unusual. Clinicians should prompt native given our current understanding of
ly ascertain if the patient has been abusing any inhalant withdrawal (Brouette and Anton
other substances and proceed with appropriate 2001). No other medications have been rou
detoxification as clinically indicated. When a tinely used for inhalant withdrawal.
patient presents with (1) a history of extensive
inhalant usage, (2) a sedativelike withdrawal
syndrome, and (3) no significant history or lab Patient Care and Comfort
oratory data that supports other substances, For patients who have only been abusing
then the clinician can assume that the patient is inhalants, treatment of insomnia during with
in inhalant withdrawal. drawal is not usually necessary. Sedative sub
stitution during the period of detoxification
As noted before, withdrawal from inhalants is
may allow the patient to sleep. However, a
similar to withdrawal from sedativehyp
period of postdetoxification insomnia should
notics. No systematic detoxification protocol
be expected and usually can be treated by the
Physical Detoxification Services for Withdrawal From Specific Substances 83
Figure 48 (continued)
Commonly Abused Inhalants/Solvents
Solvents and gases Nail polish remover Acetone, ethyl acetate
Paint remover Toluene, methylene chloride, methanol acetone, ethyl
acetate
Paint thinner Petroleum distillates, esters, acetone
Correction fluid and thinner Trichloroethylene, trichloroethane
Fuel gas Butane, isopropane
Lighter Butane, isopropane
Fire extinguisher Bromochlorodifluoromethane
Whippets Nitrous oxide
recommendation of good sleep hygiene prac
tices such as avoiding caffeine, daytime nap
Nicotine
ping, and overstimulation in the evening. In 2004, approximately 44.5 million adults
were cigarette smokers (23.4 percent were
If the patient is able to refrain from inhalant men and 18.5 percent were women) (CDC
(and other substance) use and has no serious 2005a). Nicotine addiction in the form of
psychiatric or medical consequences, then cigarette smoking accounts for more deaths
outpatient treatment should be the first each year than AIDS, alcohol, cocaine, hero
option. Inpatient or residential treatment in, homicide, suicide, motor vehicle crashes,
should be used for those patients who cannot and fires combined (U.S. Department of
achieve abstinence or have serious cooccur Health and Human Services [U.S. HHS]
ring medical or psychiatric disorders. 2000b). Between 1995 and 1999, there were
Hospitalized patients will need a thorough 490,000 smokingrelated premature deaths
history and physical exam. Therapy to annually, and smoking cost the country at
address denial, addiction, and pertinent psy least $157 billion yearly in healthrelated eco
chosocial issues should be initiated as soon as nomic losses. This amounts to approximately
possible during the hospitalization. $7.18 per pack of cigarettes (Fellows et al.
Supportive care and abstinence will resolve 2002), a truly staggering figure.
most medical problems associated with chron
ic inhalant usage (Balster 2003). Smokers are at increased risk for several
medical problems, including myocardial
infarction, coronary artery disease, hyperten
sion, stroke, peripheral vascular disease,
84 Chapter 4
chronic obstructive lung disease, chronic drink, and others have shown that continued
bronchitis, and several types of cancer (lung, nicotine dependence may be a relapse trigger
stomach, head and neck, and bladder). Other for resumption of drinking (Stuyt 1997). The
problems associated with nicotine addiction concern that smoking cessation may precipi
include gastroesophageal reflux disease and tate relapse to other substances of abuse has
gastric ulcerations, cataracts, and premature not been supported in the literature (Hughes
wrinkling of the skin. There also appears to 1995).
be an antiestrogen effect (suppression of an
important hormone) that may lead to early Treatment programs that have attempted to
development of osteoporosis in women treat nicotine dependence in conjunction with
(Okuyemi et al. 2000). other drugs of addiction have met with limit
ed success (Bobo and Davis 1993; Burling et
In 1988, the U.S. Surgeon General’s Report al. 1991; Hurt et al. 1994) and have generat
concluded that nicotine is the principal addic ed increased interest in smoking cessation as
tive agent in tobacco. Nicotine binds to nico a part of a patient’s overall substance abuse
tinic acetylcholine receptors in the brain and treatment (Sees and Clark 1993). One study
has the direct ability to stimulate the release reported that forcing unmotivated patients
of dopamine in the nucleus accumbens area. (or patients who did not consider smoking a
The nucleus accumbens has long been consid problem) to quit was countertherapeutic
ered the “reward center” in the brain. This (Trudeau et al. 1995).
increase in dopamine is similar to what occurs
when patients use stimulants and is felt to be Moreover, it has traditionally been accepted
an essential element in the reward process of that nicotine detoxification concurrent with
addiction (Glover and Glover 2001). detoxification from other substances makes
the undertaking more difficult. Several fac
As many as 90 percent of patients entering tors are involved including the following: (1)
treatment for substance abuse are current patient ambivalence and/or lack of interest in
nicotine users (Perine and Schare 1999). smoking cessation; (2) physician ambivalence
There has long been controversy in the field about the importance of smoking cessation
of addiction medicine as to how best to handle early in treatment; (3) staff’s use of nicotine;
the problem of nicotine dependence in (4) staff’s ambivalence about the importance
patients seeking treatment for other types of of nicotine cessation early in treatment; (5)
substance abuse. Traditionally, it has been easy availability of cigarettes from peers,
argued that patients would find that trying to family, visitors, staff, and at 12Step meet
stop smoking while also contending with other ings; (6) lack of sufficient training and exper
(more pressing) addiction problems would be tise on the part of physicians and staff in
too difficult and distracting in early absti managing nicotine withdrawal; and (7) staff
nence. However, others argue that nicotine resistance to patient smoking cessation
dependence is a lethal disease and that physi because withdrawal symptoms include irri
cians have the responsibility to intervene in tability, anxiety, and depression, all of which
this addiction with the same aggressiveness can make patients more difficult to manage.
they show toward other addictive substances.
This prointervention position has received
increasing attention from clinicians, inasmuch Withdrawal Symptoms
as it is now understood that alcohol consump Associated With Nicotine
tion is associated with increased nicotine The Diagnostic and Statistical Manual of
usage (Henningfield et al. 1984). Gulliver and Mental Disorders, 4th edition, text revision
colleagues (1995) have demonstrated that the (DSMIVTR) (APA 2000) notes that typically,
urge to smoke is correlated with the urge to a person in nicotine withdrawal will have four
Physical Detoxification Services for Withdrawal From Specific Substances 85
or more of the signs presented in Figure 49, 410) has been reduced to six questions
though some clinicians believe that three or (Giovino et al. 1995; Heatherton et al. 1991).
more is sufficient to make the diagnosis of Scores greater than seven are consistent with
nicotine withdrawal. Furthermore, it should nicotine dependence.
be noted that symptoms vary in duration and
intensity, with decreased heart rate and light While both the FTQ and FTND are very use
headedness resolving in 48 hours, while ful for estimating a patient’s physical depen
increased appetite may remain present for dence on nicotine, there is still a need to
weeks to months (Glover and Glover 2001). assess more accurately the degree to which
Smokers who have severe craving during smoking behavior plays a role in maintaining
withdrawal are less likely to be successful in addiction. The GloverNilsson Smoking
their attempt at quitting (Hughes and Behavioral Questionnaire (GNSBQ) is an 11
Hatsukami 1992). Depression during with question, selfadministered test that evaluates
drawal also has been linked to relapse to the impact of behaviors and rituals associated
smoking (Covey et al. 1993). with smoking (see Figure 411, p. 88). It was
designed to assist clinicians in identifying and
quantifying behavioral aspects of smoking
Assessing Severity that play a role in maintaining nicotine
Since 1978, the standard instrument used to dependence, which can then help the clinician
measure physical dependence on nicotine has develop a cessation strategy that takes into
been the eightitem Fagerstrom Tolerance account both physical dependence and behav
Questionnaire (FTQ) (Fagerstrom 1978). A ioral dependence (Glover et al. 2002).
later revision known as the Fagerstrom Test
for Nicotine Dependence (FTND) (see Figure
Figure 49
DSMIVTR on Nicotine Withdrawal
A. Daily use of nicotine for at least several weeks.
B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24
hours by 4 or more of the following signs:
1. Dysphoric or depressed mood
2. Insomnia
3. Irritability, frustration, or anger
4. Anxiety
5. Difficulty concentrating
6. Restlessness
7. Decreased heart rate
8. Increased appetite or weight gain
C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
Source: APA 2000, pp. 244–245.
86 Chapter 4
Figure 410
Items and Scoring for the Fagerstrom Test for Nicotine Dependence
Questions Answers Points
1. How soon after you wake up do you smoke your Within 5 minutes 3
first cigarette? 6–30 minutes 2
31–60 minutes 1
After 60 minutes 0
2. Do you find it difficult to refrain from smoking in Yes 1
places where it is forbidden (e.g., in church, at the No 0
library, in the cinema, etc.)?
5. Do you smoke more frequently during the first Yes 1
hours of waking than during the rest of the day? No 2
6. Do you smoke if you are so ill that you are in bed Yes 1
most of the day? No 0
Source: APA 1996.
To better understand a patient’s level of nico tine replacement therapy and patients often
tine dependence, providers can assess bio find it a helpful motivator in their attempt to
chemical markers including nicotine, coti maintain abstinence (Benowitz 1983).
nine, and carbon monoxide. Nicotine and its
metabolite cotinine can be measured in urine,
blood, or saliva. Cotinine continues to be pre Medical Complications of
sent in bodily fluids for up to 7 days after ces Withdrawal From Nicotine
sation. Clinicians should use caution when There are no major medical complications pre
interpreting the meaning of nicotine and coti cipitated by nicotine withdrawal itself.
nine assays, as they are not specific to tobac However, patients frequently experience
coderived nicotine and may indicate the uncomfortable withdrawal symptoms starting
patient’s compliance with nicotine replace within a few hours of cessation. In addition to
ment therapy rather than smoking. the symptoms previously noted, patients may
Carbon monoxide is easily measured in complain of increased coughing, a desire for
expired breath and can show whether the sweets, and difficulty concentrating (Hughes
patient has been smoking within a few hours and Hatsukami 1992). Clinicians should be
prior to the test. It can be used to monitor aware that withdrawal symptoms can masquer
smoking cessation for patients receiving nico
Physical Detoxification Services for Withdrawal From Specific Substances 87
Figure 411
The GloverNilsson Smoking Behavioral Questionnaire (GNSBQ)
Please indicate your choice by circling the number that best reflects your choice.
0 = Not at all; 1 = Somewhat; 2 = Moderately so; 3 = Very much so; 4 = Extremely so
How much do you value the following (Specific to Questions 1–2)?
1. My cigarette habit is very important to me. 0 1 2 3 4
2. I handle and manipulate my cigarette as part of the ritual of smoking. 0 1 2 3 4
Please indicate your choice by circling the number that best reflects your choice.
(Specific to Questions 3–11).
0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always
3. Do you place something in your mouth to distract you from smoking? 0 1 2 3 4
4. Do you reward yourself with a cigarette after accomplishing a task? 0 1 2 3 4
5. If you find yourself without cigarettes, will you have difficulties in concentrating
before attempting a task? 0 1 2 3 4
6. If you are not allowed to smoke in certain places, do you then play with your
cigarette pack or a cigarette? 0 1 2 3 4
7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa,
room, car, or drinking alcohol)? 0 1 2 3 4
8. Do you find yourself lighting up a cigarette routinely (without craving)? 0 1 2 3 4
9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,
chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or
frustration, etc.? 0 1 2 3 4
10. Does part of your enjoyment of smoking come from the steps (ritual) you take
when lighting up? 0 1 2 3 4
11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe,
secure, or more confident if you are holding a cigarette? 0 1 2 3 4
TOTAL_______
Scoring for Behavioral Dependence
<12 Mild
12–22 Moderate
23–33 Strong
>33 Very Strong
Source: Glover et al. 2002
88 Chapter 4
ade as other psychiatric conditions, especially lent pharmaceutical guide. Figure
anxiety and depression (see Figure 412). 413 (p. 90) shows the effects of abstinence
from smoking on blood levels of a number of
Smoking cessation also may affect the medications.
metabolism of other drugs primarily through
the Cytochrome P 450 (CYP450) system. This
system is one of many hepatic liver enzyme sys Management of Withdrawal
tems that is responsible for the metabolic Without Medications
breakdown of various drugs into inactive com
pound products. Different drugs and com About one third of current smokers attempt
pounds have varying affinities for the CYP450 to quit smoking each year and more than 90
system. The higher the affinity, the faster the percent of these try to do so without any for
breakdown of the drug or compound in the mal nicotine cessation treatment. Most smok
body. Some compounds can slow the ers will make several attempts on their own to
metabolism or breakdown of other drugs with a quit and ultimately, only about 50 percent are
lower affinity, leading to a buildup of that drug successful over a lifetime (U.S. HHS 2000b).
or compound in the body. While some smokers are able to quit on their
own, others may require intervention in the
During detoxification from nicotine, some form of behavioral treatment and/or pharma
medications will have their metabolism cotherapy.
altered, including theophylline, caffeine,
tacrine, imipramine, haloperidol, penta There are insufficient data available to deter
zocine, propranolol, flecainide, and estradiol; mine who will benefit most from a particular
in general, these effects are shortlived and type of treatment. Some patients may prefer
seldom drastic. Nicotine also reduces beta to stop smoking without the use of medica
blockers’ ability to lower blood pressure and tion. An elevated score on the GNSBQ would
heart rate and decreases the amount of seda indicate a strong behavioral component to
tion from benzodiazepines as well as de smoking that might guide the clinician in rec
creases the amount of pain relief provided by ommending behavioral treatment as a prima
some opioids, most likely because of its stimu ry intervention. Patients who also have ele
lant effects (Zevin and Benowitz 1999). A vated FTQ scores may benefit by a combina
complete discussion of nicotine’s effects on tion of behavioral and pharmaceutical inter
medications is beyond the scope of this TIP vention.
and physicians are encouraged to consult the
Physicians’ Desk Reference (2004) or equiva
Figure 412
Some Examples of Nicotine Withdrawal Symptoms That Can Be
Confused With Other Psychiatric Conditions
Anxiety
Depression
Increased REM (rapid eye movement) sleep
Insomnia
Irritability
Restlessness
Weight gain
Source: APA 1996.
Physical Detoxification Services for Withdrawal From Specific Substances 89
Figure 413
Effects of Abstinence From Smoking on Blood Levels of
Psychiatric Medications
Source: APA 1996.
The U.S. Public Health Service’s Treating interventions alone have not been very suc
Tobacco Use and Dependence: Clinical cessful at helping people achieve abstinence
Practice Guideline is a comprehensive review from tobacco. The Guideline suggests, howev
of the smoking cessation literature (Fiore et er, that selfhelp can be a useful adjunct to
al. 2000a). It discusses a range of nonphar other forms of treatment (Fiore et al. 2000a).
macological interventions for the management
of withdrawal from nicotine; these can be sep One type of selfhelp intervention that shows
arated into two basic categories: selfhelp some promise is the use of computergenerat
interventions and behavioral interventions ed personalized written feedback for patients.
(Anderson and Wetter 1997). The computer makes recommendations based
on an individual’s response to standardized
questions about her smoking (Etter and
Selfhelp interventions Perneger 2001; Shiffman et al. 2000).
Many tobacco users prefer to attempt to quit
without any assistance from professionals. A Behavioral interventions
number of selfhelp products are available
that can assist them in their cessation The U.S. Public Health Service study noted
attempts. These include a wide array of pam that when physicians took as little as 3 min
phlets, manuals, video and audiotapes (e.g., utes to advise their patients to stop smoking,
from the American Lung Association and the longterm quit rates were modestly improved
National Cancer Institute), 12Step selfhelp from 7.9 percent to 10.2 percent (Fiore et al.
support groups, and telephone helplines. The 2000a). Westmaas and colleagues note that
U.S. Public Health Service’s Guideline, which “simple, clear advice from a physician can be
analyzed all types of selfhelp interventions considered an easy, costeffective intervention
together, found that the selfhelp approach to that not only moves smokers closer to the
cessation yielded results only slightly better decision to quit, but also may motivate some
than no intervention at all. To date, selfhelp smokers to make an actual attempt”
90 Chapter 4
(Westmaas et al. 2000, p. 58). The greater the effective but not routinely recommended
amount of time in facetoface interventions, (Fiore et al. 2000a).
the higher the success rate for patients, but
interventions as short as 3 minutes have been
found to be effective (Fiore et al. 2000a). A Management of Withdrawal
counseling session of longer than 10 minutes With Medications
produced a cessation rate of 20.1 percent A U.S. Public Health Service panel recom
compared to a rate of 10.9 percent for no mends that all primary care physicians pro
treatment. The guideline also indicated that if vide a fivestep intervention, known as the “5
cessation information is given by multiple A’s,” to all tobacco users. The panel recom
types of providers (e.g., physician, psycholo mends that all smokers who want to quit
gist, dentist, nurse, and pharmacist) it can should be offered active medication that has
have a dramatic effect on cessation rates, been approved for assisting in smoking cessa
increasing the rate to 23 percent compared to tion unless there is a medical contraindication
10.8 percent for patients who had no (Fiore et al. 2000a). Figure 414 provides a
provider contact. summary of the “5 A’s” for brief intervention.
A review of behavioral intervention studies
concluded that both supportive care by a Nicotine Replacement
clinician and the ability of patients to develop
problemsolving and coping skills improved Therapy (NRT)
success rates for smoking cessation (Anderson Nicotine polacrilex gum was approved by the
and Wetter 1997). Other components such as FDA in 1984. In the 1990s other NRTs received
cigarette fading (gradually decreasing the FDA approval, including the nicotine transder
number of cigarettes smoked over a period of mal patch, the nicotine nasal spray, and the
time), establishing a quit date, enhanced envi nicotine inhaler. Nicotine gum and nicotine
ronmental support, improved diet and transdermal patch are now available over the
increased exercise, relaxation training, and counter. After the acute withdrawal period,
contingency contracting were not associated patients are then weaned off the medication
with improved outcome. Aversive condition until they become nicotine free. All NRTs are
ing, such as rapid smoking techniques, is
Figure 414
The “5 A’s” for Brief Intervention
Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.
Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.
Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this
time?
Assist in quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacother
apy to help him or her quit.
Arrange followup. Schedule followup contact, preferably within the first week after the quit date.
Source: Fiore et al. 2000a, p. 26.
Physical Detoxification Services for Withdrawal From Specific Substances 91
effective, with 1year quit rates between 11 and Bupropion SR
34 percent (Okuyemi et al. 2000).
Bupropion SR (Sustained Release) was initially
There has been some concern about the manufactured under the name Wellbutrin as a
addictive potential of NRTs, and it has been treatment for major depressive disorder. In
reported that 5 to 20 percent of patients using 1997, the FDA approved bupropion SR for
nicotine polacrilex gum continue to use it for smoking cessation, and it has been marketed
more than 1 year (Hughes 1989). There was under the name Zyban. Bupropion is a novel
also initial concern that the nicotine nasal antidepressant that is involved primarily with
spray, with its rapid onset of action and high dopamine but also affects adrenergic mecha
plasma concentrations, might become a drug nisms in the central nervous system. Its exact
of abuse. This has not been reported in the mechanism of action is unknown, but it is not a
literature, and it nicotine substitute or replacement like the
could be speculated NRTs. The recommended dose is 150mg daily
that this is because for 3 days and then 150mg twice daily for 7 to
of the nasal spray’s 12 weeks. Typically patients set their quit date
relatively uncom 1 to 2 weeks from the time they start the medi
Patients should be fortable side effects cation in order to get the drug to therapeutic
that cause many levels. This is an ideal time for the patient to
encouraged to use patients to dislike focus on making behavioral changes and enlist
the product (Schuh ing social support to augment his quit attempt.
combined NRT et al. 1997). In gen Bupropion SR has proven useful in smoking
eral, withdrawal cessation with a 12month abstinence rate of
treatments if they symptoms from 35.5 percent compared to a placebo at 15.6
NRTs are mild com percent and the nicotine patch at 16.4 percent
are unable to quit pared to those that (Westmaas et al. 2000). The most commonly
occur in smoking reported side effects include dry mouth and
cessation, and con insomnia. Bupropion SR should not be used in
using a single type
tinued use of these patients with a history of seizures, heavy alco
products may be the hol use, head trauma, or with anorexia or
of first line result of patients’ bulimia.
fear of returning to
pharmacotherapy. active smoking
(APA 1996). For
Other nonnicotine
those patients who pharmacotherapy
continue to use Covey and colleagues examined nonnicotine
NRTs, providers pharmaceutical products that have been evalu
should balance the patient’s continued depen ated in controlled trials of smoking cessation
dence on nicotine with the considerable (Covey et al. 2000). These drugs include the
health benefit of decreasing active tobacco following:
usage. It is clear that constituents of tobacco • The alpha2 agonist antihypertensive,
other than nicotine are responsible for caus clonidine
ing cancer. No ill effects have been attributed
• The tricyclic antidepressant, nortriptyline
to longterm use of nicotine replacement ther
apy (Benowitz and Gourlay 1997). • The monoamine oxidase inhibitor (MAOI)
antidepressant, moclobemide
• The serotonin 5HT1A agonist anxiolytic,
buspirone
92 Chapter 4
• The antihypertensive CNS nicotinic receptor els, several clinical trials have evaluated the
blocker, mecamylamine effectiveness of combining available products.
• Oral dextrose tablets The simultaneous use of nicotine gum and the
nicotine patch has been evaluated in several
Although none of these agents has been studies. Shortterm gains in cessation were seen
approved by the FDA for smoking cessation, with the combination compared to either medi
clonidine, nortriptyline, and moclobemide have cation alone, but no longterm benefits in absti
all been found to be effective treatments (Covey nence were demonstrated (Anderson and
et al. 2000). Clonidine may be a helpful Wetter 1997). Blondal and colleagues (1999)
adjunct to nicotine replacement during acute compared the combination of nicotine nasal
nicotine withdrawal. Doses of 0.05mg to 0.1mg spray and the nicotine patch to the patch alone
three times a day can be tried as tolerated and found that at 3 months 37 percent of the
(sedation and low blood pressure are con patients were smoke free (compared to 25 per
cerns), and the medication needs to be tapered cent for the patch alone). An openlabel study
when discontinued to avoid rebound hyperten of the combined use of nicotine inhaler and the
sion. nicotine patch found a 12week cessation rate
of 30 percent and good tolerability for the com
The Public Health Service’s Treating bination (Westman et al. 2000).
Tobacco Use and Dependence: Clinical
Practice Guideline (Fiore et al. 2000a) has Socalled “combination NRT” involves com
classified nortriptyline and clonidine as sec bining different types of nicotine replacement
ondline treatments. Clonidine is an antihy products, such as the patch and gum, on the
pertensive and may be appropriate for premise that doing so will boost nicotine
patients addicted to certain types of drugs but blood levels. Further rationale for this prac
not appropriate for others. The antidepres tice is that a “passive” nicotine delivery sys
sant selective serotonin reuptake inhibitor tem (i.e., patch) produces relatively steady
(SSRI) fluoxetine has been tested in a number levels of nicotine in the body that prevent the
of multisite trials (Cook et al. 2004; Hitsman user from going below a threshold minimum
et al. 1999; Niaura et al. 2002) and found to while “active” NRTs (i.e., gum, inhaler,
have a small benefit at best, although for spray, sublingual tablet, etc.) permit the user
patients who experience mild depressive to respond to situational cravings with ad libi
states it may be a worthwhile adjunctive tum dosing on an acute basis. Several clinical
treatment. The usefulness of other SSRIs for trials have evaluated the effectiveness of com
smoking cessation is unknown, but studies bining available NRT products (for a review
have generally been unfavorable. More infor see Silagy et al. 2000). After reviewing avail
mation on smoking cessation for people with able data, the Guideline panel (Fiore et al.
cooccurring substance use and other mental 2000a) felt that there was moderately strong
disorders can be found in appendix D of TIP evidence to conclude that “Combining the
42, Substance Abuse Treatment for Persons nicotine patch with a selfadministered form
With CoOccurring Disorders (CSAT 2005c). of nicotine replacement therapy (either the
nicotine gum or nicotine nasal spray) is more
efficacious than a single form of nicotine
Combination drug therapy replacement, and patients should be encour
Combining NRT products aged to use such combined treatments if they
NRT products typically provide less than half are unable to quit using a single type of first
the nicotine plasma levels that cigarette users line pharmacotherapy” (Fiore et al. 2000a, p.
achieve through smoking (Benowitz et al. 1997; 77).
Dale et al. 1995; Gupta et al. 1995; Lawson et
al. 1998). To attempt to increase nicotine lev
Physical Detoxification Services for Withdrawal From Specific Substances 93
NRT using highdose nicotine and emotional support to patients attempting
to quit. Discussing nicotine withdrawal symp
patch therapy toms can often help allay patient concerns.
The highest dose of nicotine available by patch
is 22mg. Several studies have evaluated Fear of weight gain is a barrier for many who
whether higher doses of nicotine (up to 44mg) want to quit smoking (French et al. 1995).
improve abstinence rates. The effect of this This is an especially important issue for
strategy has been small and the routine use of women and may deter their attempts to stop
higher dose patches is not recommended smoking (Gritz et al. 1989). Though the
(Hughes et al. 1999; Killen et al. 1999). health gains of stopping smoking clearly out
weigh the health risks of weight gain, this
argument does little to assuage patients’
Combining nicotine patch fears. Dieting during smoking cessation is not
and bupropion SR recommended in general and has been shown
to increase the likelihood of smoking relapse
In a doubleblind, placebocontrolled study,
(Hall et al. 1992). Physicians should, howev
the combination of bupropion SR and the nico
er, recommend both exercise and proper
tine transdermal patch showed higher absti
nutrition for patients attempting to stop
nence rates at 12 months (35.5 percent) com
smoking. Patients should be informed that
pared to bupropion SR alone (30.3 percent),
alcohol use also is considered a risk factor for
nicotine patch alone (16.4 percent), or placebo
relapse to smoking by most clinicians
patch and pill group (15.6 percent) (Jorenby et
(Shiffman 1982), and patients who can
al. 1999). This combination was well tolerated.
abstain from drinking during the withdrawal
Clinicians who use this combination should
period should do so.
first start the patient on bupropion SR 150mg
for 3 days and then increase the dosage to Patients generally will find a smokefree envi
150mg twice daily for 1 to 2 weeks prior to the ronment helpful during quit attempts. If the
day of smoking cessation. On the “quit day,” patient lives in a household where others
nicotine patch therapy should be initiated and smoke, household members and friends can
the combination treatment continued for 3 to 6 help by not smoking in front of the patient
months (Okuyemi et al. 2000). and limiting the number of smoking cues in
their residence.
Patient Care and Comfort Patients with more severe nicotine depen
Most smokers attempt cessation on an outpa dence may benefit from enrollment in a spe
tient basis and without any assistance from cialized smoking cessation program. They
professionals. However, if a patient decides might also benefit from more intensive medi
that she or he wants help with smoking cessa cal management using several drugs (NRT +
tion, it is important for the clinician to present anticraving), medication for longer periods of
a supportive and nonjudgmental attitude and time, closer followup, and longer enrollment
develop a therapeutic alliance with the patient. in treatment. There are a number of cessation
It must be emphasized that nicotine depen programs available from organizations such
dence is a chronic relapsing disorder and that as the American Lung Association
patients often make several attempts at quitting (http://www.lungusa.org) and the American
before succeeding. Cancer Society (http://www.cancer.org). Some
community and local organizations also spon
Most smokers who want treatment will seek sor smoking cessation programs. For the most
help from their primary care physician. The severely dependent smokers, there are a lim
physician has the responsibility of providing ited number of residential facilities that treat
pharmaceutical treatment, education about nicotine dependence on an inpatient basis
common problems associated with cessation, (Hurt et al. 1992). Providers of detoxification
94 Chapter 4
services should be familiar with the programs no immediate medication during the detoxifi
available in their communities in order to cation period and usually are selflimiting.
make referrals. However, the clinician should be aware of the
potential for more persistent problems.
Screening the patient for suicidal ideation or
Marijuana and Other other mental health
problems is warrant
Drugs Containing THC ed. Some reviews Most experts now
Marijuana and hashish are the two sub have advocated the
stances containing THC (delta9tetrahydro use of buspirone as believe that a
cannabinol) commonly used today. The field an alternative to
of addiction medicine has given considerable benzodiazepines for THCspecific with
attention to the question of whether there is a the management of
specific withdrawal syndrome associated with persistent general
cessation from prolonged THC use. In the
drawal syndrome
ized anxiety (Gatch
past, many have stated that there is no acute and Lal 1998). Other
abstinence syndrome that develops in people common problems
does occur in some
who abruptly discontinue THC (CSAT encountered during
1995d). More recently this has been called withdrawal can be patients who are
into question and most experts now believe managed with nonad
that a THCspecific withdrawal syndrome dictive, supportive heavy users,
does occur in some patients who are heavy medications. For
users (Budney et al. 2001), though cannabis patients with more though cannabis
withdrawal is not yet included in the APA’s persistent difficulty
Diagnostic and Statistical Manual of Mental sleeping, clinical withdrawal is not
Disorders. experience suggests
that Trazodone may yet included in the
The THC abstinence syndrome usually starts
be useful. Trazodone
within 24 hours of cessation. The amount of
can lead to low blood
THC that one needs to ingest in order to APA’s Diagnostic
pressure upon stand
experience withdrawal is unknown. It can be
ing, dizziness, and
assumed, however, that heavier consumption and Statistical
may increase falls,
is more likely to be associated with withdraw
particularly in indi
al symptoms. The most frequently seen symp Manual of
viduals over age 60.
toms of THC withdrawal are anxiety, restless
Benzodiazepines and
ness and irritability, sleep disturbance, and Mental Disorders.
other addictive medi
change in appetite (usually anorexia). Other
cations should be
symptoms of withdrawal are less frequently
avoided.
seen and appear to include tremor, diaphore
sis (sweating), tachycardia (elevated heart The patient should be encouraged to maintain
rate), and GI disturbances, including nausea, abstinence from THC as well as other addic
vomiting, and diarrhea. Cognitive difficulties tive substances. Some patients will require a
including depression also have been reported substancefree, supportive environment to
and may persist but usually improve with achieve and maintain abstinence. Clinicians
time. There are no medical complications of should educate all patients about the effects
withdrawal from THC, and medication is gen of withdrawal, validate their complaints, and
erally not required to manage withdrawal. reassure them that their symptoms will likely
improve with time. Symptomatic relief may be
Clinicians may see a variety of the symptoms
provided in order to increase the patient’s
mentioned above, but these generally require
comfort.
Physical Detoxification Services for Withdrawal From Specific Substances 95
There are no clinical assessment instruments use. However, neither cessation nor disclo
available that measure THC withdrawal. sure of anabolic steroid use can be assumed
Both animal and human studies indicate that when treating these individuals.
a withdrawal syndrome starts within 24 hours
of cessation and may last for up to a week.
Withdrawal Symptoms
Associated With Steroids
Anabolic Steroids Anabolic steroids can be associated with with
Anabolic steroids, as differentiated from cor drawal symptoms emerging after their abrupt
ticosteroids and female gonadotropic hor discontinuation. Withdrawal symptoms
mones, are androgens (male hormones) and include (in descending order of prevalence)
subject to abuse as a means of increasing craving for more steroids, fatigue, depres
muscle mass. These sion, restlessness, anorexia (loss of appetite),
agents also can pro insomnia, reduced libido (sex drive),
Interventions duce aggressive, headaches, and nausea (Lukas 1998). It is not
maniclike behavior known how commonly this syndrome occurs,
directed toward that may include but steroid withdrawal appears more likely in
delusions (Lukas heavy users. The clinician’s index of suspi
cessation should 1998). Males cion should be raised when evaluating indi
involved in profes viduals who are predisposed to steroid misuse
involve patient sional sports, and who exhibit these symptoms. Also indica
weight lifting, body tive of possible steroid abuse are certain
education regarding building, or other physiological signs of androgen exposure,
pursuits that value including hair loss, acne, dysuria (difficult or
the dangers and muscular mass are painful urination), small testicles, edema of
more likely to use the extremities, and rapid weight gain.
medical complica these substances Females can develop decreased breast size,
than are women, acne, virilism (clitoral enlargement, excessive
tions of anabolic although use in and abnormal bodily hair growth, male pat
women has been tern baldness) and amenorrhea (suppression
steroids, their reported. of menstruation). Males who abuse steroids
Adolescents use have been reported to possess a distorted
behavioral effects, anabolic steroids to body image and may inaccurately view them
improve their selves as small and weak (Pope et al. 1993).
and a thorough appearance and
may have increased
evaluation of the access to these com Medical Complications of
pounds (Yesalis et Steroid Withdrawal
patient’s rationale al. 1993). The large Due to anabolic steroids’ long duration of
numbers of anabol action, side effects that might emerge cannot
for misuse. ic steroid prepara be quickly reversed by the discontinuation of
tions that have these substances. Therefore, related side
medical and veteri effects might require medical management
nary uses are pri beyond the simple recommendation that
marily obtained illegally through diversion. steroids immediately be discontinued.
High doses of anabolic steroids can be medi Persistent side effects include urinary tract
cally dangerous but side effects, usually infections, bladder irritability, skin blistering
involving endocrine, liver, central nervous (at the injection site), erythema (abnormal
system, and cardiac function, tend to be skin redness) when given as a skin patch, and
reversible upon cessation of anabolic steroid
96 Chapter 4
priapism (prolonged erections lasting hours). Patient Care and Comfort
The latter condition involves a painful penile
erection and constitutes an emergency that Patient comfort during steroid withdrawal can
requires specialized medical attention. Edema be achieved by addressing side effects, if pre
(swelling) of the hands or feet, commonly seen sent, that are discussed above. Counseling also
with anabolic steroids, can be treated with is a useful intervention and specialized psychi
diuretics (medications that increase urine atric interventions may be necessary. If the
flow). Elevated liver function tests and jaun individual also is using other substances of
dice usually resolve with cessation of anabolic abuse, referral to drug or alcohol rehabilitative
steroid administration, although hepatic car treatment should be made.
cinoma (cancer of the liver) has been report
ed. Other side effects such as headache, nau
sea, vomiting, acne, insomnia, and lethargy
Club Drugs
are timelimited and resolve after steroid ces Club drugs represent diverse classes of drugs
sation. Behavioral disturbances, such as psy that include sedativehypnotic type agents as
chosis or severe aggressiveness, should be well as stimulant/hallucinogens. Club drugs are
treated symptomatically with appropriate illicit drugs used in the setting of nightclubs,
psychopharmacological interventions. In dance clubs, parties, and “raves.” Raves are
extreme cases of psychotic or manic presenta overnight dance parties, usually with several
tions, emergency psychiatric hospitalization hundred people in attendance.
might be necessary to address dangerousness
Abuse of these drugs by adolescents and
to self or others.
young adults has risen greatly in recent years.
All healthcare professionals need familiarity
Management of Steroid with their short and longterm effects.
Although withdrawal syndromes have been
Withdrawal
reported with some of these drugs, this is not
There is no recommended detoxification pro the most common clinical problem.
tocol for anabolic steroids. The key medical Intoxication and severe intoxication with
goal is that of persuading the patient to cease overdose are more frequent problems. With
steroid misuse. This intervention should be some of these compounds, there appears to be
followed by evaluating and treating any side the potential for neurotoxicity (destructive
effects (discussed above) that might be pre effects on the nervous system) and persistent
sent. Interventions directed toward cessation psychiatric and neurologic syndromes. At the
should involve patient education regarding present time, much of the available informa
the dangers and medical complications of tion regarding club drugs comes from surveys
anabolic steroids, their behavioral effects, and anecdotal case reports. Human laborato
and a thorough evaluation of the patient’s ry studies and rigorously controlled clinical
rationale for misuse. A family meeting often is trials are not common.
helpful if agreed upon by the patient.
Unfortunately, education alone often is insuf One difficulty in assessing the effects of intox
ficient. Patients with distorted body images ication, overdose, withdrawal, and longterm
might be especially difficult to dissuade from health consequences of club drugs is that in
steroid misuse, and referral to psychotherapy general, there are no baseline evaluations of
by a qualified clinician trained in the treat individuals before they used club drugs. Also,
ment of body image disorder should be con these individuals abuse more than one sub
sidered. Similarly, patients who derive signifi stance. Some of these patients may have had
cant muscle gain from anabolic steroids might moderate to severe psychopathology (includ
be resistant to cessation and may conceal con ing psychosis) prior to their introduction to
tinued steroid use. club drugs. In the past, some club drugs were
Physical Detoxification Services for Withdrawal From Specific Substances 97
referred to as “designer drugs” because of Withdrawal syndromes have not been report
their production in a laboratory rather than ed with hallucinogens; however, considerable
being processed from plant products. attention has been paid to residual effects
such as delayed perceptual illusions with anx
iety, “flashbacks,” residual psychotic symp
Hallucinogens toms, and longterm cognitive impairment.
Hallucinogens are a broad group of sub Controversies around these issues are not
stances that can produce sensory abnormali important in the clinical setting. The impor
ties and hallucinations. Most hallucinogens tant thing is to determine whether residual
have some adrenergic effects as well. symptoms are present and provide an appro
Hallucinogens also are referred to as priate environment and appropriate care for
psychedelics and psychomimetics. The more the individual who has them. Generally, staff
traditional hallucinogens such as lysergic acid of emergency rooms, clinics that treat people
diethylamide (LSD) are considered primarily who abuse substances, and social detoxifica
serotonergicacting agents. Some of the other tion centers have individuals who are very
compounds include phenylethylamines which familiar with “talking down” individuals with
have hallucinogenic properties but act like bad hallucinogenic trips.
amphetamines as well. These drugs include
mescaline and MDMA (3,4methylenedioxyN Acute intoxication and bad trips usually can
methylamphetamine). Other drugs include be managed with placement of the individual
MDA (3,4methylenedioxyamphetamine) and in a quiet, nonstimulating environment with
DOM (dimethyloxymethylamphetamine). (See immediate and direct supervision so that the
section on ecstasy below.) Other hallucinogens patient does not cause harm to herself or to
are acetylcholine antagonists. These include others. Occasionally, a low dose of a short or
belladonna, drugs such as benzotrophine intermediateacting benzodiazepine may be
used to treat parkinsonian symptoms, and useful to control anxiety and promote seda
many common overthecounter antihis tion. Individuals with chronic depressivelike
tamines. reactions may require antidepressant thera
py. Individuals with residual psychotic symp
Hallucinogen intoxication often begins with toms are likely to require antipsychotic medi
autonomic effects, sometimes nausea and cations. On rare occasions, the use of a low
vomiting, and mild increases of heart rate, dose, highpotency antipsychotic medication
body temperature, and slight elevations of may be required orally or parenterally (any
systolic blood pressure. Dizziness and dilated method other than the digestive tract, e.g.,
pupils may occur. The prominent effects dur intravenously, subcutaneously, or intramus
ing intoxication are sensory distortions with cularly). Assessment of residual psychiatric
illusions and hallucinations. Visual distor and cognitive symptoms should be made prior
tions are more common than auditory or tac to treatment referral.
tile ones. Socalled “bad trips” may involve
anxiety including panic attacks, paranoid
reactions, anger, violence, and impulsivity. Gammahydroxybutyrate
Either due to delusions or misperceptions, (GHB)
individuals may feel they can fly or have spe GHB use has increasingly been reported in
cial powers, and thus injure themselves in night clubs and at raves by adolescents and
falls or other accidents. Suicide attempts also young adult populations. GHB is a compound
can occur during “bad trips” and possible that is produced in the central nervous sys
suicidal ideation should be carefully evaluat tem, and it acts as an inhibiting neurotrans
ed, even though it may be quite transient. mitter similar to GABA (Shannon and Quang
2000). In pharmacologic (medicationpropor
98 Chapter 4
tioned) doses, GHB serves as a sedativehyp using the substance regularly over a 2year
notic medication. GHB intoxication may look period, and Rosenberg and colleagues (2003)
like alcohol or sedativehypnotic intoxication. note that in severe cases GHB withdrawal
may be lifethreatening.
Although GHB is illegal, psychotropic com
pounds similar to GHB such as gamma Milder cases of GHB withdrawal syndrome
hydroxy lactone (GBL) and 1,4butanediol may be managed with benzodiazepines such
(1,4BD) are widely available chemical com as lorazepam and supportive care. However,
pounds and may be obtained through catalogs in more severe cases high doses of intra
and the Internet. These compounds produce venous benzodi
effects similar to those of GHB. At the pre azepines (e.g.,
be seen than withdrawal syndromes. turates (e.g., pheno
respiratory management. GHB has been stud bital) may be
randomized, singleblind study comparing it and Roth 2001;
drawal. GHB was as effective as diazepam in 2003). Patients
and was said to be quicker in reducing anxi withdrawal are like
diazepam. Because of its history of abuse in erance for the seda
as a therapeutic agent any time in the near diazepines and
frequent doses to
drawal syndrome, noting that it shares fea drawal (Miotto and
withdrawal. They have found this syndrome where high doses of
GHB aroundtheclock, at 2 to 4hour inter ineffective, pento
prolonged duration of symptoms found in effective (Sivilotti et
delirium tremens that appear early (often may be used to treat
occurring within 24 hours; the delirium may cardia (rapid heart
Physical Detoxification Services for Withdrawal From Specific Substances 99
with various substitution groups off the ben tured illicitly as oral drugs of abuse. PCP fre
zene ring that give the medications hallucino quently is sold as LSD.
genic properties. There are a number of relat
ed compounds that are designated by their ini Some studies have found that ketamine and
tials (MDMA, MDA, MDEA, DOM, 2CB, and PCP act specifically at the MDMA/glutamate
DOT). Clinicians are likely to have to manage receptor as noncompetitive MDMA receptor
the complications of intoxication and overdose antagonists. Research in animals indicates
but not withdrawal. that both drugs are reinforcing, in that ani
mals will press a bar to obtain doses of either
Patients using MDMA or related compounds drug. Furthermore, in these same animal
frequently are hyperactive and hyperverbal, models, abstinence syndromes have been
reporting heightened tactile and visual sensa observed. Withdrawal symptoms in humans
tions. They frequently will use camphor on have included depression, drug craving,
the skin in facial masks, gloves, and other increased appetite, and hypersomnolence
clothing to heighten their tactile sensations. (excessive sleep).
Sometimes light sticks are used to heighten
visual experiences at raves. Hyperthermia, In the clinical setting, syndromes of acute
dehydration, water intoxication with low sodi intoxication with hallucinations, delusions,
um, rhabdomyolysis (severe muscular injury agitation, and violence are the most pressing
and breakdown of muscle fibers), renal fail problems. A human laboratory study (Lahti
ure, cardiac arrhythmia, and coma have been et al. 2001) conducted a comparison of
reported. ketamine and placebo in normal volunteers
never exposed to ketamine and to people with
MDMA has been proven to be toxic to sero schizophrenia with a previous history of
tonergic neurons in several animal studies. ketamine use. In both groups, ketamine pro
Heavy ecstasy users can have paranoid think duced a doserelated, but brief, increase in
ing, psychotic symptoms, obsessional think psychotic symptoms. The magnitude of
ing, and anxiety (Parrott et al. 2000). ketamineinduced positive psychotic symp
Impaired cognitive performance in heavy toms was similar for both groups, although
ecstasy users also has been identified the schizophrenia group had higher baseline
(GouzoulisMayfrank et al. 2000). Ecstasy scores.
users performed more poorly than control
groups in complex attention, memory, and Although originally MDMA receptor antago
learning tasks. The duration or permanence nists were felt to have neuroprotective effects
of such effects has not yet been well studied. (preventing damage to brain cells) and have
been explored as poststroke medications,
there is some evidence now that ketamine and
Ketamine and PCP PCP may in fact have some neurotoxic
(Phencyclidine) effects. Studies (e.g., Curran and Monaghan
2001) have found greater memory impairment
Ketamine and PCP (phencyclidine) were both among chronic ketamine users than infre
developed in the 1950s as anesthetic agents for quent ketamine users. Acute human laborato
humans. Phencyclidine was briefly marketed ry studies by this group indicate persistent
for human anesthetic use but taken off the memory impairment with ketamine exposure.
market because of an unusual high incidence of This same study did not find persistent psy
psychotic symptoms. PCP remains in legitimate chotic features beyond acute use.
use for veterinarian anesthesia for large ani
mals as does ketamine for small animals. In the clinical setting, ketamine and PCP use
Although both drugs were originally developed require management for the agitation and
for intravenous use, they are now manufac psychotic features produced during acute use.
Occasionally, patients will have such large
100 Chapter 4
overdoses, intentionally or accidentally, that In an evaluation of admissions to publicly
they will require airway management and funded detoxification programs in
ventilatory support for some hours. The Massachusetts between 1984 and 1996,
behavioral management of the agitation and McCarty and colleagues (2000) found a steady
violence that may be seen is best managed in increase in the number of patients using both
a controlled environment with limited stimuli alcohol and other substances in the month
and very close supervision. Occasionally, oral prior to admission. In 1988, 26 percent of
or parenteral uses of sedating medications admissions reported using two or more sub
such as benzodiazepines will be required. In stances in the previous month; by 1996 that
extreme cases, restraints may be required for number had nearly
protection of the patient and staff. doubled to 50 per
cent (McCarty et al.
Following acute management, assessment of 2000). There is no One of the most
persistent mood and cognitive effects must be reason to believe that
made prior to any treatment attempts. The this trend has not
persistence of psychotic symptoms may repre
significant changes
appeared elsewhere
sent an underlying psychiatric disorder that in this country. As
may require medication treatment. There are in detoxification
Miller and colleagues
no studies to guide the treatment of ketamine (1990a) note, “For
or PCP detoxification. The need to manage the contemporary
services in recent
withdrawal symptoms from these drugs is drug addict, multiple
unlikely, but if it should arise, benzodi drug use and addic years has been the
azepines should be administered. tion that includes
alcohol is the rule” increase in the
Other (p. 597).
number of
Rohypnol is a benzodiazepine that is sold In the Massachusetts
under trade names in Europe and Mexico as a evaluation, which
patients requiring
sedativehypnotic. Rohypnol is occasionally did not include mari
used as a club drug and at dance clubs. In the juana or nonopioid
last decade it began to be smuggled into the prescription medica detoxification
United States and was commonly used among tion use, the most
homeless youth involved in the sex industry. commonly seen com from more than
Rohypnol has a reputation as a “date rape” bination of sub
drug because it can produce powerful amnestic stances was alcohol one substance.
and hypnotic effects, as well as coma. For fur and cocaine. Thirty
ther details on benzodiazepines, see the benzo percent of patients
diazepine section regarding intoxication and admitted for detoxifi
potential withdrawal reactions. cation in 1996 reported using this combina
tion; 12 percent used alcohol, cocaine, and
heroin together; 10 percent combined alcohol
Management of and cocaine; and 7 percent combined heroin
and cocaine (McCarty et al. 2000). Other
Polydrug Abuse: An studies, evaluating patient populations at
Integrated Approach inpatient treatment centers, found that
One of the most significant changes in detoxi between 70 and 90 percent of patients who
fication services in recent years has been the reported cocaine abuse also abused alcohol.
increase in the number of patients requiring Rates of alcohol dependence among
detoxification from more than one substance. methadone patients and patients dependent
on heroin were between 50 and 75 percent,
Physical Detoxification Services for Withdrawal From Specific Substances 101
An Example of Potential Problems:
Detoxification for Polydrug Abuse
Mr. L is a 43yearold male with a 25year heroin dependence. He is well known to the detoxification center,
having been through the program there (which consisted primarily of support and hydration) on many
occasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time he
arrived, his course usually was about the same: 2 or 3 days of serious stomach cramps, nausea, and diar
rhea, then a few days of feeling poorly, and then a return to the community. This time, however, was differ
ent. He looked “sicker” than usual. Mr. L usually was a compliant patient; now he was hostile and belliger
ent. He seemed to be talking to himself and did not seem as alert as he should have been. The staff asked
him several times if he had used anything else and each time he denied it. His drug of choice was always
heroin—he drank alcohol once in a while, and occasionally smoked marijuana when he could not get any
thing else. On the third day of detoxification, Mr. L seemed acutely more ill. On his way to the bathroom he
was observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand mal
seizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates,
opioids, and trace amounts of benzodiazepines
and 80 to 90 percent who were being treated Prioritizing Substances of
for cannabis abuse also reported alcohol
abuse (Miller et al. 1990a).
Abuse
While substances of abuse may have complex
Clinicians need to be constantly aware that a interactions, it is not always possible to deter
patient may be abusing multiple substances. mine how those interactions will affect with
Even if a patient admits the abuse of one sub drawal. Therefore, it is generally best practice
stance he may not admit to using others. to prioritize the substances an individual has
Patients may not see that other substances been dependent on and treat them sequentially
are a problem, they may be worried about the according to the severity of the withdrawal pro
legal consequences of use, or they sometimes duced by the substance. The substances with
may not even be aware of what substances the most serious withdrawal syndromes, those
they have been using. For these reasons, clin where the withdrawal syndrome can be fatal,
icians should not rely on patients’ selfreports are alcohol and the sedativehypnotics. When
to determine which substances are being detoxifying a patient who has been dependent
used. Interviews with family, friends, or oth upon multiple substances, the sedativehyp
ers who know the patient may be helpful, but notics must be addressed first.
these also are insufficient. The consensus
panel strongly recommends that all patients Oral methadone, LAAM, or buprenorphine
receive an immediate urine drug screening should be used to stabilize withdrawal from
upon admission to a detoxification program to opioids while tapering the dose of the seda
determine the types of substances being tivehypnotic or anxiolytic (antianxiety medi
abused. It is not necessarily true that the per cation) by 10 percent each day. After the
son is drug free simply because a drug is not patient has been tapered off of the sedative
detected on a drug screen. It is possible that hypnotic or anxiolytic, withdrawal from the
the toxicology is not able to detect the class or substitute opioid can begin (Wilkins et al.
type of drug. Staff should be aware of what 1998). Some patients can successfully be
the program/detoxification center/hospital detoxified from both sedativehypnotics and
tests for, what is not tested for, what cannot opioids simultaneously, but this requires a
be tested for or found, and the limitations of great deal of medical and nursing attention.
“dip” tests. Most patients will benefit from opioid mainte
102 Chapter 4
nance for an extended period of time follow screening, even a handheld screening, can be
ing the completion of sedative withdrawal. an expensive item for what often is a very limit
ed budget. Besides, in this case, the patient was
If the patient has been abusing multiple seda believed to be a known quantity—someone who
tivehypnotic substances or a sedativehypnotic only used heroin.
and alcohol, withdrawal should be handled in
the same way as withdrawal from one such sub This scenario is not uncommon. It is likely that
stance. The patient should be administered a the patient himself was unaware of what was in
regularly decreasing dosage of sedativehypnot his body. One of the more frightening facts con
ic, usually a benzodiazepine that the clinician is cerning the purchase of illicit drugs is the lack
comfortable with and accustomed to using. The of knowledge of what is in them. To make buy
dosage should be decreased according to the ers believe that they are buying a higherquali
patient’s physiologic response. Providers also ty product than they are, drugs often are cut
may administer an anticonvulsant such as car with adulterants (inferior ingredients) that can
bamazepine (Tegretol XR), even in the absence produce effects similar to the drug they think
of epilepsy or withdrawal seizures, to help they are buying. In this case, Mr. L may have
ensure patient safety (Wilkins et al. 1998). been buying barbiturates and benzodiazepines
Phenobarbital also may be used for detoxifying in his heroin for some time without knowing it,
patients who have been abusing both alcohol a fact that could have had deadly conse
and benzodiazepines. When the dose of alcohol quences. Both are sedating and could have
and sedativehypnotics that a patient is taking given him some of the comfortable sedation and
is not known, tolerance testing as previously euphoria he was seeking from his drug of
described can be helpful in determining the choice. Unfortunately, however, where opioid
dose of phenobarbital. withdrawal is not lifethreatening, withdrawal
from barbiturates can be. Furthermore, he
When treating patients detoxifying from sub could have gotten PCP in the marijuana he
stances other than sedativehypnotics, manage occasionally used, again without knowing it.
ment of opioid detoxification should be the next
priority. Generally, other substances of abuse,
including stimulants, marijuana, hallucinogen Alternative
ics (LSD and similar drugs), and inhalants, will
not require specific treatment in patients who Approaches
are being detoxified from sedativehypnotics Alternative methods that have been studied sci
and/or opioids. entifically do not claim to be standalone with
drawal methods, nor standalone treatment
Patients may abuse a wide range of substances modalities. Alternative approaches are
in various combinations, and the clinician must designed to be used in a comprehensive, inte
be vigilant in assessing and treating withdrawal grated substance abuse treatment system that
from multiple substances. The case study above promotes health and wellbeing, provides pal
illustrates some of the serious problems the liative symptom relief, and improves treatment
clinician faces in evaluating and treating retention. Therefore, because isolation of any
patients withdrawing from multiple substances. of these approaches as an independent variable
In the private sector, where money for toxico in rigorous controlled studies is difficult, if not
logical screening is readily available, the first impossible, there are no conclusive data on the
question many would ask concerning the case effectiveness of alternative methods
of Mr. L. is, “Why wasn’t the drug screen done (Trachtenberg 2000).
sooner?” However, those working in public Auricular (ear) acupuncture has been used
facilities will recognize that such screenings throughout the world, beginning in Hong Kong,
often are unavailable or available only after an as an adjunctive treatment during opioid
extended turnaround time. Toxicological
Physical Detoxification Services for Withdrawal From Specific Substances 103
detoxification for about 30 years. Its use in the choosing outpatient programs with acupunc
United States originated in California ture were less likely to relapse in the 6
(Seymour and Smith 1987) and New York months following discharge than were patients
(Mitchell 1995) but has not been subjected to who had chosen residential programs
rigorous controlled research. One report (Shwartz et al. 1999).
(Washburn et al. 1993) noted that patients
dependent on heroin with mild habits appeared Ear acupuncture detoxification, which was
to benefit more than those with severe with originally developed as an alternative treat
drawal symptoms, which acupuncture did not ment for opioid agonist pharmacotherapy, is
alleviate. The 1997 National Institute of Health now augmenting pharmacotherapy treatment
Consensus Statement on acupuncture stated for patients with coexisting cocaine problems
that acupuncture treatment for addiction could (Avants et al. 2000). The advocates of
be part of a comprehensive management pro acupuncture have joined with the advocates
gram. The National Acupuncture of opioid agonist pharmacotherapy to create a
Detoxification Association has developed holistic synthesis. Each has contributed to the
acupuncture protocols involving ear acupunc success of the other, both clinically and in
ture in group settings that originated at Lincoln public perception.
Hospital in the Bronx and are used by over 400 Care must be taken to ensure sterile acupunc
drug treatment programs and 40 percent of ture needles in the heroindependent popula
drug courts. SAMHSA’s National Survey of tion, given the high incidence of HIV infec
Substance Abuse Treatment Services (NSSATS) tion, viral hepatitis, and other infections.
found that 5.4 percent of the 13,720 facilities Acupuncture is not recommended as a stand
polled in 2001 offered acupuncture as a service alone treatment for opioid withdrawal.
(Office of Applied Studies 2002b).
Other alternative management approaches
Acupuncture is one of the more widely used that are not supported by controlled studies
alternative therapies within the context of include neuroelectric therapy (the adminis
addictions treatment. It has been used as an tration of electric current through the skin)
adjunct to conventional treatment because it and herbal therapy. In fact, the former has
seems to reduce the craving for a variety of been shown to be no better than placebo in a
substances of abuse and appears to con controlled study (Gariti et al. 1992). The use
tribute to improved treatment retention rates. of herbs for healing purposes dates back to
In particular, acupuncture has been viewed the dawn of civilization, while the use of
as an effective adjunct to treatment for alco herbs in the treatment of substance abuse has
hol and cocaine disorders, and it also has been documented since 1981 in methadone
played an important role in opioid treatment programs, free clinics, therapeutic communi
(i.e., methadone maintenance). It is used as ties, outpatient programs, and hospitals
an adjunct during maintenance, such as when (Nebelkopf 1981). Herbal remedies are used
tapering methadone doses. The ritualistic in substance abuse detoxification and treat
aspect of the practice of acupuncture as part ment in a number of cultures around the
of a comprehensive treatment program pro world. However, in no scientific studies have
vides a stable, comfortable, and consistent herbs been isolated as a discrete variable to
environment in which the client can actively test their efficacy. Much research is currently
participate. As a result, acupuncture being conducted on the effectiveness of herbal
enhances the client’s sense of engagement in medicine on a wide variety of physical
the treatment process. This may, in part, conditions.
account for reported improvements in treat
ment retention (Boucher et al. 2003). A 1999
CSATfunded study showed that patients
104 Chapter 4
strong linkages to agencies that provide the
Considerations for abovementioned services and should set up
Specific Populations systems to ensure that pregnant women can
All individuals undergoing detoxification are access the additional services they need.
especially vulnerable. Patients who experience Pregnant women who present for detoxification
negative attitudes from staff may experience will benefit from a comprehensive medical
further loss of selfesteem, may leave detoxifi examination that includes a careful obstetrical
cation prematurely, or may experience other component. Since it is estimated that approxi
psychologically damaging feelings. Negative mately 44 to 70 percent of women who abuse
experiences can undermine the recovery pro substances have a his
cess. It is important to recognize that individu tory of physical, emo
als do not fit into just one population category. tional, and sexual
A person will be a member of several popula Pregnant women
abuse (Moylan et al.
tions (e.g., a Latina woman who is pregnant, 2001; Stevens et al.
bisexual, and has psychiatric diagnoses of post 1997), care should be
who present for
traumatic stress disorder and major depres given to the comfort
sion) and may benefit from a number of the of the patients during detoxification will
considerations discussed below. It also should the examination. One
be noted that the information in the specific of the major internal benefit from a
populations sections should not be used to cate barriers that prevents
gorize individuals or leave the reader with the pregnant women from comprehensive
impression that the information below will fit seeking treatment is
all individuals who are members of a group. the shame and stigma medical examina
attached to substance
Pregnant Women use, especially during tion that includes
pregnancy. Any nega
While in detoxification, pregnant women tive experience
should receive comprehensive medical care, a careful
encountered during
especially since this may be the first time they detoxification can
have sought any type of care or treatment. lead these women to obstetrical
Ideally, programs detoxifying pregnant women leave treatment and
from alcohol and illicit drugs should include not return. component.
the following services:
• Detoxification on demand Detoxification during
pregnancy poses a
• Womancentered medical services
special risk in that
• Transportation services to and from detoxifi care should be taken
cation (as well as to substance abuse treat to ensure the health and safety of both the
ment afterward) mother and fetus. From a clinical standpoint,
• Childcare services before giving any medications to pregnant
• Counseling and case management services women it is of vital importance that they
understand the risks and benefits of taking
• Access to drugfree, safe, affordable housing these medications and sign informed consent
• Help with legal, nutritional, and other social forms verifying that they have received and
service needs understand the information provided to them.
Since pregnant women often present to treat
While it is recognized that provision of all of
ment in mid to latesecond trimester and poly
these services is an ideal to be striven for, at a
drug use is the norm rather than the exception
minimum detoxification programs must have
(Jones et al. 1999), it is important first to
Physical Detoxification Services for Withdrawal From Specific Substances 105
screen these women for dependence on the two naltrexone, naloxone, or nalmefene adminis
classes of substances that can produce a life tration during pregnancy. Although propra
threatening withdrawal: alcohol and sedative nolol (Inderal), labetalol (Trandate), and
hypnotics. Pregnant women should be made metoprolol (Lopressor) are the beta blockers
aware of all wraparound services that will of choice for treating hypertension (high
assist them in dealing with newborn issues, blood pressure) during pregnancy
including food, shelter, medical clinics for inoc (McElhatton 2001), the impact of using them
ulations, as well as programs that will help with for alcohol detoxification during pregnancy is
developmental or physical issues that the unclear. The use of SSRIs, a class of antide
neonate (newborn baby) may experience as a pressant medication, is safer for the mother
result of substance and fetus than are tricyclic antidepressants
exposure. (Garbis and McElhatton 2001). Fluoxetine
(Prozac) is the most studied SSRI in pregnan
A National cy and no increased incidence in malforma
Alcohol tions was noted, nor were there neurodevel
Institutes of When pregnant opmental effects observed in preschoolage
women are detoxi children (Garbis and McElhatton 2001).
Health consensus fied from alcohol, However, possible neonatal withdrawal signs
benzodiazepine have been observed. Given that the greatest
panel tapers appear to be amount of data are available for fluoxetine,
the current practice this is the recommended SSRI for use during
recommended of choice. The cur pregnancy (Garbis and McElhatton 2001).
rent state of knowl
edge suggests that The use of anticonvulsants, such as valproic
methadone benzodiazepine acid, is associated with several disfiguring
therapy in general malformations. If this type of medication
maintenance as does not have as must be used during pregnancy, the woman
much of a terato must be told that there is substantial risk of
the standard of genic (producing a malformations (Robert et al. 2001).
deformed baby) risk Barbiturate use during pregnancy has been
care for pregnant as do other anticon studied to some extent, and phenobarbital is
vulsants as long as used therapeutically during pregnancy, but
they are given over the risk of any anticonvulsive medication
women with
a short time period. should be discussed with the patient (Robert
It appears that et al. 2001). There also are reports of a with
opioid drawal syndrome in the neonate following
shortacting benzo
diazepines, like the prenatal exposure to phenobarbital (Kuhnz et
dependence. al. 1988).
ones described to
treat alcohol with
drawal above, can Opioids
be used in low doses for acute uses such as
detoxification, even in the first trimester While it is not recommended that pregnant
(Robert et al. 2001). Longacting benzodi women who are maintained on methadone
azepines should be avoided—their use during undergo detoxification, if these women
the third trimester or near delivery can result require detoxification, the safest time to
in a withdrawal syndrome in the baby (Garbis detoxify them is during the second trimester.
and McElhatton 2001). For further information, consult the forth
coming TIP Substance Abuse Treatment:
Although no teratogenic effects have been Addressing the Specific Needs of Women
observed, little is known about the effects of (SAMHSA in development e) and TIP 43
106 Chapter 4
MedicationAssisted Treatment for Opioid but may be associated with a withdrawal syn
Addiction in Opioid Treatment Programs drome in the neonate (Jones and Johnson
(CSAT 2005d). In contrast, it is possible to 2001).
detoxify women dependent on heroin who are
abusing illicit opioids by using a methadone A National Institutes of Health consensus
taper. panel recommended methadone maintenance
as the standard of care for pregnant women
Before starting a detoxification, women with opioid dependence. Methadone currently
should weigh the risks and benefits of detoxi is the only medication recommended for med
fication, since many women eventually icationassisted treatment for pregnant
relapse to drug use and thus place themselves women. Clinical trials are being conducted to
and their fetuses at risk for adverse conse determine the efficacy and safety of
quences (Jones et al. 2001b). During pregnan buprenorphine with pregnant women but it
cy, the protein binding of many drugs, includ has not yet been approved for use with this
ing methadone and diazepam (a benzodi population. Two early studies on treatment of
azepine), is decreased (e.g., Adams and pregnant women with opioid dependence with
Wacher 1968; Dean et al. 1980; Ganrot 1972) buprenorphine showed promising results
with the greatest decrease noted during the (Fischer et al. 2000; Johnson et al. 2001).
third trimester (Perucca and Crema 1982). Comer and Annitto (2004) conclude, from
This decreased binding may be due to the their review of the research literature, that
decreased levels of albumin reported during buprenorphine should be used more aggres
pregnancy (Yoshikawa et al. 1984). From a sively to detoxify pregnant women who want
clinical standpoint, it may be that pregnant to be opioidfree at delivery.
women could be at risk for developing greater
toxicity and side effects, yet at the same time Because of the potential for premature labor
an increase in metabolism of the drug may and delivery and risks of morbidity and mor
result (such as found with methadone). This tality to the fetus related to withdrawal from
may result in reduced therapeutic effect from opioids, it is recommended that a pregnant
the drug, since many women require an woman who is dependent on opioids be main
increase in their dose of methadone during tained during pregnancy (Kaltenbach et al.
the last trimester (Pond et al. 1985). 1998). Other reasons to stabilize a pregnant
woman on methadone rather than attempt
Other medications used to treat the withdraw withdrawal are the risks of relapse, conse
al signs and symptoms include clonidine. quences associated with HIV and use of multi
Clonidine is used as a secondline drug to ple needles, and the potential lack of prenatal
treat hypertension (high blood pressure) dur care.
ing pregnancy and appears to lack teratogenic
effects (McElhatton 2001). It has reportedly The Federal government mandates that pre
been abused by pregnant women. Some preg natal care be available for pregnant women
nant women take clonidine with their on methadone. It is the responsibility of treat
methadone because it is hard to detect in ment providers to arrange this care. More
urine and it increases the high they get from than ever, there is need for collaboration
methadone. However, little is known about its involving obstetric, pediatric, and substance
effects on the baby following therapeutic abuse treatment caregivers. Comprehensive
doses given in a detoxification context or care for the pregnant woman who is opioid
doses taken in higher than therapeutic dependent must include a combination of
amounts (Anderson et al. 1997a). methadone maintenance, prenatal care, and
Buprenorphine has been examined in preg substance abuse treatment.
nancy and appears to lack teratogenic effects
Physical Detoxification Services for Withdrawal From Specific Substances 107
Pregnant women should be maintained on an Specific Needs of Women (SAMHSA in devel
adequate (i.e., therapeutic) methadone dose. opment e). There is a documented withdrawal
An effective dose prevents the onset of with syndrome in neonates who have been prena
drawal for 24 hours, reduces or eliminates tally exposed to benzodiazepines (Sutton and
drug craving, and blocks the euphoric effects Hinderliter 1990), and this syndrome may be
of other narcotics. An effective dose usually is delayed in onset more than that associated
in the range of 50–150mg (Drozdick et al. with other drugs.
2002). Dosage must be individually deter
mined, and some pregnant women may be
able to be successfully maintained on less Stimulants
than 50mg while others may require much The principles of detoxification from stimulants
higher doses than 150mg. The dose often such as cocaine are the same for pregnant and
needs to be increased as a woman progresses nonpregnant women. Since there is no current
through gestation, due to increases in blood pharmacotherapy to use in tapering individuals
volume and metabolic changes specific to from stimulant use, the use of any medications
pregnancy (Drozdick et al. 2002; Finnegan to treat medical complications that might arise
and Wapner 1988). from the withdrawal should only be done after
discussion with the patient of the risks and ben
Generally, dosing of methadone is for a 24 efits of each medication.
hour period. However, because of metabolic
changes during pregnancy it might not be pos
sible to adequately manage a pregnant woman Solvents
during a 24hour period on a single dose. The principles of detoxification from solvents
Split dosing, particularly during the third are the same for pregnant and nonpregnant
trimester of pregnancy, may stabilize the women. It should be noted that based on a
woman’s blood methadone levels and effec review of case reports, there is a complex
tively treat withdrawal symptoms and crav array of characteristics that appear to be sim
ing. ilar to fetal alcohol effects. Fetal Alcohol
Breastfeeding is not contraindicated for Syndrome (FAS) is characterized by growth
women who are on methadone. Very little deficiency (born small for gestational age;
methadone comes through breast milk; the failure to grow at a normal rate), particular
American Academy of Pediatrics (AAP) facial features (e.g., eyes are too close togeth
Committee on Drugs lists methadone as a er, ears are set low on the head), and CNS
“maternal medication usually compatible with dysfunctions (mental retardation, microen
breastfeeding” (AAP 2001, pp. 780–781). cephaly [small brain size]) and brain malfor
mations (Costa et al. 2002). Thus fetal devel
opment in pregnant women who have a histo
Benzodiazepines ry of solvent abuse should be evaluated and
The principles of detoxification from benzodi carefully monitored (Jones and Balster 1998).
azepines are the same for pregnant and non
pregnant patients. It is important to taper the Nicotine
dose of benzodiazepine slowly in order not to
induce fetal withdrawal or other adverse con There is extensive documentation that smoking
sequences in the fetus or mother. during pregnancy causes numerous adverse
Detoxification is most likely safest during the fetal consequences (see Schaefer 2001).
second trimester in order to avoid sponta Cigarette smoking during pregnancy is the
neous abortion or premature labor. For more largest modifiable risk for pregnancyrelated
information, see the forthcoming TIP morbidity and mortality in the United States
Substance Abuse Treatment: Addressing the (Dempsey and Benowitz 2001). While women
108 Chapter 4
are undergoing detoxification, they should be Marijuana, anabolic steroids,
offered education about the risk of cigarette
smoking during pregnancy and, ideally, pre
and club drugs
vented from smoking. This is especially impor The principles of detoxification from these
tant since cigarette smoking is strongly associat drugs is the same for pregnant and nonpreg
ed with decreased birth weight, which is a pre nant women. The use of anabolic steroids dur
dictor of developmental problems in newborns ing pregnancy is rare; however, these can be
(Ernst et al. 2002). If women are unable to stop catastrophic to a pregnancy, and if use is
smoking using behavioral interventions, nico found, a detailed ultrasound examination is
tine replacement products may be used; how recommended to determine the morphological
ever, the woman should fully understand the (physical or structural) development of the
possible risks and benefits of these pharma fetus (Scialli 2001).
cotherapies (Jones and Johnson 2001).
Although the class of
It also is important to point out to patients club drugs is rela While women are
that there are data to suggest that women may tively new there have
derive less benefit from NRT than do men been a few reports undergoing
and that they may derive greater benefit from (McElhatton et al.
some nonNRT medications (e.g., bupropion), 1999) suggesting that detoxification,
thus producing quit rates in women compara there is an increased
ble with those in men (Perkins 2001). risk of congenital they should be
However, the data regarding the use of malformation in
bupropion during pregnancy are limited. neonates prenatally offered education
exposed to ecstasy.
Examinations of the acute effects of NRT in Other club drugs
pregnant women reveal that nicotine has min about the risk of
such as fluni
imal impact on the maternal and fetal cardio trazepam (Rohypnol)
vascular systems. NRT may well be viewed as may have effects sim
cigarette smoking
the lesser of two evils, inasmuch as smoking ilar to those of some
thousands of chemicals. Among these are however, this is spec
toxins (e.g., carbon monoxide and lead). It is hensive information
cigarette smoking is primarily related to nico this specific popula
tine. Thus, if NRT is to be used during preg tion, see the forth
smoking.
nancy, the dose of nicotine in NRT should be coming TIP
similar to the dose of nicotine that the preg Substance Abuse
nant woman received from her ad lib (when Treatment:
ever desired) smoking. Although intermittent Addressing the Specific Needs of Women
use formulations of NRT (e.g., chewing gum) (SAMHSA in development e).
have been recommended over continuoususe
formulations (e.g., transdermal patch) due to
reductions in the total dose of nicotine deliv Older Adults
ered to the fetus (Dempsey and Benowitz It has been recommended that, when treating
2001), it is unknown what the impact of inter older adults, there should be a policy of using
mittent acute doses followed by withdrawal of agespecific group treatment that is both sup
nicotine has on the fetus. portive and nonconfrontational (Royer et al.
2000; West and Graham 1999). Older adults
may be dealing with depression, loneliness,
Physical Detoxification Services for Withdrawal From Specific Substances 109
and loss of career or a loved one. Thus, as a People With Disabilities or Co
standard policy, older adults should be
screened for depression and grief or loss
Occurring Conditions
related issues. Similar to the situation with In any patient population, the clinician
other specific populations, the detoxification should expect to encounter persons with dis
setting should ideally have in place a policy abilities including cooccurring medical or
that mandates, at a minimum, wellestab mental disorders. These patients often will
lished linkage with general medical services require special assistance to overcome both
and specialized services for the aging, because physical and psychological barriers in under
of their increased vulnerability to physical going detoxification and treatment, including
ailments. Establishing policies that create an their own psychological barriers that must be
environment that is positive and does not tol overcome, as well as those attitudinal and
erate “ageism”—a general tendency to react communication barriers that often prevent
negatively toward elderly adults—is impor complete and clear understanding between
tant for the optimal treatment of older indi patient and clinician or clinician and institu
viduals. tion. Effective communication is essential for
effective services. Accommodations must take
Alcohol and other drugrelated disorders in into consideration the expressed preference of
elderly individuals often are more severe than the individual with a disability. Substance
those of younger individuals and they are at abuse treatment programs need to be in com
increased risk for cooccurring medical disor pliance with two Federal laws regarding this
ders. It is the medical complications rather matter: the 1992 Amendments to the
than age itself for which detoxification in a Rehabilitation Act of 1973 and the Americans
medical setting is needed. The elderly may with Disabilities Act [ADA] of 1990.
have slower metabolism of medications mak According to the ADA, programs must
ing dosage adjustments necessary in some remove or compensate for physical or archi
cases. The elderly also may be at greater risk tectural barriers to existing facilities when
for drug interactions, since they may be accommodation is readily achievable, mean
receiving medications to treat other problems. ing “easily accomplishable and able to be car
A complete and careful assessment with ongo ried out without much difficulty or expense”
ing monitoring should be done to examine the (P.L. 101336 § 301). Providers should exam
existence of diseases such as, but not limited ine their programs and modify them to elimi
to, heart disease, respiratory disease, dia nate four fundamental groups of barriers to
betes, and dementia. Potential for falls also treatment for people with disabilities and/or
should be evaluated in the context of pre cooccurring disorders: (1) attitudinal barri
scribed medications. The previously present ers; (2) discriminatory policies, practices, and
ed protocols for detoxification from alcohol, procedures; (3) communications barriers; and
opioids, benzodiazepines, stimulants, sol (4) architectural barriers. Federal, State, and
vents, nicotine, marijuana, anabolic steroids, other sources of assistance might be available
and club drugs (anabolic steroids and club to fund ADArelated improvements. See TIP
drug abuse are rare in this population) 29, Substance Use Disorder Treatment for
appear to be applicable to the elderly popula People With Physical and Cognitive
tion as long as sensitivity to the withdrawal Disabilities (CSAT 1998g) for further infor
medication is considered. TIP 26, Substance mation.
Abuse Among Older Adults (CSAT 1998f),
provides comprehensive information on the The following passage clarifies terms and
treatment of this population. addresses the basic issues presented by
patients with disabilities and/or cooccurring
disorders. Diseases, disorders, and injuries,
110 Chapter 4
whether congenital or acquired, can have ties (WHO 1980). This complex system has
diverse effects on organs and body systems. been simplified here into four main cate
Conditions (and diseases) such as multiple gories:
sclerosis, traumatic brain injury, spinal cord
injury, diabetes, and cerebral palsy can lead 1. Physical impairments are caused by con
to impairments, such as impaired cognitive genital or acquired diseases and disorders
ability, paralysis, blindness, or muscular dys or by injury or trauma. For example,
function. These impairments in turn cause spinal cord injury is a disorder that can
disabilities, which limit an individual’s ability cause paralysis, an impairment.
to function in various areas of life, such as 2. Sensory impairments include blindness
learning, reading, and mobility. While dis and deafness, which may be caused by
eases, impairments, and disabilities are dis congenital disorders, diseases such as
tinct categories, they often are used inter encephalopathy or meningitis, or trauma
changeably. These essential terms are defined to the sensory organs or the brain.
in Figure 4 15. 3. Cognitive impairments are disruptions of
thinking skills, such as inattention, memo
The field of disability services has developed ry problems, perceptual problems, disrup
its own terminology to discuss physical, senso tions in communication, spatial disorienta
ry, and cognitive disabilities (see definitions tion, problems with sequencing (the ability
below), and many treatment providers of peo to follow a set of steps in order to accom
ple with substance use disorders will not be plish a task), misperception of time, and
familiar with these terms as the profession perseveration (constant repetition of
defines them. WHO has devised a method for meaningless or inappropriate words or
the classification of impairments and disabili phrases).
Figure 415
Some Definitions Regarding Disabilities
Disease: An interruption, cessation, or disorder of body functions, systems, or organs.
Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or func
tions.
Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in
the manner or within the range considered normal for a human being. A disability is always perceived
in the context of certain societal expectations, and it is only within that context that the disadvantages
resulting from a disability can be properly evaluated.
Functional capacities: The degree of ability possessed by an individual to meet or perform the behav
iors, tasks, and roles expected in a social environment.
Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain
social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation),
physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deaf
ness), or affective (e.g., depression) in origin and nature. They represent substandard performance on
the part of the individual in meeting life activities and reflect the interaction between the person and the
environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure
416, p112.)
Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.
Physical Detoxification Services for Withdrawal From Specific Substances 111
Figure 416
Impairment and Disability Chart
Impairment Category Common Disabilities
Physical Spina bifida
Spinal cord injury
Amputation
Diabetes
Chronic fatigue syndrome
Carpal tunnel
Arthritis
Sensory Blindness
Hearing impairment
Deafness
Deafblindness
Visual impairment
Cognitive Learning disabilities
Traumatic brain injury
Mental retardation
Attention deficit disorder
Affective Depression
Bipolar disorder
Schizophrenia
Eating disorder
Anxiety disorder
Posttraumatic stress disorder
Source: CSAT 1998e.
112 Chapter 4
All programs should make a good faith effort al. Physical therapy and exercise, chiroprac
to provide equal access in as comprehensive a tic care, biofeedback, hypnotism, and thera
manner as possible for all patients. Individual peutic heat or cold are some other approach
unique needs should be taken into account es to caring for persons with physical prob
when providing services. For example, lems. Most of these alternative treatments
patients with physical, sensory, or cognitive have limited or no research support of their
disabilities may need help with selfcare (e.g., efficacy; yet some clinicians believe they
eating, grooming), moving (e.g., using stairs, work. Thus, consultation with experts on
walking), communication (e.g., reading, their use is necessary before starting a person
speaking), learning, social skills, and execu with chronic pain on these remedies.
tive functions (e.g., planning and organiza
tion, decisionmaking). Unresponsiveness to An alternative model supports the idea that
instructions, lack of participation in discus patients should be treated simultaneously in
sions and activities, forgetfulness, or confu substance abuse treatment, mental/physical
sion by an individual with cognitive disabili health, and detoxification settings, yet treat
ties should not be viewed as a lack of motiva ments may occur in separate facilities and be
tion, resistance, or denial. Programs may conducted by separate staff. The consequent
need to develop the expertise or engage an task for all is to be supportive and knowl
expert on cognitive disabilities to determine edgeable about each other’s interventions.
the limitations resulting from the substance The severity of the addiction and
abuse and those resulting from the disability. medical/psychiatric problems at the time of
Both require patience in the response. detoxification entry should determine which
Information presented to the person with a acute services the patient receives first.
cognitive disability should include different Naturally, a person’s medical and psychiatric
and complementary media; for example, visu disabilities must be accounted for in the
al and tactile materials can reinforce the preparation of any treatment plan. In some
usual verbal interaction. cases, substance abuse treatment cannot
begin until issues relating to medical and psy
Programs also may need to alter their policies chiatric disabilities are settled.
regarding the use of drugs prescribed for pain
control, since most medications of this class There are a number of resources for clini
are drugs with a high abuse potential. A num cians to employ, including experts in the field
ber of patients with substance use disorders of disability services. Figure 417 (p. 114) dis
also live with chronic pain. Living in a drug cusses ways of locating expert help for treat
free state may not be desirable if it is associ ing patients with disabilities and/or cooccur
ated with unrelieved pain, which can be quite ring disorders.
disabling. The clinician should explore with Finally, integrated treatment combines sub
patients what pain management options have stance abuse treatment, treatment for co
been tried in the past, and which management occurring disorders, and detoxification services
medications are being used currently. into one program. For more complete informa
Patients should be encouraged to discuss tion on the treatment of many of these disor
their feelings about pain and how it affects ders, see chapter 5.
their daily life, and especially to what extent
it curtails or prevents their participation in
the activities of daily living. African Americans
There are a number of alternative treatments For African Americans, entrance into detoxifi
for chronic pain. Acupuncture is already in cation has been associated with enrolling in fur
use in some treatment programs for detoxifi ther treatment, reductions in HIV/AIDS risk
cation to help relieve symptoms of withdraw behaviors, and linkages with social and health
Physical Detoxification Services for Withdrawal From Specific Substances 113
Figure 417
Locating Expert Assistance
“Experts” in disability services can be located in several ways, depending upon the nature of the patient’s
disability and the local resources available. Patients who understand their disability may in fact be the best
“experts” on their condition and specific needs; however, it is not uncommon that persons requiring treat
ment for substance use disorders will not understand basic aspects of their situation or condition. In such
cases, immediate family members or close friends may be important sources of information and guidance.
The treatment team also should consider contacting other sources:
• A disabilityspecific service organization (e.g., United Cerebral Palsy, organizations for the blind or deaf
such as the National Association of the Deaf and American Deafness and Rehabilitation Association, the
Association for Retarded Citizens)
• Social workers
• Case managers
• Rehabilitation specialists
• Psychologists
• Nurses or physicians associated with a social service agency providing disability services for the individual
patient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard of
hearing, the Department of Veterans Affairs’ physical rehabilitation unit, community case management
services)
• Other organizations recognized by the disability community (e.g., Centers for Independent Living, gover
nors’ committees for persons with disabilities, Paralyzed Veterans of America, local or State consumer
coalitions for persons with disabilities)
Source: CSAT 1998e.
care services (Lundgren et al. 1999). African mind the standard of respecting the client as
Americans are at greater risk than other popu an equal partner in treatment. For further
lations for the cooccurrence of diabetes and information on this subject (as well as infor
hypertension (high blood pressure) that can mation on working with members of other
predispose them to a risk of stroke. This cultural/ethnic groups), see the forthcoming
should be taken into account when placing and TIP Improving Cultural Competence in
monitoring them on withdrawal medications. Substance Abuse Treatment (SAMHSA in
development a).
In treating AfricanAmerican patients, treat
ment efficacy and therapist efficacy may be The previously discussed protocols for detoxi
associated with the therapist’s understanding fication from all substance of abuse appear
of how race plays a role in recovery adequate for the detoxification of African
(Luborsky et al. 1988; Pena et al. 2000). In Americans. However, there are a few further
addition, when working with counselors from aspects to consider:
other cultures, African Americans may dis • If treating African Americans with beta
play mistrust and a reluctance to show any blockers, propranolol is less effective in
weakness. To overcome this mistrust and to treating African Americans than Caucasians
build rapport, especially when the clinician is (Pi and Gray 1999).
discussing the detoxification process, it is par
• African Americans are more likely (15 to 25
ticularly important for the clinician to keep in
percent) to have less of the enzyme activity
114 Chapter 4
needed to eliminate diazepam than others, so quate for the detoxification of Asians and
it may have a longer halflife in African Pacific Islanders. During the detoxification
Americans than it does in other ethnic groups process, there are a number of issues to con
(Pi and Gray 1999). sider:
• Since cooccurring disorders such as depres • If possible and appropriate, incorporate tra
sion frequently are seen in people with sub ditional healing methods (e.g., meditation
stance use disorders, it is important to know and religious exercises). These can help
that African Americans may require lower reduce stress and anxiety and promote recov
doses and may be at greater risk of develop ery (Chang 2000). While there is a large
ing toxic side effects when prescribed antide immigrant population among many Asian
pressants, since they are likely to metabolize American groups, it is erroneous to assume
tricyclic antidepressants and SSRIs less effi that all are foreign born. Variation in prac
ciently than Caucasians (Pi and Gray 1999). tice of traditional healing methods is consid
• Although the clearance of nicotine is similar erable and consistent with generational dif
for African Americans and Caucasians, the ferences. When considering detoxification,
clearance of cotinine, a metabolite of nico recognize the importance of bicultural prac
tine, is slower in African Americans, which tices, values, and beliefs that might influence
may cause different smoking patterns than responsiveness to treatment.
found in Caucasians (Ahijevych 1998). • When discussing detoxification medications,
discuss with patients their feelings about tak
Asians and Pacific Islanders ing “Western” medications for detoxification.
In some Southeast Asian cultures, Western
This group is the most diverse in nations of medications are believed to be too strong for
origin and has widely differing languages, the Asian person. It is important to assess a
beliefs, practices, dress, and values. Often person’s feelings about these since the patient
the only common thread among these people may not wish to disagree with the clinician
is their geographic origin (Chang 2000). yet may be noncompliant in taking the medi
Although this group appears to have lower cations. Compliance with detoxification medi
rates of alcohol and illicit drug use, these cation may be better achieved if doses are
problems should not be overlooked; members reduced or regimens shortened, yet this
of this group may not seek treatment until the should only be attempted if it is in the best
problems are quite severe. Successful treat interest of the patient.
ment involves the family and important val
ues include balance, harmony, wisdom, and • Racial differences in alcohol sensitivity
modesty. Thus, it may be important to talk to among Asians and Caucasians have long been
the family about the process of detoxification recognized, with more than 80 percent of
and dispel their fears and concerns as well as some Asians compared to 10 percent of
the patient’s. Caucasians being sensitive to alcohol (i.e.,
having a flushing reaction) (Wolff 1972,
Asians and Pacific Islanders tend to be con 1973). This is the result of genetic differences
cerned about the clinician’s credibility and in alcohol metabolizing enzymes.
trustworthiness. Generally speaking, male Approximately 50 percent of Asians lack the
ness, mature age, the projection of selfconfi enzyme ALDH2, found in the liver, that helps
dence, possession of sound cultural compe the body get rid of alcohol (Hsu et al. 1985;
tence skills, good educational background, Yoshida et al. 1985). One reason for lower
and level of experience are of importance. In drinking rates among Asians may be the
addition, a concrete logical approach to the flushing reaction in the face and body follow
problem at hand is valued (Brems 1998). The ing alcohol ingestion and an increase in skin
previously discussed protocols for detoxifica temperature. Other uncomfortable signs and
tion from all substances of abuse appear ade symptoms associated with the negative reac
Physical Detoxification Services for Withdrawal From Specific Substances 115
tion to alcohol ingestion can include nausea, American Indians
dizziness, headache, fast heartbeat, and anx
iety (Caetano et al. 1998). There are currently more than 500 federally
recognized AmericanIndian tribes, and there
• Five studies have shown that the metabolism is among them great variability in appear
of codeine is slower in Chinese people than ance, dress, values, religious beliefs, prac
in Caucasians. Chinese patients seem to tices, and traditions. More than 200 different
require lower doses of codeine, since the languages are spoken by AmericanIndian
slower metabolism leads to a higher concen tribes. Alcohol use varies widely among tribes
tration of codeine in the blood (Smith and (Mancall 1995). Of all ethnic and racial
Lin 1996). groups, American Indians have the greatest
• If treated with beta blockers, Asians require rates of alcohol and illicit drug use (Office of
much lower doses than Caucasians, since Applied Studies 2002a).
they are very sensitive to this medication’s
blood pressure and heart rate effects (Pi An early study of treatment utilization by
and Gray 1999). American Indians found that there was a sig
nificant association between involvement in
• Asians as a group have a higher number of
society and treatment outcomes. Those
individuals than other ethnic groups who
involved in either the traditional Indian soci
are poor metabolizers of diazepam. This
ety or both the traditional Indian society and
may result in the need for lower doses,
Caucasian society had more than a 70 percent
since they report greater sedative effects
success rate, whereas those involved in nei
with a typical dose (Lesser et al. 1997). It
ther society had a 23 percent success rate
also may be that a lower body fat, which is
(Ferguson 1976). At a 10year followup, those
typical of AsianAmerican individuals, can
who had reported greater Indian culture affil
lead to differences in the pharmacokinetics
iation and more severe liver dysfunction at
of lipophilic drugs (Lesser et al. 1997).
baseline had better alcohol treatment out
• In treatment for cooccurring depression comes (Westermeyer and Neider 1984).
and a substance use disorder, Asians
appear to metabolize clomipramine more When engaging an American Indian in the
slowly than Caucasians (Pi and Gray 1999). process of detoxification, moving through the
In contrast, Asians may metabolize process too quickly or abruptly can be per
phenelzine faster, resulting in the need for a ceived as showing a lack of caring and is con
higher dose relative to that which would be sidered contrary to trust building (Brems
appropriate for Caucasians (Pi and Gray 1998). The pace of conversation is important;
1999). a slower pace is more agreeable than a rapid
• Chinese Americans tend to metabolize nico conversation. Moreover, a confrontational
tine 35 percent more slowly than approach also is not advised with this popula
Hispanics/Latinos and Caucasians. Thus, tion (Abbott 1998). American Indians may
they may need to smoke less frequently and want a close and involved relationship with
take in less nicotine to achieve the same their therapists and often want the clinician
nicotine levels as do Hispanics/Latinos and to be a friend or relative (Brems 1998). The
Caucasians. This may have implications for trust often is built by idle small talk to a level
the dosing of NRTs (Benowitz et al. 2002). of shared understanding. Use of fables and
illustrative stories to express ideas can be
• Smoking rates among male Asian extremely helpful. According to the forthcom
Americans, especially immigrant males, are ing TIP Improving Cultural Competence in
exceedingly high and masked by the lower Substance Abuse Treatment (SAMHSA in
rates among AsianAmerican females. development a), avoidance of eye contact also
is traditional. The Talking Circle is a native
116 Chapter 4
tradition that can be helpful in the treatment Spanish or Portuguese does not guarantee
process (Canino et al. 1987; Coyhis 2000). cultural sensitivity or competence. For
The previously discussed protocols for detoxi instance, it is important that the treatment
fication from all substances of abuse appear staff understand the role of the family. The
adequate for the detoxification of American functional family can be extended and should
Indians. The following are some issues to con take into account people who have daytoday
sider during detoxification. contact with and a role in the family
• Fetal Alcohol Syndrome is 33 times higher in (Markarian and Franklin 1998).
this population than the national average Hispanics/Latinos are likely to view drug
(SAMHSA in development a). This may be dependency as moral failing or personal
important for pregnant women coming to weakness. Traditional healing such as folk
detoxification and also may be important if remedies and folk
the adult has FAS. healers may provide
benefit. The previ Hispanics/Latinos
• Indian women who drink have a sixfold
ously discussed pro
increase in cirrhosis of the liver relative to
tocols for detoxifica are now the
Caucasian women (Heath 1989).
tion from alcohol,
• Although some American Indians have opioids, benzodi
reported a flushing response to alcohol, it largest ethnic
azepines, stimulants,
appears that the flushing reaction in solvents, nicotine,
American Indians is milder and less adverse marijuana, anabolic
minority group in
than that experienced by Asians (Gill et al. steroids, and club
1999). drugs appear ade America.
• If Alcoholics Anonymous or other 12Step quate for the detoxi
programs are to be introduced, framing the fication of Assessment of the
steps in terms of a circle rather than a ladder Hispanics/Latinos.
may be better received, since the circle is patient’s level of
important concept in Indian culture
(SAMHSA in development a). Gays and acculturation can
• If possible and appropriate, other traditional Lesbians
methods that can help recovery are sweat Approximately 5 to
be helpful in
lodges, vision quests, smudging ceremonies, 33 percent of all les
sacred dances, and four circles (Abbott bian and gay individ understanding
1998). uals are estimated to
have a substance substance abuse
• Overall, detoxification for this population is
the same as for other populations, but abuse problem
American Indians are likely to seek treatment (Cochran and Mays patterns.
later and have more medical complications 2000; Hughes and
and poorer nutrition (Abbott 1998). Wilsnack 1997). A
contributing factor may be the stress and
anxiety associated with the social stigma
Hispanics/Latinos attached to homosexuality. Further, alcohol
Hispanics/Latinos are now the largest ethnic and drugs may serve as an escape and ease
minority group in America. Assessment of the social interactions at social settings such as
patient’s level of acculturation can be helpful bars. More information on this subject will be
in understanding substance abuse patterns. available in the forthcoming TIP Improving
Language is one of the most difficult barriers Cultural Competence in Substance Abuse
to treatment entry and success for Treatment (SAMHSA in development a). The
Hispanics/Latinos. However, simply knowing previously discussed protocols for detoxifica
Physical Detoxification Services for Withdrawal From Specific Substances 117
tion appear adequate for gay and lesbian there is liver toxicity or suicidal intent
patients. Since numerous misconceptions and (Giannini et al. 1991). The use of club drugs
stereotypes exist concerning gay and lesbian is higher in this population than in others.
individuals, it is important for the clinician to
assess his beliefs and take care not to impose TIP 31, Screening and Assessing Adolescents
them on the patient. for Substance Use Disorders (CSAT 1999d),
and TIP 32, Treatment of Adolescents With
There are a number of principles of care for Substance Use Disorders (CSAT 1999f), pro
treating gay and lesbian individuals, which vide comprehensive information on the treat
are outlined in A Provider’s Introduction to ment of adolescents.
Substance Abuse Treatment for Lesbian,
Gay, Bisexual, and Transgender Individuals
(CSAT 2001). These principles include: (1) Incarcerated/Detained Persons
counselors’ being able to monitor their own Substance use disorders are common among
feelings about working with this population of inmate populations. At the time of arrest and
patients in order to provide professional, eth detention, it has been estimated that 70 to 80
ical, and competent care; (2) helping patients percent of all inmates in local jails and State
heal from the negative experiences of homo and Federal prisons had regular drug use or
phobia and heterosexism; (3) helping patients had committed a drug offense, and 34 to 52
understand their reactions to discrimination percent of these inmates were intoxicated at
and prejudice; and (4) helping patients accept the time of their arresting offense (Federal
personal power over their own lives by help Bureau of Prisons 2000; Mumola 1999).
ing them improve their selfimages and build Although women comprise a small proportion
support networks. of the incarcerated population (12.3 percent
in jails and 7.4 percent in State and Federal
prisons) than men (Harrison et al. 2004),
Adolescents females have a greater prevalence of illicit
The previously discussed protocols for detoxifi drug use (i.e., 40 percent compared to 32 per
cation from all substances of abuse appear ade cent were under the influence of drugs at the
quate for the detoxification of adolescents; time the crime was committed) than do males
however, there are several additional aspects to (Greenfeld and Snell 1999).
consider:
Persons who are incarcerated or detained in
• Physical dependence generally is not as
holding cells or other locked areas should be
severe, and response to detoxification is more
screened for physical dependence on alcohol,
rapid than in adults.
opioids, and benzodiazepines and provided
• Retention is a major problem in adolescent with needed detoxification and treatment.
treatment (Thurman et al. 1995). Screening should occur over time, since the
• Peer relationships play a large role in treat onset and intensity of withdrawal is depen
ment. Among adolescents who do not use dent on the type of drug taken, when the per
drugs, few of their friends reported use. In son last took the drug, and how long the drug
one study, among those who reported specific lasts in the person’s body. The duration of
drug use, over 90 percent of their friends detention will affect what detoxification ser
reported using the same drug (Dinges and vices can be provided, and many facilities will
Oetting 1993). not be able to provide detoxification or con
• It is estimated that 75 percent of those tinuing care services. There are some special
reporting steroid use are high school stu considerations for the detoxification of this
dents, and most of them are male. Detoxifica population:
tion from steroids does not typically require • Abrupt withdrawal from alcohol can be life
specific pharmacological intervention unless threatening.
118 Chapter 4
• Abrupt withdrawal from opioids or benzo • Many correctional facilities have restric
diazepines is not lifethreatening but can tions on the use of methadone or LAAM and
cause severe withdrawal signs and symp special provisions for maintaining or taper
toms and great distress. ing the individual may need to be made.
• It should be determined whether depen • If medications are provided to medically
dence on either opioids or benzodiazepines detoxify inmates, the Federal Bureau of
is the result of illicit use and not the result Prisons’ Clinical Practice Guidelines for
of taking medications that have been pre Detoxification of Chemically Dependent
scribed to treat pain or anxiety disorders. Inmates (2000) suggest retaining strict con
• If medically supervised withdrawal is indi trol over access to these medications to pre
cated, the substitution of a longacting drug vent diversion or misuse (e.g., eating cloni
from the same class of substances the dine patches to obtain a state of euphoria).
patient is using (e.g., giving methadone to TIP 44, Substance Abuse Treatment for
treat heroin dependence) and the gradual Adults in the Criminal Justice System (CSAT
tapering of that substance (no faster than 2005b), and TIP 30, Continuity of Offender
10 to 20 percent per day) should be con Treatment for Substance Use Disorders From
ducted under closely monitored settings. Institution to Community (CSAT 1998b), pro
• There are cases when individuals main vide more detailed information about the
tained on opioid agonist medications are treatment of this population. TIP 21,
detained or incarcerated. If the incarcera Combining Alcohol and Other Drug Abuse
tion is 30 days or less, the individual should Treatment With Diversion for Juveniles in
be maintained on her usual dosage. If the the Justice System (CSAT 1995b), also pro
incarceration is longer, the individual may vides information about incarcerated youth.
be appropriate for gradual dose tapering.
• Persons who transition from a state of opi
oid dependence to a drug or medication
free state are at greater risk of overdose
upon relapse to opioid use.
Physical Detoxification Services for Withdrawal From Specific Substances 119
5 CoOccurring Medical
and Psychiatric
Conditions
In This
Chapter…
Patients undergoing detoxification frequently present with medical
and psychological conditions that can greatly affect their overall well
General Principles
being and the process of detoxification. These may simply be pre
of Care for
existing medical conditions not related to substance use or the direct
Patients With Co
outcome of the substance abuse. In either case, the detoxification pro
Occurring Medical
cess can negatively affect the cooccurring disorder or vice versa.
Conditions
Furthermore, people who abuse substances often present with medical
conditions in advanced stages or in a medical crisis. Cooccurring
Treatment of
mental disorders also are likely to be exacerbated by substance abuse.
CoOccurring
For more on treating patients with cooccurring psychiatric disorders,
Psychiatric
the reader should refer to TIP 42, Substance Abuse Treatment for
Conditions
Persons With CoOccurring Disorders (Center for Substance Abuse
Treatment [CSAT] 2005c).
Standard of Care
for CoOccurring
This chapter is intended primarily for medical personnel treating
Psychiatric
patients in detoxification settings, though nonmedical staff may find it
Conditions
informative as well. This chapter is not meant to take the place of
authoritative sources from internal medicine. Rather, it presents a
cursory overview of special conditions, modifications in protocols, and
the use of detoxification medications in patients with cooccurring
conditions or disorders. Overall treatment of specific conditions is not
addressed unless modification of such treatment is needed.
121
on the overall health of patients, staff mem
General Principles of bers are in a position to help patients see the
Care for Patients With importance of engaging in treatment for their
substance use disorders. Patients should have
CoOccurring Medical appointments for followup care made prior to
Conditions detoxification discharge for all chronic medi
Patients who use substances can present with cal conditions, conditions needing further
any of the conditions or combinations of con evaluation, and substance abuse treatment.
ditions that can be found in the general popu This section highlights the conditions most
lation. In most cases, the management of the frequently seen in individuals who abuse sub
medical condition in the patient with a sub stances, though it is not inclusive. Disorders
stance use disorder diagnosis does not differ of the following systems will be covered: gas
from that of any other patient. However, the trointestinal (including the gastrointestinal
medication used for detoxification and the [GI] tract, liver, and pancreas), cardiovascu
actual detoxification protocol may need to be lar system, hematologic (blood) abnormali
modified to minimize potentially harmful ties, pulmonary (lung) diseases, diseases of
effects relevant to the cooccurring condition. the central and peripheral nervous system,
Detoxification staff providing support should infectious diseases, and special miscellaneous
be familiar with the signs and symptoms of disorders. Where special considerations are
common cooccurring medical disorders. needed for a patient presenting with a given
Likewise, personnel at medical facilities (i.e., disorder in a detoxification setting they are
emergency rooms, physicians’ offices) should listed following the heading “Special
be aware of the signs of withdrawal and how Considerations.”
it affects the treatment of the presenting med
ical conditions. Gastrointestinal Disorders
The setting in which detoxification is carried Frequently, the use of substances can present
out should be appropriate for the medical a range of gastrointestinal problems. Cocaine
conditions present and should be adequate to use, for example, can result in various gas
provide the degree of monitoring needed to trointestinal complications, including gastric
ensure safety (e.g., oximetry [a measurement ulcerations, retroperitoneal fibrosis, visceral
of the amount of oxygen present in the infarction, intestinal ischemia, and gastroin
blood], greater frequency of taking vital testinal tract perforations (Linder et al.
signs, etc.). Acute, lifethreatening conditions 2000). Gastrointestinal disorders may affect
need to be addressed concurrently with the many different organs and organ systems
withdrawal process and intensive care unit (e.g., liver, pancreas), making diagnosis diffi
monitoring may be indicated. cult. Since symptoms can be vague and
patients are not always able to articulate the
Clinicians should keep in mind that consulta specific problem, diagnosis can be difficult.
tion with specialists in infectious diseases, For a simple rule of thumb, urgent attention
cardiology, pulmonary medicine, hematology, is needed if the patient is diagnosed with any
neurology, and surgery may be warranted. of the following:
Whenever possible, consent should be sought
• Appendicitis
to involve the patient’s primary healthcare
provider in the coordination of care. • Abdominal aortic aneurysm
Attending medical staff should be aware that • Perforated peptic ulcer
cooccurring medical conditions present an • Boerhaave’s Syndrome (spontaneous
opportunity to engage patients. By focusing esophageal rupture)
on the adverse effects of the substance abuse
• Obstructed or strangulated bowel
122 Chapter 5
• Ischemic bowel disease (a condition that may decrease lower esophageal sphincter pres
results from inadequate blood supply to the sure and aggravate reflux (Dell’Italia 1994).
intestines)
• Abcess of the pancreas or liver Mallory–Weiss Syndrome
• Ruptured spleen or other trauma to the
Mallory–Weiss Syndrome is caused by torn
abdominal area
mucosa of the esophagus at the gastro
Other possible diagnoses of abdominal pain esophageal junction due to protracted or vio
include: lent vomiting. Mallory–Weiss Syndrome is the
etiology of 5 to 15 percent of all upper GI
• Hepatitis
bleeds (SchuylzeDelrieu and Summers 1994).
• Peptic ulcer (nonperforating)
• Peritonitis
Boerhaave’s
• Acute pancreatitis
syndrome
• Pelvic inflammatory disease
Boerhaave’s syn
• Endometriosis
drome is manifested
• Nephrolithiasis (kidney stones) Cooccurring
by rupture of the
• Inflammatory bowel disease esophagus. Patients
presenting with this medical conditions
• Ovarian cysts
condition complain of
Clinicians should also be aware of some decep acute epigastric pain present an
tive causes of abdominal pain: (83 percent of
• Myocardial infarction patients), vomiting opportunity to
(79 percent), and
• Pulmonary emboli shortness of breath engage patients in
• Herpes zoster (shingles) (39 percent) as the
• Acute pylonephritis (kidney infection) predominant, nonspe treatment for
cific symptoms. This
Specific cooccurring gastrointestinal disorders lack of specificity can
requiring special attention in patients undergo
their substance
delay making the cor
ing detoxification are discussed below. rect diagnosis (Brauer
et al. 1997).
use disorders.
Tachycardia,
Reflux esophagitis cyanosis, and subcu
Reflux esophagitis can be a result of alcohol’s taneous emphysema
effect on the lower esophageal sphincter (i.e., also can be seen. If
relaxation) and a decrease in peristalsis of the this condition is left
distal esophagus, allowing gastric contents to untreated, the prognosis is severe.
come into contact with the lower esophagus.
Typical symptoms include burning in the epi
gastric or retrosternal area (commonly called Gastritis
“heartburn” or “indigestion”). Esophageal Gastritis is described as the disruption of the
bleeding can result from reflux esophagitis and gastric mucus lining that allows gastric acid to
esophageal varices (resulting from portal contact the mucosa with resultant inflammation
hypertension). and possible bleeding. The patient presents
with nausea, vomiting, and abdominal pain
Special considerations (Ivey 1981). Alcohol increases gastric acid
Several drugs used in typical protocols, such as secretion and reduces the mucosal cell barrier,
beta blockers and calcium channel blockers,
CoOccurring Medical and Psychiatric Conditions 123
allowing backdiffusion of the gastric acid into ered as an appropriate agent, as it can be
the mucosa. This frequently causes an occur administered intravenously or intramuscular
rence of erosive gastritis in the individual with ly. Opioids may have to be used to control
an alcohol use disorder (Fenster 1982). pain.
Special considerations
Aspirin and nonsteroidal medications should be Liver disorders
avoided in the withdrawal protocols. Liver disease can range from fairly benign
fatty liver, which presents usually as an
asymptomatic enlargement of the liver associ
Pancreatitis ated with mild elevation of the serum liver
Pancreatitis can be enzymes, to a broad spectrum of viral infec
caused by many fac tions and the toxic consequences of alcohol
Detoxification tors, although stud and other drug use. The end point of liver
ies suggest that alco disease is liver necrosis or failure. Midway in
staff providing hol may be a factor the progression of liver disease is acute alco
in anywhere from 5 holic hepatitis. The presentation is one of
support should be to 90 percent of all liver tenderness, jaundice, fever, ascites, and
cases (Apte et al. an enlarged liver. The patient is quite sick
1997), with some and frequently has nausea and vomiting.
familiar with the experts suggesting
about 60 percent of Special considerations
signs and all cases result from Alcoholic hepatitis usually needs acute medi
excessive alcohol cal treatment to prevent electrolyte imbalance
symptoms of com consumption and dehydration. Protocols may have to be
(Yakshe 2004). The adapted if the patient cannot take oral
mon cooccurring acute condition pre agents.
sents with abdomi
medical conditions. nal pain, which is
described as sharp, Portal hypertension
burning, and con Portal hypertension is a frequent conse
stant and is located quence of liver disease. If elevation of the
in the epigastric portal pressure goes untreated, esophageal
area of the varices develop and hemorrhage can ensue.
abdomen with radiation to the back. Treatment of acute hemorrhage includes
Presenting symptoms and signs can include endoscopic sclerotherapy or ligation. Initial
abdominal tenderness, decreased bowel therapy should include prompt and adequate
sounds, lowgrade fever, tachycardia, nausea, intravascular volume replacement, correction
and vomiting. Pancreatitis can proceed to a of severe anemia and coagulopathies, and
chronic condition where pancreatic calcifica adequate airway management.
tion, diabetes mellitus, malabsorption, and
chronic abdominal pain occur. Special considerations
Propranolol or isosorbide therapy is effective
Special considerations in the prophylaxis of variceal bleeding
There may be a need to forbid oral intake of (Trevillyan and Carroll 1997), though beta
food and medications, necessitating a change blockers can interfere with measuring the
of route of administration of both food and true heart rate that determines the content of
medications to intravenous forms. In alcohol many detoxification protocols. If bleeding is
withdrawal protocols, Ativan might be consid
124 Chapter 5
present, changeover to intravenous medica Cardiovascular Disorders
tion protocols is recommended, as the patient
will not be able to take oral medications. The presentation of chest pain or discomfort
remains one of the most difficult differential
diagnoses to sort through, as disorders of sev
Cirrhosis eral systems can cause this single complaint.
Inability to correctly diagnose this symptom
Cirrhosis, or the formation of fibrous tissue
can be brought about by the patient’s inabili
in the liver, leads to a state of increased resis
ty to be interviewed and give succinct symp
tance in the hepatic venous circulation. The
toms (the intoxicated or severely withdrawing
inability of blood to flow freely gives rise to
patient), a sociocultural or educational level
portal hypertension with ensuing esophageal
that does not allow for the verbal nuances
varices, splenomegaly, ascites, dilatation of
necessary to making a diagnosis, or fabrica
superficial veins, peripheral edema, and hem
tion of symptoms by a patient seeking to
orrhoids.
obtain pain medications or other drugs.
Liver necrosis can be seen in patients who use
A normal resting electrocardiogram does not
inhalants, particularly chronic use of benzene
rule out the presence of organic heart disease
and carbon tetrachloride. African Americans
and the presence of nonspecific changes does
and Hispanics/Latinos have higher mortality
not necessarily mean that heart disease is pre
rates from cirrhosis of the liver resulting from
sent. Final diagnoses can range from reflux to
alcohol abuse than do Caucasians and Asians
myocardial infarction brought about by
and Pacific Islanders (Sutocky et al. 1993).
underlying ischemic heart disease or the use
Liver function test abnormality and jaundice
of cocaine. Frequently, lung diseases can have
can occur in individuals who use anabolic
as their presenting symptom chest discomfort.
steroids, but this usually resolves on cessation
The consensus panel believes that this condi
of the drugs. Studies in the elderly show that
tion should never be overlooked or minimized
1year mortality was 50 percent among
and it is imperative that an especially prompt
patients over age 60 with cirrhosis, versus 7
diagnosis be made and treatment be under
percent for those under age 60 (Potter and
taken to ensure patient safety.
James 1987). Great care needs to be used
when giving diuretics to elderly patients with Underlying cardiac illness could be worsened
cirrhosis, since their total body water may by the presence of autonomic arousal (elevat
already be decreased, making them more sus ed blood pressure, increased pulse and sweat
ceptible to fluid and electrolyte depletion ing) as seen in alcohol, sedative, and opioid
(Scott 1989). withdrawal. Thus prompt attention to these
findings and aggressive withdrawal treatment
Alcoholrelated hepatic injury is seen in a
is indicated. Special considerations for the
higher proportion of women due to a possible
treatment of specific cardiac conditions are
potentiation (strengthening) of this effect by
outlined below.
estrogen (Brady and Randall 1999).
Special considerations Hypertension
For the treatment of alcohol withdrawal,
lorazepam (Ativan) is well tolerated in Hypertension frequently is seen in the detoxi
patients with severe liver disease (D’Onofrio fication patient. Evaluation should include a
et al. 1999) as is oxazepam (Serax), with its complete history to determine if the elevated
short halflife of 6 to 8 hours and simple blood pressure predated the present with
metabolism with no metabolites. drawal status. Consideration should be given
to include serum electrolytes, urinalysis,
BUN/creatinine, and an EKG in the detoxifi
CoOccurring Medical and Psychiatric Conditions 125
cation unit’s initial workup. More elaborate Ischemic heart disease
workup can be carried out after completion
of detoxification. Ischemic heart disease presents as chest pain
or pressure, palpitations, dizziness, and/or
Propranolol (Inderal), labetalol (Trandate) shortness of breath and requires immediate
and metoprolol (Lopressor) are the beta attention, which will dictate what setting is
blockers of choice for treating hypertension appropriate for the detoxification.
during pregnancy (McElhatton 2001), howev
er, the impact of using them for alcohol Cocaine use is associated with various cardio
detoxification during pregnancy is unclear. If vascular complications including angina pec
treating African Americans with beta block toris, myocardial infarction, and sudden
ers, clinicians should be aware that propra death. It is estimated that over half of the
nolol is less effective in this population than it 64,000 patients evaluated annually for
is in Caucasians (Pi and Gray 1999). Asians cocaineassociated chest pain will be admitted
require much lower doses of beta blockers to hospitals for evaluation of myocardial
than Caucasians, inasmuch as they tend to be ischemia. Only about 6 percent of patients
very sensitive to the blood pressure and heart will demonstrate biochemical evidence of
rate effects (Pi and Gray 1999). myocardial infarction (Hoffman and
Hollander 1997). The typical patient with
Special considerations cocainerelated myocardial infarction is a
The presence of a hypertensive history and male in his mid30s with a history of chronic
poorly controlled blood pressures may have tobacco and repetitive cocaine use (Hollander
an effect on the proper evaluation of with 1995). This effect of cocaine appears to be
drawal as the examiner would have difficulty increased because the drug causes an increase
determining whether the elevated blood pres in myocardial oxygen demand and thus a
sure was due to withdrawal or to the underly decrease in oxygen supply. These two factors,
ing hypertensive history. Thus modifications which are caused by vasospasm and vasocon
of the usual parameters and scheduling of striction of the coronary arteries, may lead to
detoxification medications should be consid cardiovascular disorders.
ered. In any event, severe elevation of blood Patients with recent cocaine use can experi
pressure should be treated concurrently with, ence persistent cardiac complications such as
at minimum, salt restriction and rest. If the prolonged QT interval and vulnerability for
blood pressure is still elevated in several days arrhythmia and myocardial infarction
despite a reduction in other withdrawal (Chakko and Myerburg 1995). (QT is the Q to
parameters and symptoms, then medication is T interval measured on EKGs. If the interval
warranted. is prolonged, it can lead to cardiac rhythm
Beta blockers and clonidine have been used disturbances.) Amphetamines are rarely
in the treatment of alcohol withdrawal and reported as the cause of myocardial infarc
clonidine also has been used in opioid proto tion, though a case report shows that a
cols. These medications can help control patient subsequently experienced a non–Q
blood pressure and also work well in the pro wave anterior wall infarction associated with
tocol. Calcium channel antagonists have also amphetamine use (Waksman et al. 2001).
been used to ameliorate some of the symptoms Cocaine use and HIV infection have been
of alcohol withdrawal and can be used con associated with an increased incidence of car
currently for blood pressure control. diac dysfunction, but concomitant exposure
may cause a synergistic effect (Soodini and
Morgan 2001).
126 Chapter 5
Special considerations Arrhythmias
Betaadrenergic blocking agents may exacer Arrhythmias (irregular heartbeats) can be
bate cocaineinduced coronary arterial vaso seen in the presence of ischemia and car
constriction and thereby increase the myocar diomyopathy. Two specific cases of arrhyth
dial ischemia. Nitroglycerin and verapamil mogenic disorders are “holiday heart,” where
reverse cocaineinduced hypertension and the patient who has ingested alcohol presents
coronary arterial vasoconstriction and are with supraventricular arrhythmia
the medications of choice in the patient who (Greenspon and Schaal 1983), and the indi
uses cocaine and presents with chest pain vidual who uses cocaine with the stimulant
(Pitts et al. 1999). Cocaine may cause platelet leading to significant atrial and ventricular
activation leading to acute coronary events— arrhythmias. Consumption of anabolic
thus more aggressive antiplatelet therapy may steroids also has
be indicated (Callahan et al. 2001). been associated with
hypertension,
Cocaine use is
ischemic heart dis
Cardiomyopathy
ease, cardiomyopa
Cardiomyopathy is caused by degenerative thy, and arrhythmia associated with
changes of the cardiac muscle with enlarge (Sullivan et al.
ment of the heart (cardiomegaly) and left ven 1999). various
tricular failure. Alcoholic cardiomyopathy
presents with a similar picture as cardiac fail Special consider cardiovascular
ure from other etiologies, with shortness of ations
breath on exertion, shortness of breath when Treatment of arrhyth complications
the patient is lying flat, and edema of the mia in the person who
lower extremities. abuses substances is including angina
similar to that for the
Besides alcohol as the etiology, a dilated car
patient who does not
diomyopathy can be seen with use of the pectoris,
abuse substances,
inhalant trichlorethylene. Cardiomyopathy in
though the setting of
the elderly patient with an already underlying
detoxification may myocardial
ischemic or atherosclerotic heart disease can
have to be altered to
be quite debilitating. Women have shown infarction, and
allow for cardiac
alcohol metabolism different from that of men
monitoring (teleme
and distinct pathophysiologic mechanisms, sudden death.
try).
which frequently lead to a higher sensitivity
to alcoholinduced heart damage. The preva
lence of cardiomyopathy in women is equal to Hematologic
that in men, despite cases in which women
have consumed far less ethanol (Fernandez
Disorders
Sola and NicolasArfelis 2002). Hematologic (blood) disorders can be seen due
to several factors, such as a direct toxic effect
Special considerations of the drug on the bone marrow, as seen in
Alcoholic cardiomyopathy may respond poor alcohol and benzene use, or as a result of mal
ly to digitalis with increased likelihood of digi absorption of essential nutrients (B12, folate),
talis toxicity (Zakhari 1991). or as a general poor state of nutrition.
CoOccurring Medical and Psychiatric Conditions 127
Anemia platelet count (thrombocytopenia), which is
due to enlargement of the spleen and abnor
Anemia can be seen due to folate deficiency, mally high platelet storage. Thrombocyto
iron deficiency, B12 deficiency, acute blood penia also can be seen in cases of vitamin B12
loss, or more frequently as a combination of and folate deficiency.
factors. Folate deficiency can cause a mega
loblastic anemia, which is diagnosed by The AfricanAmerican patient with sickle cell
macroovalocytes and hypersegmented neu disease or trait can be severely affected (inas
trophils seen on a peripheral blood smear. much as the patient already has an impaired
Iron deficiency anemia results from blood loss oxygen delivery system) if other harm threat
and thus subsequent iron loss. This can be ens the bone marrow.
seen in lowlevel
gastrointestinal Special considerations
bleeding, after Elevated heart rates can hinder the use of the
childbirth, and as a heart rate as a parameter in various detoxifica
result of menstrual tion protocols.
Traumatic brain blood loss. The pre
sentation of anemia
injury (TBI) usually is nonde Pulmonary Disorders (Other
script with general Than Infectious)
should always be ized fatigue and
Pulmonary disorders are common in people
weakness. With
who abuse substances, in part because of the
considered in severe anemia,
high rate of nicotine use in this population
shortness of breath
(Graham et al. 2003).
on exertion and an
patients with elevated heart rate
can be seen. Aspiration pneumonia
neurological Specific to the
Alcohol or other drug ingestion may reduce a
megaloblastic ane
impairment. patient’s gag reflex, leading to the blockage of
mias (B12 and
the airways. Aspiration pneumonia occurs
folate deficiency)
when oropharyngeal secretions and/or gastric
one can see neuro
contents enter into the lower airways. This seri
logic complications
ous condition may require prolonged hospital
such as peripheral
ization.
neuropathy.
White blood cell disorders Asthma
Asthma, a chronic condition characterized by
White blood cell disorders can occur due to
exacerbations of bronchial spasm manifested
malnutrition and liver disease. Lymphopenia
by wheezing, should be differentiated from
may be present in the patient with HIV disease.
bronchospasm, which is related to inhaled
drugs and usually is selflimited. Treatment is
Platelet disorders similar to that provided to patients who do
not use substances, with the addition of cessa
Platelet disorders frequently are attributable
tion of the substance use.
to the direct effect on the bone marrow by the
substance being abused or, as seen in alcohol The patient with underlying chronic asthma
related thrombocytopenia, are due to bone can be severely compromised if the use of a
marrow suppression. Splenomegaly caused by smokeable drug causes exacerbation of an
portal hypertension also can cause a low already impaired system.
128 Chapter 5
Special considerations ularly in hospitalized patients. Evaluation for
Asthma medications can cause a significant infections and the use of oxygen, steroids,
increase in heart rate, which can affect the and inhalers is dictated by the clinical pic
evaluation of withdrawal protocols that use ture. During detoxification, if nicotine use is
heart rate as one of the parameters. not allowed, there can be significant effects
on drug levels (see chapter 4).
Chronic Obstructive
Neurologic System
Pulmonary Disease
The neurologic system of patients with sub
Chronic obstructive pulmonary disease stance use disorders is affected directly in the
(COPD) (emphysema, chronic bronchitis) fre toxic effects on cell membranes, effects on
quently is due to cigarette use and the result neurotransmitters, associated metabolic
ing alterations of the pulmonary immune sys changes from other underlying disorders, and
tem, inflammation, and destruction of lung changes in blood flow. Researchers have
parenchyma. Presentation includes shortness found that the majority of those with an alco
of breath on exertion, a cough producing hol use disorder (75 percent) have some
mucous, and wheezing. degree of cognitive impairment (Goldstein
African Americans who smoke cigarettes take 1987). Specific disorders found in patients
in more nicotine, and therefore more tobacco with substance use disorders can affect the
smoke toxins per cigarette, than Caucasians central nervous system and the peripheral
(PerezStable et al. 1998). system. For example, a broad array of neu
ropathologic changes are seen in the brains of
Daily marijuana smoking has been shown to people who use heroin. The main findings are
have adverse effects on lung function includ due to infections as a result of endocarditis or
ing a productive cough, wheezing, and exces HIV infection. Other complications include
sive sputum production. However, the habitu hypoxicischemic changes with cerebral
al marijuanaonly smoker, in the absence of edema, ischemic neuronal damage thought to
alpha1antitrypsin deficiency, would have to be due to heroininduced respiratory depres
smoke four to five marijuana cigarettes per sion, stroke due to thromboembolism, vas
day for a span of at least 30 years to develop culitis, septic emboli, and hypotension.
overt manifestations of COPD (Van Hoozen Myelopathy occurs as a result of possible iso
and Cross 1997). lated vascular accident in the spinal cord,
and a distinct condition, leukoencephalopa
Special considerations thy, has been described after the inhalation of
During nicotine withdrawal and cessation preheated heroin (Buttner et al. 2000).
treatment, different levels of nicotine absorp
tion, as seen in some groups, will affect dosing As a final note, traumatic brain injury (TBI)
for nicotine replacement therapies (Perez should always be considered in patients pre
Stable et al. 1998). The patient with COPD, senting with neurological impairment. People
especially if elderly, would be sensitive to the who abuse substances are at high risk of falls,
sedating effects of many of the detoxification motor vehicle accidents, gang violence,
protocol medications, especially the benzodi domestic violence, etc., which may result in
azepines, which may have to be reduced in head injury (Graham et al. 2003).
dosage to avoid respiratory depression and Unrecognized TBI can affect the treatment
worsening hypoxemia and hypercarbia outcome.
(decrease in oxygen and increase in carbon
dioxide). For smokers, always consider the
use of the nicotine replacement agents, partic
CoOccurring Medical and Psychiatric Conditions 129
WernickeKorsakoff’s 50mg every 6 hours for 24 hours) when detox
ifying from alcohol.
Syndrome
WernickeKorsakoff’s Syndrome is composed Individuals with an alcohol use disorder show
of Wernicke’s encephalopathy and an increase in seizures due to withdrawal,
Korsakoff’s psychosis. Wernicke’s metabolic insults such as hypoglycemia or
encephalopathy is an acute neurological dis electrolyte imbalance, or head trauma. In one
order with a triad of study, researchers found that of 195 cases of
seizures in those with an alcohol use disorder,
• Oculomotor dysfunction (bilateral abducens
59 percent were due to alcohol withdrawal, 20
nerve palsy—eye muscle paralysis)
percent to head trauma, and 5 percent to vas
•Ataxia (loss of muscle coordination) cular disorders (Earnest et al. 1988).
•Confusion
Special considerations
Weakness and nystagmus are also seen in this Evaluation of a first seizure should include a
syndrome on examination of the eyes. neurological evaluation and evaluation for
Wernicke’s encephalopathy is clearly related to head trauma. Metabolic etiologies, such as low
thiamine deficiency. magnesium levels, should be considered.
Korsakoff’s psychosis is a chronic neurologi MayoSmith (1997) has shown that benzodi
cal condition resulting from thiamine defi azepines confer protection against alcohol
ciency that includes retrograde and antegrade withdrawal seizures and thus patients with
amnesia (profound deficit in new learning and previous seizures should be treated early with
remote memory) with confabulation (patients this class of medications. The consensus panel
make up stories to cover memory gaps). suggests that antiepileptic drug therapy
should be considered in alcohol withdrawal
Special considerations patients with multiple past seizures (of any
Thiamine initially is given parenterally and cause), a history of recent head injury, past
then oral administration is the treatment of meningitis, encephalitis, or a family history of
choice. Always give thiamine prior to glucose seizures.
administration.
Clinicians should be aware that treatment of
the first seizure with benzodiazepines does
Alcohol and sedative not prevent the likelihood of a second seizure
withdrawal seizures (D’Onofrio et al. 1999). Slower medication
Alcohol and sedative withdrawal seizures rep tapers should be considered when this condi
resent a significant medical challenge (Ahmed tion cooccurs with detoxification.
et al. 2000), since no large clinical studies Lorazepam, which can be used in patients
have been conducted to firmly establish the with liver disease, has been suggested as
best treatment practices. Up to 90 percent of appropriate, but it and other shortacting
alcohol withdrawal seizures occur in the first benzodiazepines may not prevent lateoccur
48 hours and usually are single and nonfocal. ring withdrawal seizures (Shaw 1995).
Repeated episodes of drinking and withdraw Dosages of anticonvulsant medications should
al are thought to predispose people to be stabilized before sedativehypnotic with
seizures due to a kindling phenomenon (Post drawal begins. Adequate treatment with a
et al. 1987). Patients with a history of with longacting benzodiazepine is effective in pre
drawal seizures are at greatest risk and venting withdrawal seizures (MayoSmith and
should receive prophylactic doses of a long Bernard 1995). D’Onofrio and colleagues
acting benzodiazepine (e.g., chlordiazepoxide (1999) found that a onetime dose of the rela
130 Chapter 5
tively shorter acting agent lorazepam also There is a higher than normal incidence of
reduced the risk of a subsequent seizure com hemorrhagic stroke and other intracranial
pared to placebo. However, in D’Onofrio’s bleeding among patients with heavy alcohol
study doses were small and the results were use, and a particular association of strokes
limited somewhat by use in an emergency within 24 hours of a drinking binge (Altura
room setting. 1986).
Older, firstgeneration anticonvulsants have Special considerations
limitations in that they have only been stud Nifedipine and verapamil have been shown to
ied in mild to moderate withdrawal, on rare prevent alcoholinduced vasospasm, which sug
occasions they can cause serious hepatic and gests a possible therapeutic approach to hyper
bone marrow toxicities, and they can interact tension and stroke in the patient with heavy
with other classes of medication. Newer alcohol use (Altura 1986).
drugs, such as gabapentin (Neurontin) and
oxcarbazepine (Trileptal), do not appear to
have these liabilities, but sufficient studies to Polyneu
show this have not yet been done. There is lit ropathy
tle evidence that longterm use of phenytoin is
helpful in the patient who does not have an Polyneuropathy fre
underlying seizure disorder (Kasser et al. quently is seen in
2000). Medications that may lower the seizure nutritional deficien Treatment of the
threshold, including phenothiazines, such as cies that occur in the
prochlorperazine (Compazine), and several patient with chronic
alcohol use.
first seizure with
antidepressants, such as bupropion, should
be used with great caution in the patient with Presenting signs and
symptoms include benzodiazepines
a seizure history.
lower extremity
The use of anticonvulsants, such as valproic pain, distal motor does not prevent
acid and barbiturates, has been studied in loss, numbness or
pregnant women. Valproic acid is associated tingling, and loss of the likelihood of a
with several malformations in the fetus. The reflexes.
use of any anticonvulsant medication should Polyneuropathy can second seizure.
be discussed with the pregnant patient and be seen in the
risks and benefits explained (Robert et al. inhalation of hhex
2001). ane, methylnbutyl
ketone, and toluene
(Geller 1998).
Cerebrovascular accidents
Cerebrovascular accident (stroke) can be seen
in alcohol and cocaine use, coagulation impair Hepatic encephalopathy
ment, and severe uncontrolled hypertension. Hepatic encephalopathy is a toxic brain syn
drome that results from the accumulation of
Patients with recent cocaine/amphetamine use unmetabolized nitrogenous waste products in
may present with headaches, which could a patient with severe liver dysfunction.
represent subarachnoid and/or intracerebral Presenting signs and symptoms include an
bleed, and therefore should be appropriately alteration in consciousness and behavior,
evaluated (Buxton and McConachie 2000). fluctuating neurologic signs such as a flapping
Heavy alcohol consumption increases the risk tremor (asterixis), and an elevated serum
for all major types of stroke by a variety of ammonia level. Clinicians should evaluate
mechanisms (Hillbom and Numminen 1998).
CoOccurring Medical and Psychiatric Conditions 131
patients for precipitating causes, which
Drug Abuse 2000). Hepatitis B infections are
include the following:
likely to present more often as a chronic
• GI hemorrhage infection than as an acutestage phenomenon.
Testing for chronic hepatitis B and C infec
• Electrolyte imbalance (metabolic alkalosis)
tion is appropriate during the detoxification
• Infections period.
• Excessive diuresis (dehydration)
• Use of sedatives Special considerations
• Increase of dietary protein intake Followup for hepatitis B and C should be
Those patients who are infected with
arranged for after discharge from the detoxi
Helicobacter pylori may be more prone to
fication setting. Vaccination is recommended
hepatic encephalopathy (Duseja et al. 2003). for hepatitis A and B in the patient with hep
atitis C. The vaccination schedule is over a 6
Special considerations month period, so it needs to be done after the
Clinicians should avoid the use of diuretics, detoxification program. If significant liver
identify and treat factors that may have pre
disease is present, use of shorteracting medi
cipitated the
cation with less liver metabolism should be
encephalopathy,
considered. For more on infectious disease
decrease dietary
and substance abuse, see TIP 6, Screening
Immuno for Infectious Diseases Among Substance
protein intake, and
use Lactulose to Abusers (CSAT 1993c).
compromised
decrease nitroge
nous waste prod Endocarditis
patients may not ucts via the GI
tract. Protocols Endocarditis is caused by the introduction of
react to the that use the benzo various bacterial species into the vascular
diazepines should system when the protective defense mecha
tuberculin skin be adjusted to use nisms of the skin are bypassed through injec
those specific medi tion. The patient frequently will present with
tests. cations that are fever, cardiac murmur, anemia, enlargement
hepatically metabo of the spleen, petechiae, and peripheral
lized minimally or embolic disease. The course can be subtle and
not at all. indolent to fulminant, and if untreated can
lead to a poor prognosis. In the patient who
uses drugs intravenously, the tricuspid valve
Infectious Diseases is affected in 70 percent of cases, followed by
The viral causes of hepatitis are multiple, effects on the aortic valve and the mitral
though the hepatitis B and C viruses are the valve. Seventyfive percent of all cases are
predominant causative agents. Hepatitis C caused by Staphylococcus aureus and up to
virus infection appears to be the most com 15 percent are caused by gram negative aero
mon form of infectious hepatitis in patients bic bacilli (Aragon and Sande 1994).
with substance use disorders. At least 76 per Endocarditis always should be suspected in
cent of patients who have used injection drugs the febrile patient who uses intravenous
for less than 7 years are positive for hepatitis drugs. Patients who use drugs intravenously
C, while 25 percent of patients with alcohol are 300 times more likely to die suddenly
use disorders and those who do not inject from infectious endocarditis than patients
drugs show serologic evidence of infection who use drugs nonintravenously (Burke et al.
(Fingerhood et al. 1993; National Institute on 1997). Patients who use cocaine intravenously
132 Chapter 5
may have a higher rate of endocarditis as a infected patient presents with complaints of
result of more frequent injections and the cough (most common finding), bloody spu
reduced need to solubilize cocaine solutions tum, chest pain, fever, and weight loss.
with heat (Chambers et al. 1987). Recent immigrants from countries where TB
is prevalent, socioeconomically disadvantaged
populations, homeless persons, people who
Bacterial pneumonia use illicit drugs, incarcerated people, and
Bacterial pneumonia can result from immune people who live in areas where infection with
system dysfunction, interference with normal HIV is prevalent, are at increased risk for
respiratory defense mechanisms (from alcohol this disease and should be tested. Further
or smoked drugs), direct toxicity, or aspiration. more, new strains of multidrugresistant TB
are appearing, especially among the homeless
The treating physician should be aware that population (Borgdorff et al. 2000; Moss et al.
the usual pathogens found in community 2000).
acquired pneumonia (i.e., Streptococcus
pneumoniae) may not be the causative agent TB is endemic in many areas of the world
in pneumonias seen in patients dependent on (Asia, Africa, and South and Central
alcohol. Haemophilis influenzae, Klebsiella America) (Gupta et al. 2004). As a public
pneumoniae, and other gramnegative health concern, testing all patients is of the
microorganisms must be suspected and treat utmost importance, even more so for patients
ment given until definitive culture results are from regions where TB is endemic. It is
reported. Among patients who use parenteral important to remember that immunocompro
drugs, pneumonia is the most common reason mised patients may not react to the skin tests
for admission to the hospital, accounting for (anergy). Diagnosis is made with tuberculin
38 percent of all hospitalizations in this popu skin testing, sputum smears and cultures, and
lation (Marantz et al. 1987). radiographic findings. For more information
on dealing with tuberculosis in detoxification
Special considerations and treatment settings see TIP 18, The
Careful use of respiratory depressants is rec Tuberculosis Epidemic: Legal and Ethical
ommended. Indications for hospitalization of Issues for Alcohol and Other Drug Abuse
the patient with pneumonia (Neu 1994) include Treatment Providers (CSAT 1995i).
the following:
• Old age Skin infections
• Dehydration
Skin infections frequently are seen as a result
• Vomiting and inability to take in oral fluids of the intravenous administration of drugs.
and medications Staphylococcus aureus and Streptococcus
• Multilobar disease pyogenes are frequently the infectious agents.
• Low white blood cell count The patient presents with tenderness,
swelling, pain, erythema, and warmth in the
• Respiratory acidosis injection area. The type and route of antibi
• pO2 less than 55 mm Hg otic is determined by the infecting organism
• Significant concomitant diseases and the extent and severity of the infection.
Clinicians should remember that injection
• HIV
sites can be found virtually any place on the
body where there is access to the venous sys
Tuberculosis tem.
Tuberculosis (TB) is caused by acidfast rod
(Mycobacterium tuberculosis). Transmission Patients who use drugs intravenously,
is by droplets spread through the air. The patients with peripheral vascular disease, and
CoOccurring Medical and Psychiatric Conditions 133
patients with diabetes (particularly with ing still should be educated about the risk
infections of the feet) should all be evaluated and prevention.
carefully for skin disease.
Due to increased virulence of syphilis in
patients who are HIV positive, as well as
Sexually transmitted increased resistance to the treatments indicat
diseases ed in the usual treatment protocols, all such
patients should be tested for syphilis and all
Sexually transmitted diseases can be seen in the patients who test positive for syphilis should
form of urethritis, vaginitis, cervicitis, and gen be sent for HIV testing (McNeil et al. 2004).
ital lesions. These disorders are caused by a
variety of microorganisms, and a complete his Special considerations
tory and physical that includes examination of If methadone is being used in withdrawal pro
the genitalia is indicated in all patients. The tocols, or maintenance is being continued, the
clinical picture and cultures frequently can clinician should be aware that certain HIV
guide the treatment protocols. Patients who use medications can cause an increased metabolism
drugs intravenously occasionally display a of methadone:
falsepositive serologic test for syphilis, possibly
due to a nonspecific reaction to repeated expo • Efavirenz (Sustiva)
sure of injected antigens (Hook 1992). • Nevirapine (Viramune)
• Lopinavir/ritonavir (Kaletra)
HIV/AIDS • Rifampin (a drug to prevent mycobacterium
avium complex, a serious bacterial infection,
HIV/AIDS is a serious and prevalent medical in HIVpositive clients)
condition among persons with substance use
disorders, especially those who inject drugs • Amprenavir (Agenerase)
and may share needles with other users. • Abacavir
Patients with AIDS can present with a spec • Ritonavir
trum of complaints and illnesses ranging from
an asymptomatic history to complaints of TIP 37, Substance Abuse Treatment for
fever, enlargement of the lymph nodes, diffi Persons With HIV/AIDS (CSAT 2000e) pro
culty swallowing, diarrhea, weight loss, skin vides further information about substance
lesions, shortness of breath (due to abuse treatment for patients with HIV/AIDS.
Pneumocystis carinii pneumonia), headaches
(due to Toxoplasma gondii), seizures, and
dementia. As a rule of thumb, no complaint Other Conditions
in the patient infected with HIV should be
dismissed as irrelevant. Cancer
Gay men and patients who use drugs intra Cancer occurrence is increased in people with
venously may be at higher risk for HIV/AIDS substance use disorders due to the carcino
than other groups; thus, testing or referral genicity of the drugs used. Cigarette smoking
for testing should be done and appropriate is linked to lung, larynx, oral cavity, esopha
counseling offered. All such patients should gus, stomach, bladder, and pancreatic can
be tested for HIV/AIDS or referred for test cer. Heavy alcohol consumption is associated
ing. Some States, such as Colorado, require with an increased incidence of oral, pharyn
that a risk assessment be administered to all geal, esophageal, laryngeal, respiratory tract,
clients and that clients be advised of their and breast cancer (Polednak 2005).
risk and referred for testing if they are at risk Synergism is seen with alcohol and smoking
for HIV/AIDS. Patients who decline HIV test being associated with even higher risks of
cancer (Fagerstrom 2002). A history of weight
134 Chapter 5
loss could suggest many chronic diseases, disorders appear to be particularly prone to
though cancer should be considered in the accidents of all kinds, with a spectrum of com
differential. There may be an increase in plications from head trauma to falls with frac
head and neck cancers in persons with heavy tures. Chronic pain frequently is seen in
cannabis use (Donald 1991). Liver cancer patients as a result of trauma (treated or
may be seen in patients with hepatitis C and untreated), poor health maintenance, or an
those using anabolic steroids (Socas et al. inability to deal with pain without drug use.
2005). There is a particular interrelationship Chronic pain treatment and the issues of opioid
among alcohol intake, hepatitis C, and hepa use have to be considered for each patient on
tocellular carcinoma (Yoshihara et al. 1998). an individual basis.
The surgeon should
Diabetes consider drug with
Patients who use drugs intravenously may drawal in the differ
experience infections that affect diabetic con ential diagnosis of
trol, though any infection in any detoxification any physical or neu
patient needs to be addressed both from an rologic symptoms or Certain HIV
infectious disease and diabetic viewpoint. signs that emerge
during the perioper medications can
Special considerations ative period. There
Several medications can lead to impaired glu is a two to threefold cause an increased
cose tolerance and an elevated serum glucose increase in postoper
(Garber 1994). Some examples include ative morbidity in metabolism of
patients with alcohol
• Thiazide diuretics use disorders, the
• Clonidine most frequent com
methadone.
• Glucocorticoids plications being
• Haloperidol infections, bleeding,
cardiopulmonary
• Lithium carbonate insufficiency, and
• Phenothiazines withdrawal compli
• Tricyclic antidepressants cations (Tonnesen and Kehlet 1999).
• Indomethacin Special considerations
• Olanzapine Opioids may be used to control pain in the ini
• Risperdol tial period of trauma. Detoxification protocols
should be started prior to anticipated surgery
Antidiabetic agents in concert with alcohol may and continued throughout the perioperative
produce hypoglycemia and lactic acidosis. period. Pain that causes an increased heart
Diabetes mellitus also is seen in patients who rate, as well as postoperative temperature ele
present with newonset hyperglycemia (elevated vation, may impact the detoxification parame
glucose) or with a history of diabetes and poor ters.
control.
Due to tolerance to opioids, the daily
methadone dose in a methadonemaintained
Acute trauma/fractures individual will not serve as an analgesic for
Acute trauma/fractures can be seen in any pain relief from surgical or other illnesses.
patient with a substance use disorder due to an Full therapeutic doses of analgesic drugs
altered level of consciousness or impaired gait should be given to methadonemaintained
when intoxicated. Patients with substance use
CoOccurring Medical and Psychiatric Conditions 135
patients who have cooccurring painful condi
tions (CSAT 2005d; Ho and Dole 1979).
Treatment of
CoOccurring
Since most medications for pain management
are drugs with a high abuse potential, pro Psychiatric Conditions
grams may need to alter their policies regard Pharmacological agents can be used as indi
ing the use of such drugs. Pain patients do cated for cooccurring psychiatric conditions
not require detoxification from prescribed in patients with substance use disorders.
medications unless they meet the criteria for Incidence of the cooccurrence of psychiatric
opioid abuse or dependence described in the conditions and substance use disorders is
American Psychiatric Association’s high; moreover, there is a higher rate of psy
Diagnostic and Statistical Manual of Mental chiatric conditions in patients dependent on
Disorders, Fourth Edition. Treatments for alcohol than that found in the general popula
pain include physical therapy, transcutaneous tion (Kessler et al. 2003; ModestoLowe and
electrical nerve stimulation, and therapeutic Kranzler 1999).
heat and cold.
Trials of nons Comorbidity of substance use and cooccur
teroidal antiinflam ring mental disorders serves to complicate
matory agents or diagnosis and treatment for patients (Salloum
nerve block should and Thase 2000). It is difficult to accurately
The effects of be considered prior access underlying psychopathology in a per
to the use of highly son undergoing detoxification. The effects of
drug toxicity and addictive and abus drug toxicity and withdrawal often can mimic
able medications. psychiatric disorders. For this reason, it may
withdrawal often be best to conduct psychiatric evaluations
The use of after several weeks of abstinence; however,
acetaminophen in this should be weighed against the time an
can mimic the patient with an individual has been in detoxification and
alcohol use disorder what treatment plan is set up for him. Some
psychiatric always has been patients also present to detoxification while
questioned, espe taking medications to treat underlying psychi
disorders. cially if there is evi atric disorders, such as depression and anxi
dence of liver dis ety. The risk of not treating a severe comor
ease. However, a bid psychiatric disorder predisposes the
review article of the patient to relapse; the decision needs to be
medical literature weighed against the risk of prescribing medi
showed that repeat cations when the clinician is not entirely cer
ed ingestion of a therapeutic dose of tain that a comorbid condition exists. If a
acetaminophen over 48 hours by patients with period of recent extended abstinence exists,
severe alcoholism did not produce an increase the patient’s mental condition when abstinent
in hepatic aminotransferase enzyme levels or can be better evaluated.
any clinical manifestations as compared to a
placebo group (Dart et al. 2000). Although it is the philosophy of some physi
cians to discontinue all psychiatric medica
tions upon entering a detoxification program,
this course of action is not always in the best
interest of the patient. Abrupt cessation of
psychotherapeutic medications may cause
withdrawal symptoms or the reemergence of
the psychiatric disorder. As a general rule,
136 Chapter 5
therapeutic doses of medications should be times is the best way to assess the patient’s
continued through any withdrawal if the need for the medication; however, it may not
patient has been taking the medication as pre be the best practice or in the best interest of
scribed. Decisions about discontinuing medi the patient, particularly for those with a seri
cations should be deferred until after the ous mental illness. For more information on
individual has completed detoxification. If, working with patients with cooccurring sub
however, the patient has been abusing a medi stance use and mental disorders, see TIP 42,
cation or the psychiatric symptoms were Substance Abuse Treatment for Persons With
clearly caused by substance abuse, then the CoOccurring Disorders (CSAT 2005c).
rationale for discontinuing the medication is
strengthened. Finally, practitioners should
consider withholding medications that lower Treatment for CoOccurring
the seizure threshold (e.g., bupropion or con Conditions
ventional antipsychotics) during the acute The treatment of substance use disorders can
alcohol withdrawal period, or at a minimum be difficult without adequate treatment of any
prescribing a loading dose or scheduled taper cooccurring mental disorders. For instance,
of benzodiazepine. a patient with schizophrenia who is halluci
During detoxification, some patients decom nating and delusional, but who also abuses
pensate and lapse into psychosis, depression, substances, cannot participate in substance
or severe anxiety. In such cases, careful abuse treatment without adequate control
observation of the withdrawal medication reg over the psychosis. Likewise, patients with
imen is of paramount importance. If the mania who are euphoric and delusional,
decompensation is a result of inadequate dos patients who are depressed, or patients with
ing with withdrawal medication, the appro agoraphobia who also have a substance use
priate response is to increase the dose of med disorder, will have difficulty cooperating with
ication. If it appears that the withdrawal substance abuse treatment. Treatment of the
medication is adequate, other medications substance use disorder is necessary to
may be needed. Before choosing such an improve the course of both the substance
alternative, it is important to take into abuse and cooccurring mental disorder.
account additional considerations, such as the Psychotherapy should serve as one aspect of
side effects of the added medication and the rehabilitation, initially focused around
possibility of interaction with the withdrawal relapse prevention (Aviram et al. 2001).
medication. Highly effective treatment programs may
include a combination of therapeutic tech
A patient with psychosis may need to take niques. Programs should be longterm and
neuroleptics. Medications that have a minimal approach recovery in stages. Drake and col
effect on the seizure threshold are recom leagues (2001) suggest that treatment for co
mended, particularly if the patient is being occurring substance use and other mental dis
withdrawn from alcohol or benzodiazepines. orders include skill building, illness manage
Small, frequent doses of Haldol, such as 1mg ment, cultural sensitivity, and support to
every 2 hours, may be used until the patient’s patients for the pursuit of practical goals.
symptoms of psychosis begin to disappear.
The case for emergency use of antidepres
sants is weaker than for other psychiatric Limitations of pharmacologi
medications because of the 2 to 3week lag cal agents in persons with
time between initiation of medication and substance dependence
therapeutic response. After detoxification,
the patient’s need for medication should be Pharmacologic agents have limitations in the
reassessed. A trial without medications some population of persons with substance use dis
CoOccurring Medical and Psychiatric Conditions 137
orders. Medications may impair cognition and
blunt feelings, sometimes subtly. Clinicians
Standard of Care for
treating substance use disorders advocate CoOccurring
that clients need clear thinking and access to
emotions in order to make fundamental
Psychiatric Conditions
changes in themselves. A person recovering After detoxification and stabilization with
from a substance use disorder must take an pharmacologic agents, the current treatment
active part in changing attitudes and aban of choice for substance use disorders is non
doning a longheld belief that alcohol or other pharmacologic. Further, several studies have
drugs can “treat” life problems and uncom shown that treating substance use disorders
fortable psychological states. Although these with abstinence alone results in improvement
are potential risks, the intent of pharma of the psychiatric syndromes associated with
cotherapy is to enhance a person’s ability to the substance use (Anderson and Kiefer
sustain abstinence and benefit fully from con 2004). Severe syndromes induced by alcohol
current psychosocial interventions and treat that may otherwise meet criteria for major
ments. Still, many psychiatric disorders, if depressive and anxiety disorders are best
untreated, result in mood, anxiety, or thought classified as substanceinduced disorders if
disorders that prevent or retard the behav they resolve within days to weeks with absti
ioral changes necessary to recover from sub nence. Likewise, manic syndromes induced by
stance use disorders. cocaine resolve within hours to days, and
schizophrenialike syndromes (e.g., hallucina
Risks versus benefits of pharmacological tions and delusions) induced by cocaine and
agents need to be considered carefully. PCP often resolve within days to weeks with
Untreated anxiety, mood, or thought disor abstinence.
ders can be powerful relapse triggers, espe
cially for people with a longstanding pattern Further studies are needed to confirm the
of relying on alcohol or other drugs to man clinical experience that psychiatric symptoms
age their symptoms. In many instances, the (including anxiety, depression, and personali
benefits and reduced relapse risk that appro ty disorders) respond to specific treatment of
priate pharmacotherapy can provide far out the addiction. For example, cognitive–behav
weighs the risk of taking medications. Some ioral techniques employed in the 12Step
clinicians believe that the “no pain, no gain” treatment approach have been effective in the
approach has far greater risk of interfering management of anxiety and depression associ
with recovery than of promoting it. Symptoms ated with addiction. Although challenging,
such as anxiety and depression in persons treatment of both addiction and cooccurring
recovering from substance use disorders psychiatric conditions has proven costeffec
might be vital to recovery, and pharma tive in some studies (Goldsmith 1999).
cotherapy to treat such symptoms needs to be
considered carefully in this context.
Clinically, anxiety and depression can pro
Psychotropics for CoOccurring
vide the motivation to change when the Psychiatric Conditions
patient otherwise has little awareness of the
need to alter behavior. General aspects
Because alcohol and other drugs can induce
almost any psychiatric symptom or sign or
mimic any psychiatric disorder, their effects
always must be considered before a cooccur
ring condition diagnosis is established or
treated.
138 Chapter 5
With an understanding of the interactions panic and phobia disorders, posttraumatic
between substance use and other mental dis stress disorder, victimization, and eating dis
orders, a rational approach can be applied to orders. Deficits in the management of mood
the use of pharmacologic therapies in co disturbances may be selfmedicated through
occurring conditions. The use of medications alcohol consumption in females. It has been
for psychiatric symptoms should begin only proposed that the outcomes of substance
after the knowledge of the natural history of abuse in women are different when compared
the addictive disorder and other psychiatric to those of men. For these reasons, the effica
disorders is clarified. Further, it is important cy of treatment for substance use disorders
to be able to identify the respective roles of needs to be assessed independently for both
substance use and other mental disorders in genders (Becker and WaltonMoss 2001;
the generation of psychiatric symptoms. Brady and Randall 1999).
Generally, substanceinduced psychiatric
symptoms resolve within days to weeks of Anxiety
abstinence. In many studies, the prevalence Disorders Major depressive
rates for anxiety and affective disorders in
persons dependent on alcohol were not and anxiety
greater than those for persons not dependent General
on alcohol (Schneider et al. 2001). approach disorders are best
A retrospective history of psychiatric symp Prevalence rates for
toms often can lead to an inflated diagnosis of the cooccurrence of classified as
these conditions because of rationalizations anxiety and sub
regarding drinking and drug use by the indi stance use disorders substanceinduced
vidual. Typically, psychiatric symptoms are in the general popu
emphasized by both the patient and the psy lation range from 5
to 20 percent in epi
disorders if they
chiatric examiner.
demiologic and clini
Longitudinal observation frequently clarifies cal studies resolve within
the role of alcohol and other drugs in the pro (Merikangas et al.
duction of anxiety, affective, psychotic, or 1996). days to weeks with
personality symptoms, particularly if objec
tive criteria are relied on in addition to the Some antianxiety abstinence.
subjective report of the person who is addict agents can overse
ed. Also, specific treatment of substance use date and dull the
disorders can result in improvement of mood, individual’s reaction
psychotic behavior, and personality distur to internal and external influences. Because
bances if related to the alcohol or other drug anxiety in recovery can be critically impor
use. Mood lability and personality states can tant for emotional growth, the individual will
be a manifestation of substance use disorders, feel a certain amount of anxiety to motivate
and treatment of the addictive disorder can change in behavior, attitudes, and emotions.
lead to stabilization of these psychiatric (The expression “emotional growth” is related
symptoms. to the anxiety or discomfort a recovering indi
vidual feels while undergoing the process of
Furthermore, treatment plans and efficacy change to reach a more mature state.) It is
may rely on the gender of the patient. Women important for the clinician to distinguish
with a substance use disorder appear to have between anxiety that can promote growth and
higher rates of cooccurring mental disorders, anxiety that can impair a person’s ability to
such as depression and anxiety, as well as make change. Adapting behavior in response
higher rates of physical and sexual abuse, to anxiety or other emotion requires coping
CoOccurring Medical and Psychiatric Conditions 139
skills that may not be available to persons in patient from participating in treatment. A
early recovery. A fully symptomatic anxiety thorough evaluation to assess whether the
disorder may significantly limit a person’s individual is abstinent, involved in continuing
capacity to learn nonpharmacological coping treatment, and/or attending selfhelp meetings
strategies. Medications with minimal addic usually is necessary before a diagnosis of a
tion potential can be helpful and in some cooccurring psychiatric condition can be def
cases necessary if patients are to make initely established. After such an evaluation,
progress in their recovery. treatment of the anxiety disorder can proceed
separately from similar symptoms arising
Depressants (e.g., alcohol) can produce anxi from the addictive disorder.
ety during withdrawal, and stimulants (e.g.,
cocaine) can produce anxiety during intoxica
tion. Because people with substance use dis Pharmacologic therapies
orders are in a relatively constant state of The ideal medication works against abnormal
withdrawal (it is anxiety but not against the “normal” anxiety
impossible to main needed for recovery. Some of the physical
tain a constant symptoms of anxiety include sweating,
blood level), they tremors, palpitations, muscle tension, and
regularly experi increased urination. Psychological symptoms
Medication is ence anxiety as the include nervousness, feelings of dread or
result of pharmaco impending doom, unpleasant tenseness, and
indicated when logical withdrawal many more.
from dependence.
the anxiety is As the substance The most common agents used in anxiety dis
abuse becomes orders are benzodiazepines and antidepres
preventing the more chronic, the sants. The benzodiazepines most frequently
anxiety produced used are alprazolam and lorazepam.
by withdrawal from Diazepam and clonazepam are used less
patient from pharmacologic often. Because the benzodiazepines can cause
dependence can significant problems in patients who are
participating in become increasingly addicted as well as in patients who are not
severe. Relapse addicted, they generally are not recommend
treatment. and/or periods of ed for people with substance use disorders or
abstinence (some for longterm treatment of anxiety or depres
times prolonged— sive disorders.
for weeks or
months) should be Antidepressants may be considered sooner if
considered (confirm depression is a known preexisting condition
abstinence with laboratory drug testing, if or historical experience and collateral infor
necessary) before the effects of depressant or mation suggests a comorbid depression. Again
stimulant drugs in inducing anxiety can be the risk of treating prematurely needs to be
ruled out. It can take weeks or months for weighed against the risk of not treating a con
these effects to subside completely, although a dition that may prevent recovery from a sub
period of only a few days to weeks often is stance use disorder. Antidepressants such as
sufficient in clinical practice. imipramine and nortriptyline and selective
serotonin reuptake inhibitors (SSRIs) such as
Treatment is indicated when the anxiety per fluoxetine (Prozac) have a low addiction
sists after adequate effort in a substance potential and can be used with relative safety.
abuse treatment program, or when the clini They differ in their tendency to produce
cian suspects that anxiety is preventing the sedation and anxiety and have a withdrawal
140 Chapter 5
syndrome of their own. Because of its anti fered by the patient with an addictive disor
cholinergic properties, imipramine is more der. Likewise, and analogous to the role of
sedating, but nortriptyline and the SSRIs can anxiety, depression also is a part of the heal
produce anxiousness in some individuals and ing process that the patient with a substance
sedation in others. Not all individuals react use disorder experiences during recovery.
the same way to these medications.
Depressant drugs (e.g., alcohol) can produce
When medications are used, a specific target depression during intoxication which often
symptom should be the focus. Also, medica resolves following abstinence. A survey of 69
tions should be tried in timelimited intervals, adults with alcohol use disorders showed a
such as weeks to months. A “drug holiday” strong correlation between the reduction in
(i.e., a brief period where the patient stops cravings for alcohol over 2 weeks of absti
taking medications) should then be attempted nence and the lifting of depressive mood. The
to see if the medication is still necessary. patients’ cravings were assessed with the
ObsessiveCompulsive Drinking Scale (OCDS)
The patient should be instructed that the and their depressive symptoms measured with
medications will not “cure” the addiction, the Selfrating Depressive Scale (SDS).
that treatment of anxiety will not control the Between day 1 and day 14, their cravings
addiction, and that treatment of the addiction score dropped nearly a third, while the scores
will not necessarily ameliorate the anxiety dis for severity of depression fell by about one
order. In essence, the substance use disorder fourth. The correlation between the reduction
must be treated independently of the anxiety in cravings and the lifting of depression per
disorder and vice versa. sisted after controlling for sex, age, duration
and extent of alcohol abuse, and the amount
Depressive Disorders of clomethiazole administered (Anderson and
Kiefer 2004).
General approach Stimulant drugs (e.g., cocaine) can produce
Prevalence rates for the cooccurrence of depression during withdrawal. These effects
depressive and addictive disorders range may be prolonged with certain drugs that
from 5 to 25 percent in epidemiologic and linger in the body (i.e., are stored in fat),
clinical studies. Depressive disorders include such as cannabis and benzodiazepines. These
major depressive and dysthymic disorders, drugs can produce depression or anxiety that
which can occur independently with addictive is indistinguishable from other psychiatric
disorders, or similar depressive symptoms causes of depression. Therefore, they must be
can be induced by substance use disorders. considered causative whenever depression is
Major depressive disorder is more common in present, and the possibility of addiction needs
older individuals and in women and can be to be assessed when these drugs are identi
difficult to distinguish from substance fied. While depression may persist for weeks
induced depression. or months, it often resolves within days with
abstinence from these drugs.
Depression can be viewed as protective and
can be associated with “healing” in many con
ditions involving emotions. For example, a Pharmacologic therapies
grief reaction is an expected experience after The use of medication is recommended if the
loss, with depression an essential emotion in depression persists beyond a few weeks of
this process. Recovery from a substance use drug withdrawal or arises during confirmed
disorder has been compared to a grief reac abstinence (laboratory drug testing may be
tion because of losses (e.g., of the substance necessary to confirm abstinence). The risk of
or relationships based on substance use) suf suppressing normal depressive processes dur
CoOccurring Medical and Psychiatric Conditions 141
ing recovery versus the benefit from sup Bipolar disorder may be complicated by the
pressing depression that is interfering with influence of substances (Sonne and Brady
function should be weighed, as is the case 1999). The manic state can be produced by
with anxiety disorders. stimulants (e.g., cocaine) during intoxication,
and from depressants (e.g., alcohol) during
Antidepressants are the main treatment for withdrawal. A period of confirmed abstinence
depression. The target symptoms are a sad usually is necessary before moodstabilizing
mood, tearfulness, appetite and sleep distur drugs are started. Generally, a period of a
bances, and other neurovegetative symptoms. week or two may be required for the role of
Depression can be found in many conditions, drugs in inducing manic symptoms to be
including a variety of psychiatric and medical properly assessed.
conditions. SSRIs are the drug of choice for
many physicians treating depressed patients
with substance use disorders. Although some Pharmacologic therapies
are costly, they provide adequate treatment Mood stabilizers control bipolar disorders in
of depression with fewer side effects than patients with or without cooccurring sub
other medications commonly used (Thase et stance use disorder. These medications can
al. 2001). control either the manic or depressed phase,
Depressive disorders are thought to have a or both.
significant biological component, including Manic episodes can occur cyclically, alterna
deficiencies in such central nervous system tively, and concurrently with depressive
neurotransmitters as serotonin, nore episodes. One theory of the pathogenesis of
pinephrine, and dopamine. Interestingly, bipolar disorder involves the neurotransmit
these neurotransmitters are also affected by ter norepinephrine (i.e., excessive in mania
substances of abuse. These agents are thought and deficient in depression).
to act by increasing the activity of these neu
rotransmitters, ultimately alleviating depres Lithium is a natural salt, available in the car
sion and stabilizing mood. bonate form and slow release preparations.
Its exact mechanism of action is unknown,
but it can be effective in reducing or prevent
Bipolar Disorders ing the recurrence of manic and depressive
episodes. Lithium carbonate must be taken
General approach daily in doses of 600 to 2,400mg to achieve
Prevalence rates for the cooccurrence of plasma levels in the 0.5 to 1.5m equiv/L
bipolar and addictive disorders range from 30 range. It should be noted that studies have
to 60 percent, depending on the population shown that lithium has no conclusively posi
studied, in epidemiologic and clinical studies tive effect on rates of abstinence in either
(Chen et al. 1998; Sallom and Thase 2000; depressed or nondepressed patients.
Sonne and Brady 1999; Strakowski and Anticonvulsant mood stabilizers, such as
DelBello 2000). divalproex sodium and carbamazepine, can
Mania is a condition associated with elevated be effective in controlling mania and, some
mood, grandiosity, hyperactive behavior, evidence suggests, in cooccurring addictive
poor judgment, and lack of insight. The conditions as well. Carbamazepine is known
patient with mania will show excess such as to be as effective as some benzodiazepines in
spending sprees, sexual promiscuity, intru inpatient treatment of alcohol withdrawal
siveness, and abnormal alcohol and drug use. and, because of its anticonvulsant properties,
A manic episode can follow, precede, or alter it may be a good choice for treating those
nate with depressive moods. patients at high risk of withdrawal seizures
142 Chapter 5
(Malcolm et al. 2001). One theoretical expla the neurotransmitter dopamine at its postsy
nation for the mechanism of action for carba naptic receptor sites.
mazepine involves suppression of mood cen
ters in the limbic system that act like seizure
foci. In this context, a “kindling” model has Adverse
been proposed for both mood and addictive Effects
disorders (Gelenberg and Bassuk 1997).
Antianxiety A period of
Psychotic Disorders agents
confirmed
While benzodi
General approach azepines are useful
in the short term, abstinence usually
Prevalence rates for cooccurrence of
schizophrenic and addictive disorders range their efficacy wanes
with longterm use, is necessary
from 40 to 80 percent, depending on the pop
ulation studied, in epidemiologic and clinical probably because of
studies. the development of before mood
pharmacologic toler
Schizophrenia is a chronic illness character ance and depen stabilizing drugs
ized by bizarre thinking and behavior. dence. It should be
Hallucinations and delusions are “positive” noted that benzodi are started.
symptoms of the psychotic process, while azepines can be
symptoms such as social withdrawal and addicting, particu
poverty of emotions are “negative” symptoms larly in those already
(or deficit syndrome). Conventional neurolep addicted to other
tics are more effective for positive symptoms, substances.
whereas behavioral, group, and individual
psychotherapy are more effective for negative
symptoms. New agents such as clozapine and Antipsychotic agents
risperidone may be more effective in treating Antipsychotics can produce sedation and
both the positive and negative symptoms. hypotension (at times causing lightheadedness
in some individuals), particularly with postu
Psychosis can be caused by stimulant drug ral changes. Conventional neuroleptics pro
use during intoxication and depressant duce acute extrapyramidal reactions, which
drug/alcohol use during withdrawal. A period include pseudoparkinsonism, dystonia, and
of weeks or months may be necessary to akathisia. Dystonia usually responds to treat
assess the effects of substances of abuse, but ment with anticholinergic drugs such as ben
as with anxiety, depression, or mania, medi ztropine or diphenhydramine. Akathisia is
cations can be started at almost any time as the subjective feeling of anxiety and tension,
the psychosis is persistent and waiting is not causing the patient to feel compelled to move
possible. Moreover, the greater the number of about restlessly. This symptom usually
psychiatric admissions, the greater the proba requires beta blocker, as a decrease in the
bility of a chronic mental disorder associated antipsychotic dose does not have the desired
with the cooccurring psychiatric disorder. effect. Alternatively, switching to risperidone
may accomplish the intended effect while
High or moderatepotency neuroleptics (e.g.,
avoiding intolerable neurologic syndromes.
haloperidol or atypical agents) generally are
the agents of choice in the treatment of
schizophrenia. The clinical potency correlates
with the drug’s ability to block the action of
CoOccurring Medical and Psychiatric Conditions 143
Antidepressants use the 12 steps of Alcoholics Anonymous
(AA) and to accept psychiatric advice will
Antidepressants, particularly the tricyclics,
depend on clear thinking and emotional bal
can produce sedation, hypotension, syncope,
ance, which is stressed as central to the
and other anticholinergic effects. The SSRIs
recovery process in AA. In other cases—such
can produce anxiousness, sedation, insomnia,
as patients with traumatic brain injuries—
and gastrointestinal upset. A withdrawal syn
treatment venues should be adaptable to their
drome also has been reported with most
cognitive abilities.
antidepressant medications.
Accordingly, the use of medications should be
The SSRIs are preferred in patients with
conservative, taking into consideration the
addiction and cooccurring psychiatric condi
pros and cons of their expected positive and
tions because of their reduced side effect pro
negative effects. Unfortunately, few psychi
file and low risk of dangerous drug interac
atric medications are totally free of mood
tions; for example, there are no anticholiner
altering properties. However, the cognitive
gic effects on the senses and no risk of lethal
state of individuals who have a serious mental
effects from overdose.
illness often is more distorted when not medi
cated appropriately. The very nature of their
Cognitive State in Recovery illness is a disruption to their cognitive pro
cesses.
A person recovering from a substance use dis
order must have a clear mind and a stable
mood. Medications have a tendency, some Dosing
times subtly and other times obviously, to dull Because of inherent susceptibility to drug
the senses and thinking and blunt or disrupt effects by people with substance use disorders,
the emotions. People with substance use dis it is important to use the lowest effective doses
orders must eventually change and control possible. Also, the intervals for administration
feelings to remain abstinent and also to com should be selected to reduce effects on cogni
ply with psychiatric management. The ability tion and feelings.
of a person with a substance use disorder to
144 Chapter 5
6 Financing and
Organizational
Issues
In This
Chapter…
Preparing and Developing a
Preparing and
Program
Developing a
Developing a detoxification program is a major financial challenge,
Program
whether the program requires building an entirely new organization
or is part of an existing treatment entity. The process of program
Working in
development requires careful planning, especially to ensure adequate
Today’s Managed
financial support for the operation. The decision to develop a detoxifi
Care Environment
cation program should be based on a welldeveloped strategic plan
ning process (see chapter 2) and a clear understanding of what a
Preparing for the
detoxification program entails. Because the new program will incur
Future
major costs for office space, furniture, staff, computers, and other
equipment before clients can be provided with services and payment
can be received, significant amounts of initial capital may be needed.
As soon as the administrator or planner identifies a market need for
detoxification services, potential fiscal support and other resources
should be identified and checked to see if such support is likely and
sufficient. Both implementation and initial operating costs must be
covered. It may be possible to find strategic partners who will provide
resources, work with the program planner, provide office space, or
help obtain funding. Community organizations that see a need for
establishing detoxification and treatment services are likely partners.
Locally based foundations and businesses also may be approached for
assistance with developing a program, especially if a case can be made
to the potential funder that ongoing costs can be covered from opera
tions.
It is important to have documented assurance from major referral
and payment sources that they will refer patients with information on
payment sources; that is, by the referral source, by a third party, or
145
by patients who have the documented finan health plans may be necessary to ensure both
cial resources to pay for detoxification treat private sector demand for services and
ment themselves. Signed contracts with appropriate reimbursement of the services.
expected payors may be useful to ensure ade
quate cash flow and to establish a budget for Forming strategic alliances with other compo
the new program’s fee structure. nents of the treatment environment can be
both an important source for referrals and a
Identifying and recruiting strategic partners resource for clients with needs other than
is one of the most important steps in the pro detoxification. Vertical alliances facilitate
gram development process. Before and during referrals up and down the continuum of care.
the program development process, adminis An alliance with a larger organization can
trators and planners should work closely with increase leverage when negotiating with an
potential referral and payment sources to MCO.
determine their needs and to see if the detoxi
fication program will fit those needs.
Programs also will need to learn whether The Dramatically Changing
referral sources are open to new partners, the Pattern of Utilization of
types of contracts they utilize, their time Detoxification Services
frames for reimbursement, and the process
for negotiating a contract. Among useful tac The settings for detoxification services have
tics to employ is holding focus groups and changed dramatically over the last decade, as
strategy meetings with individuals from have patients’ primary substances of abuse. As
potential referral sources; these groups can the setting for detoxification services has shift
suggest the types of services they need and for ed from inpatient to outpatient, the primary
which they will reimburse. Potential referral substance abuse problem of clients has shifted
sources will be more invested in the program from alcohol and cocaine/crack to heroin and
if they are involved throughout the planning other opioids. This shift has created significant
process. All potential stakeholders should be opportunities in the market for detoxification
informed regularly of the developing plans services for communitybased and
and milestones achieved. entrepreneurial providers that are not part of
hospitals, or for freestanding detoxification
Program planners should follow up on all facilities that are owned by hospitals.
potential leads for both funding sources and
potential referral sources. Relationships with Changes in practice patterns and in the epi
referral sources are important to build and demiology of substance abuse in the last
maintain. Obviously, referral sources need to decade have been dramatic. Between 1993
be carefully assessed to ensure that they can and 2000, the number of admissions to hospi
provide patients who have needs and tal inpatient settings for detoxification of
resources appropriate for the services the patients with a primary problem of alcohol
program will provide. Leads for potential abuse declined by 79.6 percent. During the
sources of funding and referrals may include same period, the total admissions to inpatient
the contacts made during a focus group pro hospital detoxification services declined by
cess, public system payors and planners, pri 69.3 percent, from 23.5 percent of total
vate insurance plans, contracting agents for detoxification admissions in 1993 to 8.8 per
private insurance (e.g., managed care organi cent of total detoxification admissions in
zations [MCOs]), and local employers large 2000, while admissions to 24hour freestand
enough to have employee assistance programs ing detoxification units increased by the same
(EAPs) or managed behavioral health plans 14.7 percentage points, from 60.5 percent of
that cover detoxification services. Direct con total admissions in 1993 to 75.1 percent of
tact with the EAPs or managed behavioral total admissions for detoxification services in
146 Chapter 6
2000. During this same period, the number of the reporting needs and performance require
alcohol admissions to freestanding clinics ments of each purchaser, to provide informa
decreased by 32.0 percent and the number of tion that meets their requirements, and to
cocaine/crack admissions decreased by 42.5 generate the appropriate bills/invoices.
percent. Concurrently, heroin admissions (to Detoxification program administrators must
freestanding clinics) increased substantially be knowledgeable about efficient business
from just under a quarter of total detoxifica practices, the use of databased performance
tion admissions in 1993 to just over a third of measures, accounting, budgeting, financing,
total admissions in 2000. and financial and clinical reporting.
Of course, these statistics reflect national It also is important to reach out to other
trends and regional differences in patterns of potential sources of support such as founda
both practice and substance abuse. Changes tions, board mem
in specific geographic areas will vary. bers, and local or
Prospective programs should carefully national corporate
Identifying and
research their own local market for detoxifi donation programs
cation services and should obtain data on for any assistance
current utilization of and demand for detoxi that will help to recruiting
fication in their local area before proceeding reduce costs,
with program development. increase revenue, or strategic partners
improve productivity
and effectiveness is one of the most
Funding Streams and Other and aid in the suc
Resources in the Substance cess of the organiza important steps in
Abuse Treatment Environment tion. Searching for
support does not end the program
Substance abuse treatment and detoxification with ensuring initial
services in the United States are financed funding. Planners
through a diverse mix of public and private development
must make good use
sources, with substantially more being spent of the Internet to
by the public sector. Public sources account uncover potential
process.
for 64 percent of all substance abuse treat cash and inkind
ment spending, a much higher percentage donations that can
than public expenditure for the rest of health supplement major funding sources, discussed
care (Coffey et al. 2001). The existence of below.
diverse funding streams presents both man
agement challenges and opportunities for pro Entrepreneurial, forprofit programs may be
gram independence and stability. However, a able to attract private capital. Notforprofit
program with only one major funding source entities that are similarly entrepreneurial
is financially and clinically vulnerable to may be able to take advantage of this poten
changes in its major source’s budget and pri tial source of funding through establishment
orities, and this situation should be avoided. of a forprofit subsidiary. Detoxification pro
Diversification of funding sources should be a grams in particular, as opposed to some other
major goal for detoxification programs. areas of substance abuse treatment, may be
attractive candidates for private financing
Usually, each funding stream has different because of their potential to serve privately
approval and reporting requirements. insured and selfpay patients. However,
Because of this, any new or existing detoxifi acceptance of private capital usually carries
cation program requires a fairly sophisticated with it requirements for rapid growth in rev
management and accounting system to meet
Financing and Organizational Issues 147
enues and profitability that may be difficult services. Any episode of detoxification may be
to meet and may limit operational flexibility, denied reimbursement under a plan if medi
at least in the short term. In the longer term, cal necessity is not demonstrated to the satis
successful detoxification programs may be faction of the plan or if the service is provid
able to generate profits. ed at a higher level of care than is judged
medically necessary.
Funding streams associated with public and
private health insurance often provide bene It is important to decide whether to make a
fits to covered individuals that vary according new detoxification program hospitalbased,
to whether or not the services are facility facilitybased, or officebased. Services that
based and accord are considered hospital or facilitybased, like
ing to the level or those in hospital outpatient departments,
setting of care. often are eligible for higher payment rates
The Substance Complexity arises than officebased services to reflect their
because coverage greater capital and other overhead costs.
Abuse Prevention and reimbursement Similarly, hospital inpatient services often are
depend both on reimbursed at a higher payment rate than
and Treatment whether a service is outpatient services, but medical necessity
considered to be a determinations also require patients to need
Block Grant medical service or a more intensive services. Sometimes, patient
substance abuse copayments or coinsurance rates may be
program is the treatment service higher for officebased services than facility
and whether a ser based services. This is true for Medicare as
cornerstone of vice is facility well as for other health insurance plans.
based. Detoxification programs that are parts of hos
Federal funding pitals, affiliated with a hospital, or consid
Many public and ered as a licensed facility themselves may be
for substance private benefit eligible for higher rates of reimbursement
plans still classify than are those that are considered to be out
abuse treatment substance abuse patient programs with no facility license.
detoxification as a However, utilization management criteria to
and detoxification medical rather than authorize payment for admission to and con
a substance abuse tinued stay in a hospital inpatient setting
programs. treatment service. require a significantly greater severity of
In general, and patient diagnosis than do criteria for admis
especially for sion and continued stay in a freestanding or
employerbased outpatient program. On the other hand, often
coverage, benefits under a medical plan are there are high barriers to obtaining a facility
provided at higher reimbursement rates with license to open a freestanding 24hour facility
fewer limits and restrictions than are benefits or licensed outpatient detoxification facility.
for substance abuse treatment (Merrick et al. Programs that are part of or affiliated with
2001). Requirements for outofpocket pay hospitals also must contend with overhead
ments by those covered under these plans cost allocations from the hospital as well as
typically are lower under the medical portion with oversight from hospital administrators
of a plan than under the substance abuse who may know little about substance abuse
treatment portion. However, it is important treatment or detoxification. In addition, some
to note that benefit plan features are but one health insurance plans actually exclude cov
component of coverage; utilization manage erage for hospitalbased or freestanding facil
ment procedures continue to play a very itybased detoxification programs and others
important role in a patient’s access to specific may subject admissions to such programs to
148 Chapter 6
more intensive review than admissions to intermediary agencies. Services may be paid
non–facilitybased detoxification programs. for through grants, contracts, feeforservice,
Program planners should consider carefully and/or managed care arrangements. The
all alternatives; decisions concerning affilia Children’s Health Act of 2000 mandated a
tion with a hospital or pursuit of a facility gradual transition from SAPT Block Grants
license have farreaching financial and politi to Performance Partnership Grants (PPGs).
cal ramifications and should be made with as Providers should follow developments
much information as possible. through their SSA, which include
• Changes in reimbursement. Treatment
Following is a discussion of the key funding
purchasing systems may evolve over time;
streams and resources that are available for
managed care arrangements and require
programs providing detoxification services.
ments are increasingly common.
• Performance outcome data. In accordance
SAPT Block Grant with Federal legislation, PPGs eventually
The Substance Abuse Prevention and will replace SAPT Block Grants and will
Treatment (SAPT) Block Grant program is provide more flexibility for States as well as
the cornerstone of Federal funding for sub require more accountability based on out
stance abuse treatment and detoxification come and other performance data.
programs. These funds are sent to the State’s Substance Abuse and Mental Health
Single State Agency (SSA) for substance Services Administration (SAMHSA) and the
abuse for distribution to counties, municipali States are establishing performance out
ties, and designated programs. Some of the come measures for funding programs under
funds are subject to required setasides for the block grants. All data for core measures
special populations. Each program should are collected from States receiving PPG
check to see if the clients it intends to serve dollars.
are eligible for block grant funding, either for
setasides or for other funds. Each State Medicaid
maintains its own criteria for eligibility and Medicaid, administered by the Centers for
the criteria and definitions vary greatly Medicare and Medicaid Services (CMS) in
among States. Multistate providers will need conjunction with the States, provides finan
to check specifically in each State in which cial assistance to States to pay for medical
they operate. care of specifically defined eligible persons.
The Substance Abuse and Mental Health Medicaid is being used by many States as a
Services Administration (SAMHSA) provides vehicle for experimentation with public sector
funding for substance abuse treatment and managed care in an effort to expand medical
prevention through the block grants as well as coverage to the uninsured. About 2 percent of
a large variety of other mechanisms, includ total Medicaid expenditures nationally are for
ing both discretionary grants and contracts. substance abuse treatment services (Mark et
A portion of the SAMHSA Web site is devoted al. 2003a) but Medicaid supports about 20
to various funding opportunities. percent of national expenditures for sub
stance abuse services (Coffey et al. 2001). The
The most recent available data indicate that level of expenditure varies greatly by State.
the SAPT Block Grant accounts for approxi Medicaid is an entitlement program with sev
mately 40 percent of public funds nationally eral distinct eligible groups: lowincome chil
expended for prevention and treatment of dren, pregnant women, the elderly, and peo
substance abuse (U.S. Department of Health ple who are blind or disabled, all or some of
and Human Services 2003). Funds from the whom can be enrolled in a detoxification pro
block grant may come directly from the SSA gram population. Some substance abuse
or be channeled through regional or county treatment programs will want to target pro
Financing and Organizational Issues 149
grams to the Medicaid population; if the the IMD exclusion in their program planning
State’s coverage and payment rates are mini process.
mal, however, other funders should be
explored in greater depth. The Medicaid Early Periodic Screening
Detection and Treatment (EPSDT) mandate
The reason for substantial variation in State requires States to screen all children and ado
Medicaid expenditures and coverage is that lescents on Medicaid for physical and behav
substance abuse treatment and rehabilitation ioral health disorders. Further, EPSDT
is an optional benefit under Medicaid that requires that any needed medical treatment is
States have the discretion to include or not provided to children, even if the service is not
include in their Medicaid program. Medicaid in the State’s Medicaid plan submitted to
may pay for substance abuse treatment either CMS. Although the procedures and screening
directly through feeforservice arrangements tools vary by State, and there is significant
or through a managed behavioral health care variation in their identification of substance
or other MCO with which it contracts. More abuse issues, the EPSDT program is an
than one type of arrangement may exist with important entrance to substance abuse treat
in the same State. Rates of payment/reim ment for children and adolescents (Semansky
bursement are determined by each State inde et al. 2003).
pendently and may vary within the State
among the various coverage arrangements. If When available, Medicaid coverage offers the
a State decides to include benefits for sub following advantages:
stance abuse treatment in its Medicaid pro • It can provide significant treatment funding
gram, it can choose the precise services and for certain highrisk groups, such as low
levels of care that will be reimbursed. The income mothers and adolescents.
services provided under managed care may • Client copays traditionally have not been
differ from those under feeforservice required so the program receives the entire
arrangements. Although most States offer negotiated fee without having to collect funds
some coverage for detoxification services from clients. (However, some States have
under their Medicaid program (Office of the changed this provision due to budget crises.)
Inspector General 1998), not all types or set
• A Medicaid contract can provide a useful
tings for detoxification programs are covered
lower limit for rate negotiations with com
in those States that do provide coverage.
mercial payors by essentially prohibiting
Therefore, a State Medicaid program may
acceptance of contract terms with any other
cover certain substance abuse treatment ser
purchaser at rates lower than those estab
vices but not cover detoxification services.
lished for Medicaid.
For more information, readers should contact
their State Medicaid office. • Certification as a Medicaid provider also can
position the program to receive patients from
An important distinction of the Medicaid ben other public sector referral sources, making
efit structure since its inception has been the it possible to obtain patients from sources
exclusion of coverage for services provided in such as social services, indigent care funds,
an Institute for Mental Disorders (IMD), and criminal justice systems.
defined as a facility with more than 16 beds • The criminal justice and juvenile justice sys
that treats mental disorders, including sub tems and drug court administrators typically
stance abuse, for individuals between the ages favor providers that are eligible for Medicaid
of 21 and 64 (Rosenbaum et al. 2002). reimbursement because treatment of some
Although services furnished by outpatient offenders can then be billed to Medicaid in
detoxification programs are not excluded, some States.
detoxification programs should be aware of
150 Chapter 6
Medicaid link to Medicarecertified medical practitioners;
however, clients whose services are reim
Supplemental Security bursed under Part B are required to pay 50
Income percent of Medicareapproved amounts. For
Supplemental Security Income (SSI) is a pro more information, contact the Social Security
gram financed through general tax revenues. Administration, Medicare provider enrollment
SSI recipients are one of the mandated popu department, or State Medicare services.
lations for Medicaid, but specific provisions
vary by State. SSI disability benefits are
payable to adults or children who are blind
Medicare link to Social
or have certain other disabilities that make it Security Disability Insurance
impossible for them to work, who have limit The Social Security Administration provides
ed income and resources, who meet the living Social Security Disability Insurance (SSDI) to
arrangement requirements, and who are oth individuals and cer
erwise eligible. Congress has excluded a pri tain members of
mary diagnosis of substance abuse as a quali their family if they Medicaid supports
fying disability under the Social Security have worked long
Administration’s programs, but if there is enough and paid
another primary disability that qualifies the
about 20 percent
Social Security
person for SSI, a secondary substance abuse taxes. Recipients of
diagnosis remains acceptable. Many SSI SSDI benefits are
and Medicare
recipients with a mental disorder diagnosis covered by Medicare
have a cooccurring substance abuse following a 2year
supports about
diagnosis. waiting period. SSDI
is a program 8 percent
financed with Social
Medicare provides coverage to individuals by workers, employ
certified disabilities, and people with end employed persons.
stage renal disease. Medicare supports about In order to be eligi
substance abuse
8 percent of national expenditures for sub ble for a Social
stance abuse treatment services. Medicare Security benefit, the
may provide Part A coverage to clients in treatment
worker must earn
detoxification programs that are based in hos sufficient credits
pitals certified by Medicare. However, detoxi based on taxable services.
fication programs that provide only a struc work. Disability
tured environment, socialization, and/or benefits are payable
vocational rehabilitation are not covered by to disabled workers, disabled widow(er)s, or
Medicare. Medicare imposes very strict adults disabled since childhood, who are oth
review requirements for detoxification pro erwise eligible. A substance abuse diagnosis
grams based in hospitals and detoxification was excluded by Congress as a qualifying dis
programs that are considered to be partial ability for SSDI, but a secondary substance
hospitalization programs, and for patients in abuse diagnosis is acceptable if the person is
those detoxification programs. Alternatively, qualified by another primary diagnosis, such
Medicare may provide Part B coverage to as mental illness, which often cooccurs.
clients in detoxification programs with
Financing and Organizational Issues 151
State Children’s Health
Navy, and Air Force with networks of civilian
healthcare professionals. TRICARE consists
Insurance Program
of TRICARE Prime, where Military
The State Children’s Health Insurance Treatment Facilities are the principal source
Program (SCHIP) provides funds for sub of health care; TRICARE Extra, a preferred
stance abuse treatment of children and ado provider option; and TRICARE Standard, a
lescents in many States. This program pro feeforservice option that replaced the pro
vides lowcost health insurance for children gram formerly known as CHAMPUS. The
of lowincome fami TRICARE Extra and Standard benefits
lies who are not eli include treatment for substance abuse, sub
gible for Medicaid. ject to preauthorization requirements, but
Substance abuse States have the programs will need to check to see if detoxifi
option of providing cation programs are eligible or preauthorized
treatment and SCHIP benefits under TRICARE managed care arrange
under their existing ments. TRICARE is run by managed care
detoxification Medicaid program contractors, each of whom may have different
or designing a sepa authorization procedures.
services in the rate children’s
health insurance
program entirely Indian Health Service
United States are
separate from The Indian Health Service (IHS) is an agency
Medicaid. If the within the Department of Health and Human
funded through a program is part of Services that operates a comprehensive health
Medicaid, then the service delivery system for approximately 1.6
diverse mix of substance abuse million of the Nation’s estimated 2.6 million
benefits will mirror American Indians and Alaska Natives. Most
public and private those under IHS funds are appropriated for American
Medicaid. If the Indians who live on or near reservations.
sources. State designs its Congress also has authorized programs that
own program, CMS provide some access to care for Indians who
has promulgated a live in urban areas. IHS services are provid
set of rules to ed directly and through tribally contracted
ensure that coverage meets minimum stan and operated health programs. Health ser
dards. A State’s Alcohol and Drug Abuse vices also include health care purchased from
Agency also may be able to provide informa more than 9,000 private providers annually.
tion on resources available for treatment of The IHS behavioral health program supports
transitionage youth who have exceeded the alcoholism and other drug dependency treat
maximum age for the SCHIP program in the ment, detoxification, rehabilitation, and pre
State. For more information see the State vention services for individuals and their
SCHIP program office. families.
TRICARE Department of Veterans
TRICARE is a regionally managed health Affairs
care program for active duty and retired
The Department of Veterans Affairs provides
members of the uniformed services and their
the Civilian Health and Medical Program of the
families and survivors. TRICARE supple
Veterans Administration to eligible beneficia
ments the healthcare resources of the Army,
152 Chapter 6
ries. Medically necessary treatment of sub Workforce Investment Boards, Workforce
stance abuse is a covered benefit; beneficiaries Development Boards, and similar bodies at
are entitled to three substance use disorder the State and community levels. Although
treatment benefit periods in their lifetimes. States may not use TANF funds for “medi
cal” services, States have considerable lati
Social Services tude in the definition of “medical,” and
Funding for substance abuse treatment, have used TANF funds to support the fol
which may include detoxification services, lowing substance abuse treatment services:
also may be available through arrangements screening/assessment, detoxification, outpa
with agencies funded by the U.S. Depart tient treatment, nonhospital residential
ments of Labor, Housing and Urban treatment, case management, education/
Development (HUD), and Education (ED). prevention, housing, employment services,
Some Federal sources of funding for sub and monitoring (Rubinstein 2002). Even if
stance abuse treatment under these programs these funds are not available for substance
may prohibit use of funds for “medical” ser abuse treatment in a State or program, the
vices. However, services performed by those program’s clients may be able to access this
not in the medical profession (e.g., coun source of assistance for employment train
selors, technicians, social workers, psycholo ing, child care, and other support needs.
gists) and services not provided in a hospital • Social Services Block Grant. Under Title
or clinic (including 24hour care programs) XX of the Social Security Act, the
may be considered nonmedical. The precise Administration for Children and Families
definition of “medical” under some of these provides a block grant to each State for the
Federal programs may be determined by each purpose of furnishing social services. Funds
State individually, so administrators need to may not be used for medical services
check with their State authorities to deter (except initial detoxification of an individu
mine exactly which services may be funded al who is alcohol or drug dependent). In
through these sources. Even if funding for 2002, these funds provided close to $8 mil
detoxification services is not available lion for substance abuse treatment in 14
through these programs, programs may be States (Administration for Children and
able to link their clients to them for support Families 2002).
for services that enable them to initiate and • Public housing. HUD funds substance
complete treatment successfully. Oppor abuse treatment of public housing residents
tunities include the following: under the Public Housing Drug Elimination
• Temporary Assistance to Needy Families Program. HUD awards grants to public
(TANF). Under the TANF programs, each housing authorities, tribes, or tribally desig
State receives a Federal block grant to fund nated housing entities to fund treatment.
treatment for eligible unemployed persons Funds are channeled to local public housing
and their children, usually women with authorities, which contract with service
dependent children. Services that overcome providers. In addition, special housing pro
barriers to employment (e.g., substance grams are available for people who are home
abuse treatment) are eligible for formula less and have substance use disorders.
grants—with one quarter of the money allo • Vocational rehabilitation. Federal ED
cated to local communities through a com funds support services that help people with
petitive grant process. The funding chan disabilities participate in the workforce.
nels vary by State. Funds may be directed Treatment of substance use disorders is eli
through Private Industry Councils, gible for funding. Funds are channeled to
Financing and Organizational Issues 153
the State agencies responsible for vocational • Correctional residential facilities serve
rehabilitation. offenders returning from a State correction
• Children’s protective services. Title IV of al system; the programs may extend con
the Social Security Act provides funding tracts for substance abuse treatment to pre
for foster care and services to prevent child vent relapse of treated offenders.
abuse and neglect. Eligible services include • Juvenile court systems may provide con
substance abuse treatment for parents who tracts to programs with expertise in treating
are ordered by a court to obtain treatment adolescents to treat juvenile offenders in
and are at risk for losing custody of their correctional facilities or who are otherwise
children. Medicaid also covers these chil involved in the criminal justice system.
dren, as they are a mandatory eligibility
group. Providers should understand the culture, val
ues, and needs of the CJ/JJ system so they
• Ryan White. The Federal Ryan White can develop responsive services for this spe
CARE Act, enacted in 1990, provides cial needs population. For more information,
health care for people with HIV disease. see TIP 21, Combining Alcohol and Other
Under Title I of the Ryan White CARE Act, Drug Abuse Treatment With Diversion for
which provides emergency assistance to Juveniles in the Justice System (CSAT
Eligible Metropolitan Areas that are most 1995b), TIP 30, Continuity of Offender
severely affected by the HIV/AIDS epidem Treatment for Substance Use Disorders From
ic, funds are available for substance abuse Institution to Community (CSAT 1998b), and
treatment. Over 500,000 people are served TIP 44, Substance Abuse Treatment for
through this program each year. Adults in the Criminal Justice System (CSAT
2005b).
Criminal justice/juvenile
justice (CJ/JJ) systems Byrne Formula Grant
Both State and local CJ/JJ systems purchase
substance abuse treatment services. The man
Program
ner in which these systems work varies across The Byrne Formula Grant Program awards
locales. The following are common components grants to States to improve the functioning
of these systems: of the criminal justice system. Grants may
• State corrections systems may provide be used to provide rehabilitation of offend
funds for treatment of offenders who are ers who violate State and local laws. One of
returning to the community, through parole the 26 Byrne Formula Grant purpose areas
offices, halfway houses, or residential cor is providing programs that identify and
rectional facilities. meet the treatment needs of adult and juve
nile offenders who are drug and alcohol
• Community corrections systems may dependent. However, the availability of
include a system of presentence diversion or Byrne Formula Grant funds depends on
parole services, including drug court, that annual Congressional appropriations and
may mandate substance abuse treatment in declines have been proposed for funding in
lieu of incarceration. recent years.
• Community drug courts may send lowrisk,
nonviolent offenders to substance abuse
treatment in lieu of incarceration—pro
grams can be under contract to provide this
treatment.
154 Chapter 6
County and local efits offered by their health plans are inade
governments quate.
• Contracts with EAPs. Some employers have
County and local governments often contract EAPs that can provide direct service con
for the delivery of substance abuse treatment tracts for a particular detoxification pro
services using locally available funds. The gram.
annual availability of these funds depends in
part on State fiscal conditions.
Contributions
By developing relationships with people in the
Schools community, an administrator can find new
Local public schools may be a source of fund sources for support of capital and operations.
ing for assessments; however, they rarely pay Even if a source is reluctant to provide funds to
for ongoing treatment. Some services may be support treatment
reimbursable under the special entitlements for services directly,
children with disabilities. other aspects of pro
gram development, Many public and
organizational
Private Payors growth, and opera private benefit
Private sources of revenue include a range of tions or equipment
entities from large MCOs to local or self may be eligible for plans still classify
insured national employers. Most health support. A variety of
plans offered by large employers operate support may be detoxification as a
under managed care arrangements. available from
Sometimes, a health plan may cover some sources in the com medical rather
substance abuse treatments under the mental munity, ranging from
health benefit portion of their plan; others financial support to
than a substance
may provide coverage through the medical donations of time,
component. In many cases, substance abuse expertise, used or
treatment benefits, when offered, are provid lowcost furniture abuse treatment
ed through Managed Behavioral Healthcare and equipment, and
Organizations (MBHOs) (see “Working In space for a variety of service.
Today’s Managed Care Environment,” p. activities. Some
157, for a more detailed discussion of man potential sources
aged care arrangements). Because substance include
abuse coverage is a minor cost to employers, • Fundraisers. People who do fundraising
accounting for about 0.4 percent of the cost can help the program develop a campaign.
of health insurance overall (Schoenbaum et Many States and the District of Columbia
al. 1998), it may be difficult to get employers’ require that charitable organizations regis
attention, despite the high profile that sub ter and report to a governmental authority
stance abuse problems sometimes present. In before they solicit contributions in their
general, three broad categories of private jurisdiction.
funding may be distinguished: • Foundations and local charities. A pro
• Contracts with health plans, MCOs, and gram may qualify as a recipient of funds for
MBHOs. capital, operations, or other types of sup
• Direct service contracts with local employers. port such as board development from foun
Local employers may contract directly with dations, the Community Chest, United Way,
substance abuse services providers if the ben or other charities.
Financing and Organizational Issues 155
• Alumni. Graduates from a program may gram for women, enhancing the cultural com
donate money to the program or provide petence of staff members, or treating under
support for clients. served populations.
• Internships. Local colleges and universities Writing grant applications requires special
may need internship slots for their students skills. A program can hire a consultant to
who are planning careers in human ser write the application or use its own planning
vices. or research staff, if available. Successful
• Volunteers. Some programs use volunteers grant applications address areas of genuine
in various capacities. Sources include local need, propose ideas worthy of support,
retirement organizations and faithbased express these ideas well, and explicitly follow
agencies. the requirements of the request for applica
• Community groups. Faithbased agencies tion or proposal. To design a fundable pro
and community centers may let the program ject, the program may need to establish links
use rooms for meetings, alumni groups, with other resources. Each donor agency or
recovery support groups, or classes. foundation has its own application format
Community groups can contribute reading and requirements that should be followed
materials, clothes, toys for clients’ children, exactly. It is especially important when using
furniture, or computers. a consultant to have program staff closely
• Local stores and vendors. Local businesses involved in the process of developing a grant
may contribute useful supplies such as application to ensure that affirmations in the
snacks, office supplies, or even computers. application are completely aligned with agen
cy capabilities. Programs that fail to involve
their own staff in the grant application pro
Research funding cess risk falling into the “implementation
In addition to SAMHSA’s other roles, such as trap” when a grant is awarded for projects
technical assistance, helping communities use they are not prepared to perform. SAMHSA
research findings to implement effective treat offers a variety of resources to assist commu
ment programs, and funding of prevention and nitybased organizations and others in devel
treatment, the institutes of the National oping successful grant applications. See the
Institutes of Health conduct research on best text box on page 157 for sources of informa
practices in substance abuse treatment. tion on grants for treatment and detoxifica
The Research Assistant tion programs.
(http://www.theresearchassistant.com) may be
a helpful source for information. For current
funding opportunities, visit the National Selfpay patients
Institute on Drug Abuse Web site Some patients pay for some or all of a course
(http://www.nida.nih.gov) and the National of treatment themselves, without seeking
Institute on Alcohol Abuse and Alcoholism Web reimbursement from a thirdparty payor.
site (http://www.niaaa.nih.gov). These patients may have no or inadequate
thirdparty coverage for substance abuse
treatment and are not eligible for public pay
Grants ment sources. Some patients who have cover
Government agencies and private foundations age may prefer to pay out of their own pock
offer funding through competitive grants. ets due to concerns about the confidentiality
Grant money usually is designated for discrete of their information with their employer or
projects, such as creating a videotape on family others.
issues, providing childcare services in a pro
156 Chapter 6
Where To Get Information on Grants
• SAMHSA provides information about the grants it provides at http://www.samhsa.gov/grants/block-grants.
Information on grants throughout the Federal government is available from http://www.grants.gov.
• The Web site http://www.cybergrants.com provides information about corporate foundations.
• The National Center on Addiction and Substance Abuse at Columbia University’s Web site at
http://www.casacolumbia.org provides links to several helpful sites.
• The Substance Abuse Funding Week provides public and private funding announcements for alcohol,
tobacco, and drug abuse programs. It is available by subscription in print.
• The Grantsmanship Center at http://www.tgci.com offers some useful information.
• The Non-Profit Resource Center, http://www.nprcenter.org/, has information on a variety of funding
sources.
158 Chapter 6
arrangements and benefit plans for customers Elements of Financial Risk in
whose employees or enrollees are in the
detoxification program’s client population.
Managed Care Contracts
Case management programs operated in the Cost of services
private sector often are utilization review
To assess and negotiate a managed care con
programs rather than the clinical case man
tract and to monitor a program’s perfor
agement programs typical in the public sec
mance under that contract, it is imperative to
tor. Moreover, the process of case manage
know what it costs the detoxification program
ment in the private sector often differs from
to provide each unit of service that is pro
the one found in traditional public sector
duced. The cost of services includes staff time
mental health or substance abuse treatment
spent with clients, administrative time spent
agencies. Instead, it primarily involves tele
on meetings and paperwork, and capital and
phone contact, usually with a nurse, in high
operating expenses. Only when the actual cost
risk or highcost cases. Case management
of delivering a unit of a particular service is
usually is not performed onsite or in person
known can an agency negotiate a reasonable
in MCOs unless under contract to a public
rate for specific services when negotiating
agency that requires this. If a detoxification
contracts and a fiscally prudent arrangement.
program client has a public sector and a man
Determining the cost of services often entails
aged care case manager, the detoxification
many challenges but is absolutely essential in
program will have to interact with both to
the current environment of accountability.
obtain initial and continuing approvals of
See the text box on page 160 for a list of
treatment in what is called a case or utiliza
resources from the literature. Following are
tion management program.
the recognized but evolving cost methodolo
In general, programs will be required to gies developed specifically for substance
obtain utilization management approval abuse services:
and/or case management approval for any • The first systematic cost data collection
proposed treatment plan before they can bill method, the Drug Abuse Treatment Cost
the MCO. Programs will have to bear the cost Analysis Program (DATCAP) (French 2003a,
of pursuing denials and requesting exceptions b), was developed in the early 1990s by
as well. The more the program’s staff can economists at Research Triangle Institute
develop a relationship with the MCO’s utiliza (French et al. 1997). The Treatment Services
tion management and case management staff, Review used with DATCAP provides unit ser
the more they will learn about the internal vice costs (French et al. 2000).
criteria and protocols that drive approval or • The Uniform System of Accounting and
denial decisions and the more latitude they Cost Reporting for Substance Abuse
will have to request special arrangements for Treatment Providers is a cost estimation
a particular client. Most MCOs and MBHOs method developed about the same time by
have Web sites with provider portals. Once a CSAT (1998d).
program identifies the name of the managed
care plan from which payment is to be • Another estimation approach has been
requested staff should be sure to check its developed by Yates (1996, 1999): the
Web site. Some managed care plans offer Cost–Procedure–Process–Outcome
electronic data interchange with network Analysis.
providers to facilitate claims submission. • Anderson and colleagues (1998) have devel
oped a cost of service methodology.
Financing and Organizational Issues 159
Resources on Service Costs
Anderson, D.W., Bowland, B.J., Cartwright, W.S., and Bassin, G. Servicelevel costing of drug abuse
treatment. Journal of Substance Abuse Treatment 15(3):201–211, 1998.
Center for Substance Abuse Treatment. Measuring the Cost of Substance Abuse Treatment Services: An
Overview. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998.
Center for Substance Abuse Treatment. Uniform System of Accounting and Cost Reporting for
Substance Abuse Treatment Providers. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 1998.
Center for Substance Abuse Treatment. Summary Report on Assessment and Measurement of
Treatment Costs. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000.
Dunlap, L.J., and French, M.T. A comparison of two methods for estimating the costs of drug abuse
treatment. Journal of Maintenance in the Addictions 1(3):29–44, 1998.
Flynn, P.M., Porto, J.V., RoundsBryant, J., and Kristiansen, P.L. Costs and benefits of methadone
treatment in DATOS—Part 1: Discharged versus continuing patients. Journal of Maintenance in the
Addictions 2(1/2):129–150, 2003.
French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): Program Version. 8th ed.
Miami, FL: University of Miami, 2003.
French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): User’s Manual. 8th ed. Miami,
FL: University of Miami, 2003.
French, M.T., Dunlap, L.J., Zarkin, G.A., and Karuntzos, G.T. The costs of an enhanced employee
assistance program (EAP) intervention. Evaluation and Program Planning 21(2):227–236, 1998.
French, M.T., Dunlap, L.J., Zarkin, G.A., McGeary, K.A., and McLellan, A.T. A structured instru
ment for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost
Analysis Program (DATCAP). Journal of Substance Abuse Treatment 14(5):445–455, 1997.
French, M.T., Roebuck, M.C., McLellan, A.T., and Sindelar, J.L. Can the Treatment Services Review
be used to estimate the costs of addiction and ancillary services? Journal of Substance Abuse
12(4):341–361, 2000.
French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefitcost analysis of a
modified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning
25(2):137–148, 2002.
French, M.T., Salome, H.J., and Carney, M. Using the DATCAP and ASI to estimate the costs and ben
efits of residential addiction treatment in the State of Washington. Social Science & Medicine
55(12):2267–2282, 2002.
Yates, B.T. Analyzing Costs, Procedures, Processes, and Outcomes in Human Services. Applied social
research methods series v. 42. Thousand Oaks, CA: Sage, 1996.
Yates, B.T. Measuring and Improving Cost, CostEffectiveness, and CostBenefit for Substance Abuse
Treatment Programs: A Manual. NIH Publication No. 994518. Rockville, MD: National Institute on
Drug Abuse, 1999.
Zarkin, G.A., and Dunlap, L.J. Implications of managed care for methadone treatment. Findings from
five case studies in New York State. Journal of Substance Abuse Treatment 17(12):25–35, 1999.
Zarkin, G.A., Dunlap, L.J., and Homsi, G. The substance abuse services cost analysis program (SAS
CAP): A new method for estimating drug treatment services costs. Evaluation and Program Planning
27(1):35–43, 2004.
160 Chapter 6
• The Substance Abuse Services Cost Analysis For more information on managed care pur
Program (Zarkin et al. 2004) is an emerging chasing and negotiation from the perspective
treatment services cost estimation method. of a purchaser, see TAP 22, Contracting for
• Variants of these methods have been applied Managed Substance Abuse and Mental Health
to several treatment studies (Flynn et al. Services: A Guide for Public Purchasers
2003; Koenig et al. 1999; Mojtabai and (CSAT 1998c).
Zivin 2003).
Three major categories of financial arrange Networks, Accreditation, and
ments may be distinguished in managed care Credentialing
contracts: (1) feeforservice agreements, (2) To join an MCO’s network of providers and
capitation agreements, and (3) case rate negotiate a contract specific MCO minimum
agreements. Program administrators need to standards for staff credentials and program
understand the differences among these types accreditation must be met. These minimum
of arrangements so they can manage financial standards generally are not negotiable
risk. Sometimes, administrators may think because they have their basis in that MCO’s
that the contract itself is the goal. However, accreditation requirements. The provider
the existence of a contract is no guarantee of credentialing requirements vary by MCO and
a referral; it only enables referrals that are by customer within the MCO and often
medically necessary. The closer the relation include primary verification of specific aca
ship the program staff can develop with a demic degrees or specific levels of licensure
given MCO, the easier it will be for them to for staff, as well as verified minimum levels of
understand their clinical criteria, to obtain malpractice insurance. Some MCOs may use
more than intermittent referrals, and to nego what are called independent Credentialing
tiate a financial arrangement for the program Verification Organizations (CVOs) for this
that is reasonable and fair. process. These CVOs verify the credentials of
Managed care contracts vary according to two providers on behalf of MCOs to ensure, for
principal dimensions: (1) the method of pay example, that their licenses are valid and up
ment and the corresponding type of risk to date.
assumed by the provider, and (2) the amount MCOs sometimes are not familiar with sub
of payment. Each of the three major types of stance abuse treatment and, moreover, typi
financial arrangements or methods of pay cally include only those types of providers
ment (described in Figure 61, p. 162) is asso that are licensed by a given State to engage in
ciated with major financial risks that private practice in their provider networks.
providers should be aware of in negotiating Usually such providers are licensed in psy
each type. Risk, of course, is a continuous chology, nursing, medicine, or social work.
variable, so that no arrangement is devoid of MCOs explain that this has to do with mal
any risk whatsoever. The key is to ensure that practice insurance issues. This credentialing
a program has the tools and capabilities to practice has a disproportionate impact on
manage the risks it assumes. Many managed those substance abuse treatment providers
care systems rely on feeforservice arrange that do not have as many staff with these cre
ments with providers, so that most providers dentials as do mental health providers, by
are paid on a discounted feeforservice basis, presenting an obstacle to contracting with
based on a schedule of fees described in the these MCOs. However, it is not an insur
contract. Capitation agreements usually are mountable obstacle. Substance abuse treat
reserved for very large networks of ment providers often must help MCOs under
providers, who in turn pay individual stand the substance abuse treatment environ
providers on a feeforservice basis. ment, the types of providers that deliver ser
Financing and Organizational Issues 161
Figure 61
Financial Arrangements for Providers
Method of Reimbursement Cautions/Risks for Programs
FeeforService Agreement. Feeforservice pro When negotiating a feeforservice contract, an
grams are the least risky to providers. They gen administrator needs to ensure that the rate is suf
erally require precertification and utilization ficient to cover the actual costs to a program of
management for some or all procedures and ser providing the specified services. During negotia
vices. The client’s benefit plan document or the tions, the MCO has the option of saying that it will
public payor’s contract dictate the services that not pay for some of the bundled services. All ser
may be approved. In a feeforservice contract, a vices should be costed out prior to negotiation, so
rate is received for the services provided; typical actual costs of treatment components are known
ly, a standard program session with specific ser and can be compared to the reimbursement
vices bundled in. This is referred to as an “all offered. Programs must understand that even if a
inclusive rate.” feeforservice contract is successfully negotiated,
referrals may or may not follow.
Some common bundled services are urine drug
screens and group, family, and individual counsel
ing. Thus the payment rate for one visit may
include a 50minute group counseling session and
a urine drug screen. The rate for a day of treat
ment could include, for example, onefifth of a 25
minute psychologist visit, onehalf of a urine drug
screen, onehalf of a vocational training session,
and two sessions of group counseling. The
assumption is that these services will occur at a
specified frequency during the course of the
client’s treatment. Psychiatric services can be
incorporated into the bundled services, but usual
ly they are negotiated separately and treated as an
additional service.
vices, and the qualifications and standards fication benefits may be considered either
they must meet so that the MCO can modify medical or behavioral benefits.
its policies appropriately. MCOs often are
more willing to contract with organizations In addition to the credentials of the staff and
that have a facility license from their State practitioners, the program itself may have to be
than with individual substance abuse treat accredited by one of the major national health
ment providers who may not possess creden care accrediting organizations. These include
tials that meet the MCO’s licensure criteria. the Commission on Accreditation of
Rehabilitation Facilities, the National
Many managed care plans have separate Committee for Quality Assurance and the Joint
provider networks for behavioral health ser Commission on Accreditation of Healthcare
vices. It is important for detoxification Organizations. In general, accreditation from
providers to participate in both medical and CARF is considered most important by sub
behavioral health networks, given that detoxi stance abuse treatment providers for their
162 Chapter 6
Figure 61 (continued)
Financial Arrangements for Providers
Method of Reimbursement Cautions/Risks for Programs
Financing and Organizational Issues 163
programs. However, providers that wish to external performance measures implemented
offer inpatient detoxification services general by MCOs can be extremely important to a
ly must obtain accreditation from JCAHO to program’s financial and organizational suc
meet the requirements of most MCOs. cess, affecting a program’s ability to remain a
viable, respected network provider. Some
performance management systems implement
Organizational Performance ed by MCOs also use financial incentives
Measurement and/or disincentives keyed to performance.
Performance measurement is becoming an Regardless of the specific measures imple
increasingly important component of man mented by particular MCOs, wellmanaged
aged and feeforservice care in both the organizations will also develop and use their
public and private sectors. SAMHSA’s SAPT own internal performance measures and con
Block Grants now require the collection of stantly strive to improve their own perfor
measures of program performance and out mance. Among these should be measures of
comes. MCOs have their own performance both process and outcomes, such as
measures established by the agencies that
• The percentage of clients who complete a
accredit them, such as the NCQA. Their cus
defined treatment regimen that meets their
tomers, employers, or public purchasers may
individual needs
use adequacy of performance on these mea
sures in their decisions to acquire or retain • The percentage of clients who drop out of
their plans for their employees. NCQA has treatment in the first 7 days following treat
established a set of measures specifically ment initiation
relating to substance abuse and mental • The percentage of clients who remain in doc
health treatment services for all the MCOs umented but less intensive treatment 30 days
that it accredits, including new measures of after discharge from the program
the identification of enrollees with substance • The percentage of clients who are employed
abuse diagnoses, the rate of initiation of or attending school 6 months after discharge
treatment, and a measure of treatment from the program
engagement. Programs will be asked to par
ticipate in measuring these indicators and When using performance measures, it is impor
report that information to the MCO, and tant for programs to account for differences
doing so will likely be a condition of the con among clients that may affect measured results,
tract. The MCO may reward good perfor such as a client’s previous history of abuse or
mance with an additional fee. medical conditions. Nevertheless, it is equally
important to recognize that employing mea
Similarly, MCOs evaluate the performance of surement is an integral component of external
the members of their provider network. Each and internal accountability as well as continu
MCO has its own measures and procedures ous clinical improvement.
for implementation, some of which are pre
scribed by the organizations that accredit One of the primary independent entities
them. Not all MCOs are diligent about this involved in the construction of national per
provider evaluation process. Only a few formance measures for substance abuse treat
MCOs have implemented sophisticated mea ment is the Washington Circle Group.
surement systems, and some of the methods NCQA’s new substance abuse performance
used today may be crude but they still are measures on identification and initiation of
required. Nevertheless, regardless of how treatment and treatment engagement were
simple or complex they may be, the results of developed by the WCG over a 4year period.
164 Chapter 6
They have identified four major “domains” receive subsequent substance abuse services
for substance abuse treatment measures: from the formal treatment system and that the
1. Prevention/Education lack of substance abuse treatment following
detoxification has been getting worse instead of
2. Recognition or Identification of Substance
better (Mark et al. 2002). It is incumbent on
Abuse
providers of detoxification services to ensure
3. Treatment that clients are linked to substance abuse treat
•Initiation of alcohol and other plan ser ment following detoxification.
vices
•Linkage of detoxification and alcohol and Recordkeeping and manage
other drug plan services
ment information systems
•Treatment engagement
Like indemnity insurers, MCOs also require
•Use of interventions for family members
detailed records of
and significant others
services provided to
4. Maintenance of Treatment Effects clients in order for
These and other substance abuse performance
them to pay for ser Performance
vices received. The
measures are now used in NCQA’s MCO
program’s account measurement is
accreditation process. The WCG and others
ing system needs to
have defined a variety of such measures and
track counselors’ becoming an
administrators should think of these measures
time spent on the
as ways to improve their own performance, as
phone, on paper
an essential element in the reporting system, increasingly
work, and directly
and as a means for documenting success to
with clients. Clinical
their customers and other stakeholders. important compo
records should
Performance measurement is becoming reflect accurately
increasingly important outside of managed care the claims records nent of managed
contracts as well as inside them. For example, submitted to the
as mentioned in the previous section on fund MCO. Periodically, and feeforservice
ing, SAMHSA began integrating performance payors and MCOs
measurement into the SAPT Block Grant as of may audit the clini care in both the
fiscal year 2004. Each State will expect pro cal records to
grams to understand and be able to measure ensure that the ser public and private
the required indicators accurately and in a vices billed for actu
timely way. ally have been pro sectors.
vided. Failure to
One of the most important performance mea adequately docu
sures in the future for detoxification programs ment clinical ser
is likely to be linkages to substance abuse treat vices can result in nonpayment and put a con
ment following detoxification (Mark et al. tract in jeopardy. On the other hand, individ
2002). Research has shown that patients who uals’ private information and identity must
receive continuing care following detoxification be handled in a confidential manner pursuant
have better outcomes in terms of drug absti to the Health Insurance Portability and
nence and readmission rates than those who do Accountability Act (HIPAA) and Federal con
ages is a likely result of research indicating that substance abuse.
many people who undergo detoxification do not
Financing and Organizational Issues 165
Managing multiple contracts requires sophis should be billed as payor number one and the
ticated management, a fiscal management drug court as payor number two. Any unpaid
information system (MIS), and constant portion might then be billed to the block
scrutiny. The need for information is even grant agency as payor of last resort, if it is an
more crucial for capitationbased arrange eligible service under the block grant. Some
ments that place risk on the service provider providers have successfully used the strategy
than it is for feeforservice arrangements. In of first using the reimbursement of those pay
essence, the MIS needs to be capable of two ors with the most restrictive array of services;
way information transfer between the MCO later, the more flexible funds can be used to
and the program. Data such as membership, cover the remaining services. A clearly docu
benefits, copays, deductible amounts, and mented strategy for managing payment that is
other financial information must be passed communicated effectively to the accounts
between the pro payable staff is critical and will help pro
gram and the grams be successful in this important area.
Successfully insured entity or
payor. The MIS
also should be able Utilization and Case
addressing the
to analyze key per Management
formance data for All MCOs use methods to manage the service
needs of the internal and exter utilization of their members and ensure that
nal reports. The they are receiving the most appropriate array
utilization and MIS must pass use of services in the most appropriate environ
ful data to staff ment or level of care for the appropriate
case management members responsi length of time. Although technically, utiliza
ble for managing tion management focuses on a single type of
staff at MCOs is a benefits and pro service and case management focuses on the
viding services. coordination of the appropriate array of ser
critical element in vices needed by a specific individual, in prac
Program data will
need to meet State tice the same individual professionals may be
the relationship data requirements responsible for both types of management.
as well as require Utilization and case management staff at an
with an MCO. ments by each MCO authorize specific services for purposes
payor, while of payment. A wide variety of specific criteria
respecting confiden and protocols may be used to determine
tiality. whether services may be authorized for sub
stance abuse, typically including the
American Society of Addiction Medicine
Managing payment from
(ASAM) patient placement criteria (ASAM
multiple funding streams
2001) and other level of care or diagnosis
based criteria sets.
Especially in the public arena, multiple con
tracts with and grants from several funding Successfully addressing the needs of the uti
streams and payors may be used to support lization and case management staff at MCOs
services for a single client. These contracts responsible for authorizing care is a critical
will specify order of payment. The provider element in the relationship with an MCO and
needs to manage the funds carefully and in maintaining the program’s clinical and
appropriately to be in compliance with con financial viability. To do so, program staff
tracts and grants. For example, a contract must understand what their counterparts do
with a drug court may specify that Medicaid and be well trained in conducting professional
166 Chapter 6
relationships over the telephone, be familiar additional costs of these services need to be
with the criteria and protocols employed by a component of a program’s rate and con
the MCOs with which the program has con tract. Having highly reputable, recognized,
tracts, and have easy access to the multitude and efficient providers is a major marketing
of clinical and service information required and regulatory advantage for the health
by an MCO to help them complete a review plan, as well as for the program. All these
and authorize services. Excellent records are program characteristics can be marketing
essential. Program staff also should be famil advantages. Programs also may apply to
iar with each MCO’s appeal or exceptions SAMHSA’s National Registry of Evidence
process for those occasions when the outcome based Programs and Practices, which recog
of a firstlevel review is unsatisfactory. nizes model, effective, and promising pro
grams. Check SAMHSA’s Web site to find
Utilization management cannot proceed if the out how to apply for this status, which is a
program is not recognized as an eligible net major achievement and marketing asset.
work provider; the program will have to
ensure that it is an accepted network • Serve specific populations. Providing low
provider before it can participate in the uti cost, highquality treatment to a population
lization management or case management no other program serves (e.g., adolescents,
process. clients with HIV/AIDS, clients with co
occurring mental disorders, pregnant
women, women with young children, clients
Strengthening the Financial who are deaf) also is a possible marketing
Base and Market Position of a advantage. Treating these clients can result
in client referrals from a larger geographic
Program area and multiple sources. Such clients may
The following strategies may strengthen the bring with them higher reimbursement rates
market position of a detoxification program to too, but this also may simply reflect higher
facilitate both larger numbers of patients and costs to provide care to the population.
greater revenues per patient: Using special capabilities to attract clients is
• Achieve recognition for the quality and a good idea, but not at the cost of inade
effectiveness of services. If a program has quate payment for services.
a reputation for providing effective care, • Develop economies of scale. Adding clinic
then managed care enrollees and other sites or increasing the number of branch
potential clients will want to use it. A pro clinics may permit spreading some fixed
gram can be of value to a client, a purchas costs (e.g., management, information,
er, and/or an MCO if it can reduce repeated financial systems, executive staff) among a
detoxification, repeated treatment, and re larger number of patients, thus driving
admissions, and thus manage unnecessary down a program’s per capita costs.
costs and interventions. Effective substance However, larger size requires greater
abuse treatment provided promptly may administrative coordination, which itself
reduce medical care and hospitalization can be costly.
costs in the long run. A program that effec • Gain community visibility and support.
tively manages the care of highutilization Having governmental, community agency
substance abuse clients by also providing executives, or political figures (e.g., the
psychiatric treatment, case management, mayor, council members) as board members
and housing support is a good candidate for raises the program’s profile in the commu
“preferred” or “core” status with one or nity. Of course, programs should be sure to
several MCOs or MBHOs. Of course, the include board members who have specific
Financing and Organizational Issues 167
skills and connections that will advance the and assurance of funding from reputable and
purposes of the detoxification program. varied referral sources are essential for new
• Form alliances with other treatment and existing programs. As a buffer against
providers. Setting up coalitions to compete shrinking budgets, all programs should con
with or work with MCOs and other pur sider broadening their funding streams and
chasers such as Medicaid may be useful. referral sources, expanding the range of
However, consultation with an attorney is clients they can serve, and promptly referring
strongly advised prior to developing such a clients for other services not provided on site.
coalition or other collaboration with local Partnerships can be a critical factor to the
treatment providers as the laws regarding financial success of a program. To operate
antitrust and other matters related to such effectively, administrators and other staff
relationships are complex. For programs must thoroughly understand the managed
serving publicly funded clients, technical care and community political environment
assistance may be available through including its terminology, contracts, negotia
SAMHSA; the SSA can provide details. tions, payments, appeals, and priority popu
lations. A successful working relationship
with an MCO, a health plan, other pur
Preparing for the chasers, or with another agency or group of
Future agencies depends on daytoday interactions
in which staff members serve as informed,
Major forces that shape and limit provider professional advocates for their clients and
financing are unlikely to change substantially the program.
in the near future. Careful strategic planning
168 Chapter 6
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220 Appendix A
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Bibliography 221
Appendix B: Common
Drug Intoxication
Signs and Withdrawal
Symptoms
Cocaine Alcohol Heroin Cannabis
(marijuana)
Intoxication
D BP, HR, temp, bBP, DHR,
Denergy, brespiration, bintraocular pres
Characteristics of • Sedation, Drowsiness, “nod
Dparanoia,
intoxication ding,” euphoria
Dfatigue,
• Depresses CNS (happy giddiness) sure (pressure in
bappetite,
system, can the eyes)
result in coma, conjunctival injec
move bowels/ death tion (reddening of
urinate the eyes)
Withdrawal
223
Cocaine Alcohol Heroin Cannabis
(marijuana)
DBP, DHR,
Dtemp,
Characteristics Sleeplessness or Nausea, vomiting, Irritability,
excessive restless diarrhea, goose appetite distur
sleep, appetite nausea/vomiting/ bumps, runny bance, sleep dis
increase, depres diarrhea, nose, teary eyes, turbance, nausea,
sion, paranoia, seizures, delirium, yawning concentration
decreased energy death problems, nystag
mus, diarrhea
224 Appendix B
Appendix C: Screening
and Assessment
Instruments
Please note that this list of screening and assessment instruments has
been divided into two sections. The first section comprises those instru
ments used for patients with suspected alcohol abuse or dependence
only; the second lists instruments used to screen and assess for abuse of
or dependence on any substances. Thus those tools that screen for all
substances of abuse are listed in section II.
Section I: Screening and
Assessment for Alcohol Abuse
This section of the appendix lists common screening and assessment
instruments specifically used in cases where abuse of or dependence
upon alcohol is in question.
The Alcohol Use Disorders Identification Test
(AUDIT)
Purpose: The purpose of the AUDIT is to identify persons whose alco
hol consumption has become hazardous or harmful to their health.
Clinical utility: The AUDIT screening procedure is linked to a deci
sion process that includes brief intervention with heavy drinkers or
referral to specialized treatment for patients who show evidence of
more serious alcohol involvement.
Groups with whom this instrument has been used: Adults, particular
ly primary care, emergency room, surgery, and psychiatric patients;
DWI offenders; offenders in court, jail, and prison; enlisted men in
the armed forces; workers receiving help from employee assistance
programs and in industrial settings.
225
Norms: Yes, heavy drinkers and people with Administrator training and qualifications: No
alcohol use disorders training required.
226 Appendix C
Clinical Institute Withdrawal Norms: N/A
Assessment (CIWA-Ar) Format: Consists of 25 questions
Purpose: Converts DSM-III-R items into
Administration time: Ten minutes
scores to track severity of withdrawal; mea-
sures severity of alcohol withdrawal. Scoring time: Five minutes
Clinical utility: Aid to adjustment of care Computer scoring? No
related to withdrawal severity.
Administrator training and qualifications: No
Groups with whom this instrument has been training required.
used: Adults
Fee for use: Fee for a copy, no fee for use
Norms: N/A
Available from: Can be downloaded from
Format: A 10-item scale for clinical quantifi- Project Cork Web site:
cation of the severity of the alcohol withdraw- http://www.projectcork.org
al syndrome.
Addiction Severity Index (ASI) Clinical utility: The CSSA is able to predict a
patient’s response to treatment and could be
Purpose: The ASI is most useful as a general
used to identify patients at greater risk for
intake screening tool. It effectively assesses a
treatment failure so that these patients could
client’s status in several areas, and the com-
be targeted for additional interventions. This
posite score measures how a client’s need for
instrument could also be used to evaluate the
treatment changes over time.
effectiveness of medications intended to treat
Clinical utility: The ASI has been used exten- cocaine abstinence symptoms.
sively for treatment planning and outcome
Groups with whom this instrument has been
evaluation. Outcome evaluation packages for
used: Adults
individual programs or for treatment systems
are available. Norms: N/A
Groups with whom this instrument has been Format: Eighteen items
used: Designed for adults of both sexes who
are not intoxicated (on illicit drugs or alcohol) Administration time: Less than 10 minutes
when interviewed. It is also available in
Spanish. Scoring time: N/A
Norms: The ASI has been used with males Computer scoring? No
and females with substance use disorders in Administrator training and qualifications:
both inpatient and outpatient settings. Requires little training; clinician-adminis-
Format: Structured interview tered
Administration time: Fifty minutes to 1 hour Available from: Kampman, K.M., Volpicelli,
J.R., McGinnis, D.E., Alterman, A.I.,
Scoring time: Five minutes for severity rating Weinrieb, R.M., D’Angelo, L., and
Epperson, L.E. Reliability and validity of the
Computer scoring? Yes
228 Appendix C
Cocaine Selective Severity Assessment. Format: A psychiatric interview form in
Addictive Behaviors 23(4):449–461, 1998. which diagnosis can be made by the examiner
asking a series of approximately 10 questions
of a client.
Objective Opiate Withdrawal
Scale (OOWS) Administration time: Administration of Axis I
and Axis II batteries may require more than 2
Purpose: Used to record symptoms of opiate hours each for patients with multiple diag
withdrawal. noses. The Psychoactive Substance Use
Clinical utility: Allows staff to share informa Disorders module may be administered by
tion about a client’s withdrawal, especially itself in 30 to 60 minutes.
objective signs observed by staff. Scoring time: Approximately 10 minutes
Groups with whom this instrument has been Computer scoring? No. Diagnosis can be
used: Adults made by the examiner after the interview.
Norms: N/A Administrator training and qualifications:
Format: Thirteen manifestations of with Designed for use by a trained clinical evalua
drawal; observer scores tor at the master’s or doctoral level, although
in research settings it has been used by bach
Computer scoring? No elor’s level technicians with extensive train
ing.
Administrator training and qualifications:
Staff must be familiar with withdrawal signs Fee for use: Yes
(e.g., registered nurse, physician) or trained.
Available from:
K.J., Aronson, M.J., Ness, R., Rubinstein, 1400 K Street, N.W.
K.J., and Kanof, P.D. Two new rating scales Washington, DC 20005
for opiate withdrawal. American Journal of
Alcohol Abuse. 13:293–308, 1987.
Stages of Change Readiness
and Treatment Eagerness
Structured Clinical Interview
Scale (SOCRATES)
for DSMIV Disorders (SCID)
Purpose: Designed to assess client motivation
Purpose: Obtains Axis I and II diagnoses to change drinking or drugrelated behavior.
using the DSMIV diagnostic criteria for Consists of five scales: precontemplation, con
enabling the interviewer to either rule out or templation, determination, action, and main
to establish a diagnosis of “drug abuse” or tenance. Separate versions are available for
“drug dependence” and/or “alcohol abuse” or alcohol and illicit drug use.
“alcohol dependence.”
Clinical utility: The SOCRATES can assist
Clinical utility: A psychiatric interview clinicians with necessary information about
client motivation for change, an important
Groups with whom this instrument has been
predictor of treatment compliance and out
used: Psychiatric, medical, or community
come, and aid in treatment planning.
based normal adults.
Norms: No Groups with whom this instrument has been
used: Adults
Screening and Assessment Instruments 229
Norms: N/A Clinical utility: Assessment of stages of
change/readiness construct can be used as a
Format: Forty items; paperandpencil predictor, and for treatment matching and
Administration time: Five minutes determining outcome variables.
Computer scoring? No Groups with whom this instrument has been
used: Both inpatient and outpatient adults
Administrator training and qualifications: No
training required. Norms: Yes, for an outpatient alcoholism
treatment population
Fee for use: No
Format: The URICA is a 32item inventory
Available from: Center for Substance Abuse designed to assess an individual’s stage of
Treatment. Enhancing Motivation for Change change located along a theorized continuum
in Substance Abuse Treatment. Treatment of change.
Improvement Protocol (TIP) Series 35. HHS
Publication No. (SMA) 993354. Rockville, Administration time: Five to 10 minutes to
MD: Substance Abuse and Mental Health complete
Services Administration, 1999. Scoring time: Four to 5 minutes
Computer scoring? Yes, using computer
Subjective Opiate Withdrawal scannable forms
Scale (SOWS)
Administrator training and qualifications:
Purpose: Used to record client’s impressions N/A
or complaints of opiate withdrawal symptoms.
Fee for use: No—the instrument is in the
Groups with whom this instrument has been public domain
used: Adults
Available from: Center for Substance Abuse
Norms: N/A Treatment. Enhancing Motivation for Change
Format: Sixteenitem questionnaire; interview in Substance Abuse Treatment. Treatment
or paperandpencil Improvement Protocol (TIP) Series 35. HHS
Publication No. (SMA) 993354. Rockville,
Computer scoring? No MD: Substance Abuse and Mental Health
Services Administration, 1999.
Available from: Handelsman, L., Cochrane,
K.J., Aronson, M.J., Ness, R., Rubinstein,
K.J., and Kanof, P.D. Two new rating scales
for opiate withdrawal. American Journal of
Alcohol Abuse. 13:293–308, 1987.
University of Rhode Island
Change Assessment (URICA)
Purpose: The URICA operationally defines
four theoretical stages of change (precontem
plation, contemplation, action, and mainte
nance), each assessed by eight items.
230 Appendix C
Appendix D:
Resource Panel
Note: The information given indicates each participant's affiliation dur-
ing the time the panel was convened and may no longer reflect the indi-
vidual's current affiliation.
Brad Austin
Public Health Advisor
Division of State and Community Assistance PPG Program Branch
Center for Substance Abuse Treatment
Rockville, Maryland
Christina Currier
Public Health Analyst
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Herman Diesenhaus
Public Health Analyst
Scientific Analysis Branch
Office of Evaluation, Scientific Analysis and Synthesis
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
231
Robert Lubran, M.S., M.P.A. Dennis Scurry, M.D.
Director Chief Medical Officer
Division of Pharmacologic Therapies Addiction of Prevention and Recovery
Center for Substance Abuse Treatment Administration
Substance Abuse and Mental Health Government of the District of Columbia
Services Administration
Department of Health
Rockville, Maryland
Washington, DC
James J. Manlandro, D.O., FAOAAM, Alan Trachtenberg, M.D., M.P.H.
FACOFP Medical Officer
Medical Director Division of Pharmacologic Therapies
Family Addiction Treatment Services, Inc. Center for Substance Abuse Treatment
Somers Point, New Jersey Substance Abuse and Mental Health
Services Administration
Carol RestMincberg Rockville, Maryland
State Project Officer
Center for Substance Abuse Treatment
Substance Abuse and Mental Health
Services Administration
Rockville, Maryland
232 Appendix D
Appendix E:
Field Reviewers
Note: The information given indicates each participant's affiliation dur-
ing the time the review was conducted and may no longer reflect the indi-
vidual's current affiliation.
Patricia T. Bowman
Probation Counselor
Fairfax Alcohol Safety Action Program
Fairfax, Virginia
233
David A. Chiriboga, Ph.D. Robert Holden, M.A.
Professor Program Director
Department of Aging and Mental Health Partners in Drug Abuse Rehabilitation
Florida Mental Health Institute Counseling
University of South Florida Washington, DC
Tampa, Florida
Kyle M. Kampman, M.D.
Carol J. Colleran, CAP, ICADC Associate Professor of Psychiatry
Director of Primary Programs Medical Director
Center of Recovery for Older Adults Treatment Research Center
HanleyHazelden Center University of Pennsylvania
West Palm Beach, Florida Philadelphia, Pennsylvania
Joy Davidoff Michael Warren Kirby, Jr., M.A., Ph.D.
Coordinator of Addiction Medicine Chief Executive Officer
New York State Office of Alcoholism and Arapahoe House, Inc.
Substance Abuse Services
Thornton, Colorado
Albany, New York
James J. Manlandro, D.O., FAOAAM,
John P. de Miranda, Ed.M. FACOFP
Executive Director Medical Director
National Association on Alcohol, Drugs Family Addiction Treatment Services, Inc.
and Disability, Inc.
Somers Point, New Jersey
San Mateo, California
Ethan Nebelkopf, Ph.D., MFCC
B.J. Dean Director
Executive Director Family and Child Guidance Clinic
Island Grove Regional Treatment Center, Native American Health Center
Inc.
Oakland, California
Greeley, Colorado
Robert E. Olson, M.S.
Ralph W. Edwards, M.P.H., M.P.A. Project Director
Director California Alcohol, Drug and Disability
Office of Citizen Leadership Technical Assistance Project
Massachusetts Department of Mental National Association on Alcohol, Drugs
Health and Retardation
and Disability, Inc.
Boston, Massachusetts
Belmont, California
Michael I. Fingerhood, M.D. Christopher Pond
Associate Professor of Medicine Director of Adult Services
Johns Hopkins Bayview Medical Center Arapahoe House, Inc.
Baltimore, Maryland Thornton, Colorado
Michael M. Galer, D.B.A. Anthony B. Radcliffe, M.D.
Chair Chief of Addiction Medicine
Graduate School of Business Fontana SCPMG
University of Phoenix Greater Boston Kaiser Permanente/CDRP
Campus
Fontana, California
Braintree, Massachusetts
234 Appendix E
Jay Renaud Leslie R. Steve, M.A.
Member/Editor Native American Coordinator
J & M Reports Center for the Application of Substance
Guidepoints: Acupuncture in Recovery Abuse Technologies
Vancouver, Washington University of Nevada
Reno, Nevada
Joseph P. Reoux, M.D.
Assistant Professor Richard T. Suchinsky, M.D.
Department of Psychiatry and Behavioral Associate Chief for Addictive Disorders and
Sciences Psychiatric Rehabilitation
VA Puget Sound Health Care System Mental Health and Behavioral Sciences
University of Washington School of Services
Medicine
Department of Veterans Affairs
Seattle, Washington
Washington, DC
Timothy M. Scanlan, M.D. Nancy R. VanDeMark, M.S.W.
Medical Director Director
Addiction Specialists of Kansas Research and Program Evaluation
Wichita, Kansas Arapahoe House, Inc.
Thornton, Colorado
Lawrence Schonfeld, Ph.D.
Professor Melvin H. Wilson, M.B.A., LCSWC
Louis de la Parte Florida Mental Health Baltimore HIDTA Coordinator
Institute Maryland Department of Parole and
Department of Aging and Mental Health Probation
University of South Florida Clinton, Maryland
Tampa, Florida
Ann S. Yabusaki, M.Ed., M.A., Ph.D.
Steven Shevlin Substance Abuse Director
Executive Director Psychologist
Signs of Sobriety, Inc. Substance Abuse Programs and Training
Ewing, New Jersey Coalition for a DrugFree Hawaii
Kaneohe, Hawaii
Carla Shird, M.A., CSCAD
Counselor
Mental Health Center
Gallaudet University Kellogg Conference
Center
Washington, DC
Mickey J.W. Smith, M.S.W.
Senior Policy Associate, Behavioral Health
Program, Policy & Practice Unit
Division of Professional Development &
Advocacy
National Association of Social Workers
Washington, DC
Field Reviewers 235
Index
Because the entire volume is about detoxifica B
tion and substance abuse treatment, the use barbiturates, 61–62
of these terms as entry points has been mini barriers to treatment
mized in this index. Commonly known access, 43–44
acronyms are listed as main headings. Page administrative, 39
references for information contained in fig benzodiazepine
ures appear in italics contraindications, 61
limitations in outpatient treatment, 60–61
and phenobarbital withdrawal equivalents, 77
A and pregnant women, 106, 108
acupuncture, 103–104, 113
symptomtriggered therapy, 58–59
acute care inpatient settings, 19–20
tapering dosages, 59
adolescents, 30–31, 118
and treatment of alcohol withdrawal, 58–61
and club drugs, 97
benzodiazepine withdrawal
Adult Detoxification levels of care, 13
management with medication, 75–76
adults, older, 109–110
medical complications of, 75
African Americans, 113–115
signs and symptoms, 74–75
aggressive behavior, 27
biochemical markers, 48
strategies for deescalating, 28
biomedical evaluation domains, 25
alcohol withdrawal bipolar disorders, 142–143
and benzodiazepine treatment, 58–61 blood alcohol content, 48–49
contraindications to using benzodiazepines breath alcohol levels, 50
during, 61
buprenorphine
management with medication, 57–58
and opioid withdrawal, 71–72
management without medication, 55
and pregnant women, 107
medical complications, 54
bupropion, 92
and seizures, 64–65
Byrne Formula Grant Program, 154
signs and symptoms, 52–54
alternative treatment, 34, 103–104 C
and disabilities, 113
carveouts, 157
American Indians, 116–117
case management, 44
American Medical Association, position on
case studies, 48, 102
alcoholism, 3
CDT levels, 51
Americans With Disabilities Act, 110
central nervous system depression, 66
amphetamines. See stimulants
children’s protective services, 154
anabolic steroid withdrawal, 96
Civilian Health and Medical Program of the
management, 97
Veterans Administration, 152–153
medical complications of, 96–97
client advocates, 33
patient care and comfort, 97
clinically managed residential detoxification, 17
signs and symptoms, 96
Clinical Practice Guidelines for Detoxification of
anticonvulsants, 62
Chemically Dependent Inmates, 119
antipsychotics, 62
clonidine
anxiety disorders, 139–141
detoxification, 72
antianxiety agents, 143
and opioid withdrawal, 70–71
Asians and Pacific Islanders, 115–116
and pregnant women, 107
assessment
and rapid detoxification, 73
and determining rehabilitation plans, 40
club drugs, 97
of psychosocial needs, 39
ecstasy, 99–100
of severity of nicotine dependence, 86–87
GHB, 98–99
audience for this TIP, 2
hallucinogens, 98
Index 237
ketamine and PCP, 100–101
substancerelated disorder, 5
and pregnant women, 109
substance withdrawal, 5
cocaine. See stimulants
treatment/rehabilitation, 5–6
Commission on Accreditation of Rehabilitation
delirium, 63–66
Facilities, 17, 27
delirium tremens, 63
Community Reinforcement and Family Training
depressive disorders, 27, 141–142
(intervention), 34
antidepressants, 144
complementary medicine. See alternative
detoxification
treatment
building a program, 145–146
confidentiality, 28, 165
clinically managed residential, 17
confrontation, 35
definition of, 4
Contracting for Managed Substance Abuse and
as distinct from substance abuse treatment, 4
Mental Health Services: A Guide for
history of services, 2–3
Public Purchasers, 161
inpatient versus outpatient programs, 20, 21
contracts, managed care, 158–159
linkage with substance abuse treatment, 8
cooccurring medical conditions, 24–26, 26,
medical model of, 3
110–113
outpatient, 13
acute trauma, 135
principles for care during, 24
cancer, 134–135
rapid, ultrarapid, 73
cardiovascular disorders, 125–127
service setting changes, 146
diabetes, 135
social model of, 3, 55
gastrointestinal disorders, 122–125
strengthening market position of program,
general principles of care, 122
167–168
hematologic disorders, 127–128
disabilities, 110–113, 112
infectious disease, 132–134
definitions, 111
neurologic system effects, 129–132
locating expert assistance, 114
pulmonary disorders, 128–129
domestic violence, 31
cooccurring psychiatric conditions, 27–28,
Drug Addiction Treatment Act of 2000, 72
136–137
drugfree environment, maintaining, 34
anxiety disorders, 139–141
bipolar disorders, 142–143
E
depressive disorders, 141–142
ecstasy, 99–100
and pharmacologic agents, 137–138
enhancing motivation, 34
psychotic disorders, 143
ERs, and urgent care facilities, 15
and psychotropic medications, 138–139
evaluation
substance induced, 139
definition of, 4
cost methodologies, 159–161
initial, 24
criminal justice systems, 118–119, 154
cultural competence, 32–33, 44
questions to guide practitioners, 32
F
Fetal Alcohol Syndrome, 108, 117
fostering entry to treatment, definition of, 5
D freestanding substance abuse treatment
decisional balancing strategies, 37
facility, 16–17
definitions, 6
funding issues, 147–148, 155, 162–163
detoxification, 4
grant funding, 156, 157
disabilities, 111
multiple funding streams, 166
evaluation, 4
fostering entry to treatment, 5
maintenance, 6
G
regarding disabilities, 111
gays and lesbians, 117–118
social detoxification, 17
GGT levels, 51
stabilization, 4
GHB, 98–99
substance, 5
grant funding, 156, 157
substance intoxication, 5
guiding principles, 7
238 Index
H linkages
hallucinogens, 98
to followup medical care, 45
hepatitis, and GGT levels, 51
to ongoing psychiatric services, 44
Hispanics/Latinos, 117
to treatment and maintenance activities, 42
history of detoxification services, 2–3
HIV/AIDS, 134
M
detoxification as a means to inhibit spread
malnutrition, 28
of, 3
managed care
homeless patients, 43
accreditation, 161–162
contracts, 158–159
I
financial risk in, 159–161
incarcerated persons, 118–119
performance measurement, 164–165
Indian Health Service, 152
recordkeeping, 165–166
infectious disease, 26–27, 132–134
marijuana, 95
inhalant/solvent withdrawal
and pregnant women, 109
management with medication, 83
market position, strengthening, 167–168
management without medication, 82
MCV levels, 51
medical complications of, 82
Medicaid, 149–150
patient care and comfort, 83–84
medically monitored inpatient detoxification, 17
signs and symptoms, 82
medical model of detoxification, 3
inhalants/solvents, commonly abused, 83–84 Medicare, 151
inpatient detoxification programs, versus methadone
outpatient programs, 20, 21
detoxification, 72
instruments, for dependence and withdrawal, 49
and opioid withdrawal, 69–70
intensive outpatient programs, 18–19
and pregnant women, 106
interventions
motivational enhancements, 34
Community Reinforcement and Family
Training, 34
N
Johnson Intervention, 35
nicotine, 84–85
intoxication, signs and symptoms, 52, 53
assessing severity of dependence, 86–87
Fagerstrom Test for Nicotine Dependence, 87
J GloverNilsson Smoking Behavioral
Johnson Intervention, 35
Questionnaire, 88
Joint Commission on Accreditation of
and pregnant women, 108–109
Healthcare Organizations, 17, 27
Treating Tobacco Use and Dependence:
Clinical Practice Guidelines, 90, 93
nicotine replacement therapy, 91–92
K combining, 93–94
ketamine, 100–101
and pregnant women, 109
kindling effect, 54, 56
nicotine withdrawal, 86
effects of abstinence on blood levels of
L psychiatric medications, 90
least restrictive care, 12
interventions, 90–91, 91
levels of care, 39
management with medication, 91–94
acute care inpatient settings, 20
management without medication, 89–90
Adult Detoxification, 13
medical complications of, 87–89
ambulatory detoxification, 14
patient care and comfort, 94
clinically managed residential
signs and symptoms, 85–86, 89
detoxification, 17
nutrition
intensive outpatient programs, 18–19
deficits, 29–30
medically monitored inpatient
evaluation, 28–29
detoxification, 17
urgent care facilities and ERs, 16
Index 239
O public housing, 153
officebased detoxification. See detoxification,
public intoxication, prior to 1970s, 2–3
outpatient
older adults, 109–110
R
opioid withdrawal
rapid detoxification, 73
and buprenorphine, 71–72
recordkeeping, 165–166
and clonidine, 70–71
referral sources, 146
management with medication, 68–69
Rehabilitation Act of 1973, 110
management without medication, 68
reimbursement systems, 8
and methadone, 69–70
relapse
signs and symptoms, 66–68, 67
chronic, 33
outpatient programs, versus inpatient
prevention, 62–63
programs, 20, 21
research funding, 156
rohypnol, 101
P Ryan White CARE Act, 154
parents, 31
partial hospitalization programs. See intensive
S
outpatient programs
scope of this TIP, 2
patient care and comfort, 66, 73–74
sedativehypnotics, and phenobarbital
anabolic steroid withdrawal, 97
withdrawal equivalents, 78
inhalant/solvent withdrawal, 83–84
seizures, 63–66
nicotine withdrawal, 94
alcohol withdrawal, 64–65, 130
stimulant withdrawal, 81
what to do in the event of, 65
patient education, 33
selfpay patients, 156
Patient Placement Criteria, ASAM, 12–13, 39
service costs, resources on, 160
performance measurement, 164–165
service delivery, pitfalls of, 8
pharmacotherapy
social detoxification, 3, 17, 55–57
and anxiety disorders, 140–141
Social Security Disability Insurance, 151
and bipolar disorders, 142–143
social services, 153–154
and depressive disorders, 141–142
Social Services Block Grant, 153
nonnicotine, 92–93
solvents, and pregnant women, 108
phenobarbital withdrawal
stabilization, definition of, 4
and benzodiazepine, 77
staffing issues
and sedativehypnotics, 78
acute care inpatient settings, 20
physicians, and preparing patients to enter
inpatient detoxification programs, 18
detoxification, 13
intensive outpatient programs, 19
placement matching, challenges to, 11–12
in outpatient detoxification, 14
polydrug abuse, 101–102
stages of change, 35–37, 36
prioritizing substances of abuse, 102–103
State Children’s Health Insurance Program, 152
pregnant women, 43, 105–106
steroids, anabolic, 96
and alcohol, 106
stimulants, 76
and marijuana, 109
and pregnant women, 108
and nicotine, 108–109
stimulant withdrawal
and opioids, 106–108
management with medication, 81
and solvents, 108
management without medication, 80
and stimulants, 108
medical complications of, 80, 81
principles for care during detoxification, 24
patient care and comfort, 81
Provider’s Introduction to Substance Abuse
symptoms, 79–80
Treatment for Lesbian, Gay, Bisexual,
substance
and Transgender Individuals, A, 118
changing patterns of use, 3
psychiatric services, linkages to, 44
definition of, 5
psychosocial evaluation domains, 25
dependence, chronic, 45
psychotic disorders, 143
induced psychiatric conditions, 139
240 Index
intoxication, definition of, 5
Substance Abuse Among Older Adults (TIP 26),
related disorder, definition of, 5
110
withdrawal, definition of, 5
Substance Abuse: Clinical Issues in Intensive
Substance Abuse Prevention and Treatment
Substance Abuse Treatment: Addressing the
Block Grant, 149
Specific Needs of Women (in development),
substance abuse treatment
39, 106, 108, 109
as distinct from detoxification, 4
Substance Abuse Treatment and Domestic
funding issues, 147–148, 155, 156, 157,
Violence (TIP 25), 32
162–163
Substance Abuse Treatment for Adults in the
linkage with detoxification, 8
Criminal Justice System (TIP 44), 119, 154
suicide, 27
Substance Abuse Treatment for Persons With
Supplemental Security Income, 151
Child Abuse and Neglect Issues (TIP 36), 44
support systems, 33–34 Substance Abuse Treatment for Persons With
symptomtriggered benzodiazepine therapy, CoOccurring Disorders (TIP 42), 27, 45, 93,
58–59 112, 121, 137
Substance Abuse Treatment for Persons With
T HIV/AIDS (TIP 37), 134
tapering dosages, benzodiazepine, 59
Substance Abuse Treatment: Men’s Issues (in
Temporary Assistance to Needy Families, 153
development), 39
THC abstinence syndrome, 95
Substance Use Disorder Treatment for People
therapeutic alliance, 37–38
With Physical and Cognitive Disabilities (TIP
and clinician characteristics, 38
29), 44, 110
TIPs cited
Treatment of Adolescents With Substance Use
Clinical Guidelines for the Use of
Disorders (TIP 32), 31, 118
Buprenorphine in the Treatment of Opioid
Tuberculosis Epidemic: Legal and Ethical Issues
Addiction (TIP 40), 71
for Alcohol and Other Drug Abuse
Combining Alcohol and Other Drug Abuse
Treatment Providers, The (TIP 18), 133
Treatment With Diversion for Juveniles in
transtheoretical model. See stages of change
the Justice System (TIP 21), 119, 154
Treating Tobacco Use and Dependence: Clinical
Comprehensive Case Management for
Practice Guidelines, 90, 93
Substance Abuse Treatment (TIP 27), 44, 45
treatment
Continuity of Offender Treatment for
definition of, 5–6
Substance Use Disorders From Institution to
initiation of, 42
Community (TIP 30), 119, 154
settings, 41
Detoxification From Alcohol and Other Drugs
TRICARE, 152
(TIP 19), 1
Enhancing Motivation for Change in Substance
U
Abuse Treatment (TIP 35), 34, 35
ultrarapid detoxification, 73
Improving Cultural Competence in Substance
Uniform Alcoholism and Intoxication Treatment
Abuse Treatment (in development), 7, 44,
Act, 3
114, 116, 117
urgent care facilities, and ERs, 15
MedicationAssisted Treatment for Opioid
urine drug screens, 50
Addiction in Opioid Treatment Programs
utilization and case management, 166–167
(TIP 43), 58, 69, 107
Role and Current Status of Patient Placement
Criteria in the Treatment of Substance
V
Use Disorders, The (TIP 13), 13, 41
violence, 27
Screening and Assessing Adolescents for
domestic, 31
Substance Use Disorders (TIP 31), 31, 118
vocational rehabilitation, 153–154
Screening for Infectious Diseases Among
Substance Abusers (TIP 6), 132
Index 241
W National Institute on Drug Abuse, 156
Washington Circle Group, 4, 164
Patient Placement Criteria, ASAM, 166
Web sites
public housing, 153
American Cancer Society, 94
Research Assistant, The, 156
American Lung Association, 94
Ryan White CARE Act, 154
Byrne Formula Grant Program, 154
SAMHSA funding opportunities, 149
children’s protective services, 154
Social Security Disability Insurance, 151
Civilian Health and Medical Program of the
State Children’s Health Insurance Program,152
Veterans Administration, 152–153
Temporary Assistance to Needy Families, 153
Commission on Accreditation of
TRICARE, 152
Rehabilitation Facilities, 17, 20, 21, 27, 162
vocational rehabilitation, 154
grant funding sources, 157
Washington Circle Group, 164
Health Insurance Portability and
withdrawal, 24–26, 33. See also alcohol with
Accountability Act, 165
drawal; anabolic steroid withdrawal; benzodi
Indian Health Service, 152
azepine withdrawal; inhalant/solvent withdraw
Joint Commission on Accreditation of
al; nicotine withdrawal; opioid withdrawal;
Healthcare Organizations, 17, 20, 21, 27, 162
stimulant withdrawal
legal aspects of prescribing buprenorphine, 72
women, pregnant, 43, 105–106
Medicaid, 150
wraparound services, 43
Medicare, 151
model programs, 167
Z
National Committee for Quality Assurance,
Zyban, 92
162
National Institute on Alcohol Abuse and
Alcoholism, 156
242 Index
SAMHSA TIPs and Publications Based on TIPs
What Is a TIP?
Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,
program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs
are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)
to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.
Ordering Information
Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call
1-877-SAMHSA-7 (1-877-726-4727) (English and Español).
TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 13 Role and Current Status of Patient Placement
TIP 43 Criteria in the Treatment of Substance Use
Disorders
TIP 2 Pregnant, Substance-Using Women—Replaced by Quick Guide for Clinicians
TIP 51
Quick Guide for Administrators
TIP 3 Screening and Assessment of Alcohol- and Other KAP Keys for Clinicians
Drug-Abusing Adolescents—Replaced by TIP 31
TIP 14 Developing State Outcomes Monitoring Systems for
TIP 4 Guidelines for the Treatment of Alcohol- and Other Alcohol and Other Drug Abuse Treatment
Drug-Abusing Adolescents—Replaced by TIP 32
TIP 15 Treatment for HIV-Infected Alcohol and Other Drug
TIP 5 Improving Treatment for Drug-Exposed Infants Abusers—Replaced by TIP 37
TIP 6 Screening for Infectious Diseases Among Substance TIP 16 Alcohol and Other Drug Screening of Hospitalized
Abusers—Archived Trauma Patients
Quick Guide for Clinicians
TIP 7 Screening and Assessment for Alcohol and Other
Drug Abuse Among Adults in the Criminal Justice KAP Keys for Clinicians
System—Replaced by TIP 44
TIP 17 Planning for Alcohol and Other Drug Abuse
TIP 8 Intensive Outpatient Treatment for Alcohol and Treatment for Adults in the Criminal Justice
Other Drug Abuse—Replaced by TIPs 46 and 47 System—Replaced by TIP 44
TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues
TIP 9 Assessment and Treatment of Patients With for Alcohol and Other Drug Abuse Treatment
Coexisting Mental Illness and Alcohol and Other Providers—Archived
Drug Abuse—Replaced by TIP 42
TIP 19 Detoxification From Alcohol and Other Drugs—
TIP 10 Assessment and Treatment of Cocaine- Abusing Replaced by TIP 45
Methadone-Maintained Patients—Replaced by TIP 43
TIP 20 Matching Treatment to Patient Needs in Opioid
TIP 11 Simple Screening Instruments for Outreach for Substitution Therapy—Replaced by TIP 43
Alcohol and Other Drug Abuse and Infectious
Diseases—Replaced by TIP 53 TIP 21 Combining Alcohol and Other Drug Abuse
Treatment With Diversion for Juveniles in the
TIP 12 Combining Substance Abuse Treatment With Justice System
Intermediate Sanctions for Adults in the Criminal Quick Guide for Clinicians and Administrators
Justice System—Replaced by TIP 44
243
TIP 22 LAAM in the Treatment of Opiate Addiction— TIP 31 Screening and Assessing Adolescents for Substance
Replaced by TIP 43 Use Disorders
See companion products for TIP 32.
TIP 23 Treatment Drug Courts: Integrating Substance Abuse
Treatment With Legal Case Processing TIP 32 Treatment of Adolescents With Substance Use
Quick Guide for Administrators Disorders
Quick Guide for Clinicians
TIP 24 A Guide to Substance Abuse Services for Primary
Care Clinicians KAP Keys for Clinicians
Concise Desk Reference Guide TIP 33 Treatment for Stimulant Use Disorders
Quick Guide for Clinicians Quick Guide for Clinicians
KAP Keys for Clinicians KAP Keys for Clinicians
TIP 25 Substance Abuse Treatment and Domestic Violence TIP 34 Brief Interventions and Brief Therapies for Substance
Linking Substance Abuse Treatment and Domestic Abuse
Violence Services: A Guide for Treatment Providers Quick Guide for Clinicians
Linking Substance Abuse Treatment and Domestic KAP Keys for Clinicians
Violence Services: A Guide for Administrators
Quick Guide for Clinicians TIP 35 Enhancing Motivation for Change in Substance Abuse
KAP Keys for Clinicians Treatment
Quick Guide for Clinicians
TIP 26 Substance Abuse Among Older Adults KAP Keys for Clinicians
Substance Abuse Among Older Adults: A Guide for
Treatment Providers TIP 36 Substance Abuse Treatment for Persons With Child
Substance Abuse Among Older Adults: A Guide for Abuse and Neglect Issues
Social Service Providers Quick Guide for Clinicians
Substance Abuse Among Older Adults: Physician’s KAP Keys for Clinicians
Guide Helping Yourself Heal: A Recovering Woman’s Guide to
Quick Guide for Clinicians Coping With Childhood Abuse Issues
KAP Keys for Clinicians Also available in Spanish
Helping Yourself Heal: A Recovering Man’s Guide to
TIP 27 Comprehensive Case Management for Substance Coping With the Effects of Childhood Abuse
Abuse Treatment
Also available in Spanish
Case Management for Substance Abuse Treatment: A
Guide for Treatment Providers TIP 37 Substance Abuse Treatment for Persons With
Case Management for Substance Abuse Treatment: A HIV/AIDS
Guide for Administrators Quick Guide for Clinicians
Quick Guide for Clinicians KAP Keys for Clinicians
Quick Guide for Administrators Drugs, Alcohol, and HIV/AIDS: A Consumer Guide
TIP 28 Naltrexone and Alcoholism Treatment—Replaced by Also available in Spanish
TIP 49 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for
African Americans
TIP 29 Substance Use Disorder Treatment for People With
Physical and Cognitive Disabilities TIP 38 Integrating Substance Abuse Treatment and
Quick Guide for Clinicians Vocational Services
Quick Guide for Administrators Quick Guide for Clinicians
KAP Keys for Clinicians Quick Guide for Administrators
KAP Keys for Clinicians
TIP 30 Continuity of Offender Treatment for Substance Use
Disorders From Institution to Community TIP 39 Substance Abuse Treatment and Family Therapy
Quick Guide for Clinicians Quick Guide for Clinicians
KAP Keys for Clinicians Quick Guide for Administrators
Family Therapy Can Help: For People in Recovery
From Mental Illness or Addiction
244
TIP 40 Clinical Guidelines for the Use of Buprenorphine in TIP 50 Addressing Suicidal Thoughts and Behaviors in
the Treatment of Opioid Addiction Substance Abuse Treatment
Quick Guide for Physicians Quick Guide for Clinicians
KAP Keys for Physicians Quick Guide for Administrators
TIP 41 Substance Abuse Treatment: Group Therapy TIP 51 Substance Abuse Treatment: Addressing the Specific
Quick Guide for Clinicians Needs of Women
KAP Keys for Clinicians
TIP 42 Substance Abuse Treatment for Persons With Co- Quick Guide for Clinicians
Occurring Disorders
Quick Guide for Administrators
Quick Guide for Clinicians
Quick Guide for Administrators TIP 52 Clinical Supervision and Professional Development
KAP Keys for Clinicians of the Substance Abuse Counselor
Quick Guide for Clinical Supervisors
TIP 43 Medication-Assisted Treatment for Opioid Addiction Quick Guide for Administrators
in Opioid Treatment Programs
Quick Guide for Clinicians TIP 53 Addressing Viral Hepatitis in People With Substance
KAP Keys for Clinicians Use Disorders
Quick Guide for Clinicians and Administrators
TIP 44 Substance Abuse Treatment for Adults in the KAP Keys for Clinicians
Criminal Justice System
Quick Guide for Clinicians TIP 54 Managing Chronic Pain in Adults With or in
KAP Keys for Clinicians Recovery From Substance Use Disorders
Quick Guide for Clinicians
TIP 45 Detoxification and Substance Abuse Treatment KAP Keys for Clinicians
Quick Guide for Clinicians You Can Manage Your Chronic Pain To Live a Good
Quick Guide for Administrators Life: A Guide for People in Recovery From Mental
KAP Keys for Clinicians Illness or Addiction
245
Detoxification and
Substance Abuse Treatment
Collateral Products
Based on TIP 45
Quick Guide for Clinicians
KAP Keys for Clinicians