A Treatment Improvement

Protocol

Detoxification andSubstance Abuse Treatment

TIP45

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov DETOXIFICATION

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health ServiceSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse Treatment

1 Choke Cherry RoadRockville, MD 20857

Detoxification andSubstance Abuse

Treatment

Norman S. Miller, M.D., FASAMConsensus Panel Chair

Steven S. Kipnis, M.D., FACPConsensus Panel Co-Chair

A Treatment Improvement

Protocol

TIP45

AcknowledgmentsNumerous people contributed to the develop-ment of this TIP (see pp. ix–xii and appendicesD and E). This publication was produced byThe CDM Group, Inc. (CDM) under theKnowledge Application Program (KAP) con-tract numbers 270-99-7072 and 270-04-7049with the Substance Abuse and Mental HealthServices Administration (SAMHSA), U.S.Department of Health and Human Services(DHHS). Andrea Kopstein, Ph.D., M.P.H.,Karl D. White, Ed.D., and Christina Currierserved as the Center for Substance AbuseTreatment (CSAT) Government ProjectOfficers. Rose M. Urban, M.S.W., J.D.,LCSW, CCAC, CSAC, served as the KAPExecutive Project Co-Director. ElizabethMarsh Cupino served as CDM KAP ManagingProject Co-Director. Sheldon Weinberg,Ph.D., served as KAP SeniorResearcher/Applied Psychologist. Other KAPpersonnel included Raquel Witkin, M.S.,Deputy Project Manager; Susan Kimner,Editorial Director; Jonathan Max Gilbert.M.A., Editor/Writer; Deborah Steinbach,M.A., Editor/Writer; James M. Girsch, Ph.D.,Editor/Writer; Michelle Myers, QualityAssurance Editor; and Sonja Easley andElizabeth Plevyak, Editorial Assistants. Inaddition, Sandra Clunies, M.S., ICADC,served as Content Advisor. Jonathan MaxGilbert, M.A. served as a writer. Specialthanks go to Suzanne Gelber, Ph.D., for hercontributions to chapter 6, and JoanDilonardo, Ph.D., for her input on the TIP.

DisclaimerThe opinions expressed herein are the views ofthe consensus panel members and do not neces-sarily reflect the official position of CSAT,SAMHSA, or DHHS. No official support of orendorsement by CSAT, SAMHSA, or DHHSfor these opinions or for particular instru-ments, software, or resources described in thisdocument are intended or should be inferred.The guidelines in this document should not beconsidered substitutes for individualized clientcare and treatment decisions.

Public Domain NoticeAll materials appearing in this volume exceptthose taken directly from copyrighted sourcesare in the public domain and may be repro-duced or copied without permission fromSAMHSA/CSAT or the authors. Do not repro-duce or distribute this publication for a feewithout specific, written authorization fromSAMHSA’s Office of Communications.

Electronic Access and Copiesof PublicationCopies may be obtained free of charge fromSAMHSA’s National Clearinghouse for Alcoholand Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearingimpaired), (800) 487-4889, or electronicallythrough the following Internet World WideWeb site: www.ncadi.samhsa.gov.

Recommended CitationCenter for Substance Abuse Treatment.Detoxification and Substance AbuseTreatment. Treatment Improvement Protocol(TIP) Series 45. DHHS Publication No.(SMA) 06-4131. Rockville, MD: SubstanceAbuse and Mental Health ServicesAdministration, 2006.

Originating OfficePractice Improvement Branch, Division ofServices Improvement, Center for SubstanceAbuse Treatment, Substance Abuse and MentalHealth Services Administration, 1 ChokeCherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 06-4131Printed 2006

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........................1Purpose of the TIP.....................................................................................................1Audience ..................................................................................................................2Scope ......................................................................................................................2History of Detoxification Services...................................................................................2Definitions................................................................................................................3Guiding Principles in Detoxification and Substance Abuse Treatment .....................................7Challenges to Providing Effective Detoxification ................................................................8

Chapter 2—Settings, Levels of Care, and Patient Placement ...........................................11Role of Various Settings in the Delivery of Services ...........................................................11Other Concerns Regarding Levels of Care and Placement...................................................20

Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification .......23Evaluating and Addressing Psychosocial and Biomedical Issues ...........................................24Strategies for Engaging and Retaining Patients in Detoxification ..........................................33Referrals and Linkages ..............................................................................................38

Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .......47Psychosocial and Biomedical Screening and Assessment .....................................................47Alcohol Intoxication and Withdrawal.............................................................................52Opioids ..................................................................................................................66Benzodiazepines and Other Sedative-Hypnotics ...............................................................74Stimulants...............................................................................................................76Inhalants/Solvents.....................................................................................................82Nicotine..................................................................................................................84Marijuana and Other Drugs Containing THC ..................................................................95Anabolic Steroids......................................................................................................96Club Drugs..............................................................................................................97Management of Polydrug Abuse: An Integrated Approach.................................................101Alternative Approaches ............................................................................................103Considerations for Specific Populations........................................................................105

iii

iv

Chapter 5—Co-Occurring Medical and Psychiatric Conditions.......................................121General Principles of Care for Patients With Co-Occurring Medical Conditions .....................122Treatment of Co-Occurring Psychiatric Conditions..........................................................136Standard of Care for Co-Occurring Psychiatric Conditions ...............................................138

Chapter 6—Financing and Organizational Issues .........................................................145Preparing and Developing a Program...........................................................................145Working in Today’s Managed Care Environment.............................................................157Preparing for the Future...........................................................................................168

Appendix A—Bibliography......................................................................................169

Appendix B—Common Drug Intoxication Signs and Withdrawal Symptoms .....................223

Appendix C—Screening and Assessment Instruments ...................................................225Section I: Screening and Assessment for Alcohol Abuse ....................................................225Section II: Screening and Assessment for Alcohol and Other Drug Abuse..............................228

Appendix D—Resource Panel..................................................................................231

Appendix E—Field Reviewers..................................................................................233

Index ..................................................................................................................237

CSAT TIPs and Publications....................................................................................243

FiguresFigure 1-1 DSM-IV-TR Definitions of Terms .....................................................................6Figure 1-2 Guiding Principles Recognized by the Consensus Panel .........................................7Figure 2-1 Issues To Consider in Determining Whether Inpatient or Outpatient

Detoxification Is Preferred .......................................................................................21Figure 3-1 Initial Biomedical and Psychosocial Evaluation Domains......................................25Figure 3-2 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26Figure 3-3 Strategies for De-escalating Aggressive Behaviors ...............................................28Figure 3-4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural

Framework ...........................................................................................................32Figure 3-5 The Transtheoretical Model (Stages of Change) ..................................................36Figure 3-6 Clinician’s Characteristics Most Important to the Therapeutic Alliance....................38Figure 3-7 Recommended Areas for Assessment To Determine Appropriate

Rehabilitation Plans...............................................................................................40Figure 3-8 Strategies To Promote Initiation of Treatment and Maintenance Activities ................42Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and

Specific Illicit Drugs................................................................................................49Figure 4-2 Symptoms of Alcohol Intoxication...................................................................53Figure 4-3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67Figure 4-5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77

Contents

v

Figure 4-6 Other Sedative-Hypnotics and Their Phenobarbital Withdrawal Equivalents ............78Figure 4-7 Stimulant Withdrawal Symptoms....................................................................79Figure 4-8 Commonly Abused Inhalants/Solvents..............................................................83Figure 4-9 DSM-IV-TR on Nicotine Withdrawal ...............................................................86Figure 4-10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87Figure 4-11 The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) ........................88Figure 4-12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With

Other Psychiatric Conditions ....................................................................................89Figure 4-13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90Figure 4-14 The “5 A’s” for Brief Intervention .................................................................91Figure 4-15 Some Definitions Regarding Disabilities ........................................................111Figure 4-16 Impairment and Disability Chart.................................................................112Figure 4-17 Locating Expert Assistance.........................................................................114Figure 6-1 Financial Arrangements for Providers............................................................162

Contents

What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center forSubstance Abuse Treatment (CSAT), part of the Substance Abuse andMental Health Services Administration (SAMHSA) within the U.S.Department of Health and Human Services (DHHS), are best-practiceguidelines for the treatment of substance use disorders. CSAT draws onthe experience and knowledge of clinical, research, and administrativeexperts to produce the TIPs, which are distributed to facilities and indi-viduals across the country. The audience for the TIPs is expandingbeyond public and private treatment facilities to include practitioners inmental health, criminal justice, primary care, and other healthcare andsocial service settings.

CSAT’s Knowledge Application Program (KAP) Expert Panel, a distin-guished group of experts on substance use disorders and professionals insuch related fields as primary care, mental health, and social services,works with the State Alcohol and Drug Abuse Directors to generate topicsfor the TIPs. Topics are based on the field’s current needs for informationand guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agenciesand national organizations to be members of a resource panel that recom-mends specific areas of focus as well as resources that should be consid-ered in developing the content for the TIP. Then recommendations arecommunicated to a consensus panel composed of experts on the topic whohave been nominated by their peers. This consensus panel participates ina series of discussions. The information and recommendations on whichthey reach consensus form the foundation of the TIP. The members ofeach consensus panel represent substance abuse treatment programs, hos-pitals, community health centers, counseling programs, criminal justiceand child welfare agencies, and private practitioners. A panel chair (or co-chairs) ensures that the guidelines mirror the results of the group’s collaboration.

vii

viii What Is a TIP?

A large and diverse group of experts closelyreviews the draft document. Once the changesrecommended by these field reviewers havebeen incorporated, the TIP is prepared forpublication, in print and online. The TIPs can be accessed via the Internet atwww.kap.samhsa.gov. The online TIPs areconsistently updated and provide the field with state-of-the-art information.

While each TIP strives to include an evidencebase for the practices it recommends, CSATrecognizes that the field of substance abusetreatment is evolving, and research frequentlylags behind the innovations pioneered in thefield. A major goal of each TIP is to convey

“front-line” information quickly but responsi-bly. For this reason, recommendations prof-fered in the TIP are attributed to either pan-elists’ clinical experience or the literature. Ifresearch supports a particular approach, cita-tions are provided.

This TIP, Detoxification and SubstanceAbuse Treatment, revises TIP 19,Detoxification From Alcohol and OtherDrugs. The revised TIP provides the clinicalevidence-based guidelines, tools, andresources necessary to help substance abusecounselors and clinicians treat clients who aredependent on substances of abuse.

ix

Consensus Panel

ChairNorman S. Miller, M.D., FASAMProfessor and Director of Addiction MedicineDepartment of Psychiatry Michigan State UniversityEast Lansing, Michigan

Co-ChairSteven S. Kipnis, M.D., FACPMedical DirectorRussell E. Blaisdell Addiction Treatment

CenterNew York State Office of Alcoholism and

Substance Abuse ServicesOrangeburg, New York

Workgroup Managers and Co-ManagersAnne M. Herron, M.S.Director Division of State and Community Assistance Center for Substance Abuse Treatment Substance Abuse and Mental Health Services

Administration Rockville, Maryland

Ronald J. Hunsicker, D.Min., FACATAPresident/Chief Executive OfficerNational Association of Addiction Treatment

ProvidersLancaster, Pennsylvania

Robert J. Malcolm, Jr., M.D.Professor of Psychiatry, Family Medicine,

and Pediatrics Associate Dean for Continuing Medical

Education Center for Drug and Alcohol Programs Institute of Psychiatry Medical University of South Carolina Charleston, South Carolina

Anthony Radcliffe, M.D., FASAMChief of Addiction MedicineKaiser PermanenteSouthern California Permanente Medical

GroupFontana, California

Carl Rollynn Sullivan, III, M.D.Professor Director of Addiction Program Department of Behavioral Medicine and

Psychiatry School of Medicine West Virginia University Morgantown, West Virginia

Nancy R. VanDeMark, M.S.W.Director of Colorado Social Research

AssociatesArapahoe House, Inc.Thornton, Colorado

Panelists Louis E. Baxter, Sr., M.D., FASAM Executive Director Physicians Health Program Medical Society of New JerseyLawrenceville, New Jersey

Kenneth O. Carter, M.D., M.P.H., Dipl.Ac.PsychiatristAcupuncture Detoxification Specialist Carolinas Medical Center Charlotte, North Carolina

Jean Lau Chin, M.A., Ed.D., ABPPPresident CEO ServicesAlameda, California

x Consensus Panel

Charles A. Dackis, M.D. Assistant Professor Department of Psychiatry University of Pennsylvania School of MedicinePhiladelphia, Pennsylvania

Sylvia J. Dennison, M.D. Chief/Medical Director Division of Addiction Services Department of Psychiatry University of IllinoisChicago, Illinois

Patricia L. Mabry, Ph.D. Health Scientist Administrator/Behavioral

ScientistOffice of Behavioral and Social Sciences

ResearchOffice of the DirectorNational Institutes of HealthBethesda, Maryland

Hendree E. Jones, M.A., Ph.D. Assistant Professor CAP Research Director Department of Psychiatry and Behavioral

Sciences Johns Hopkins University CenterBaltimore, Maryland

Frances J. Joy, R.N., CD, CASAC Manager Alcohol and Drug Abuse Unit State of Missouri Department of Mental Health Fulton State Hospital Fulton, Missouri

xi

KAP Expert Panel and FederalGovernment Participants

Barry S. Brown, Ph.D.Adjunct ProfessorUniversity of North Carolina at WilmingtonCarolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC,CCDC III, CJS

Professor of Clinical PsychiatryCollege of MedicineUniversity of CincinnatiCincinnati, Ohio

Deion CashExecutive DirectorCommunity Treatment & Correction

Center, Inc.Canton, Ohio

Debra A. Claymore, M.Ed.Adm.Owner/Chief Executive OfficerWC Consulting, LLCLoveland, Colorado

Carlo C. DiClemente, Ph.D.ChairDepartment of PsychologyUniversity of Maryland Baltimore CountyBaltimore, Maryland

Catherine E. Dube, Ed.D.Independent ConsultantBrown UniversityProvidence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CACChief Services Research BranchNational Institute on Drug AbuseBethesda, Maryland

Michael Galer, D.B.A., M.B.A., M.F.A.Independent ConsultantWestminster, Massachusetts

Renata J. Henry, M.Ed.DirectorDivision of Substance Abuse and Mental HealthDelaware Health and Social ServicesNew Castle, Delaware

Joel Hochberg, M.A.PresidentAsher & PartnersLos Angeles, California

Jack Hollis, Ph.D.Associate DirectorCenter for Health ResearchKaiser PermanentePortland, Oregon

Mary Beth Johnson, M.S.W.DirectorAddiction Technology Transfer CenterNational OfficeUniversity of Missouri—Kansas CityKansas City, Missouri

Eduardo Lopez, B.S.Executive ProducerEVS CommunicationsWashington, DC

Holly A. Massett, Ph.D.Academy for Educational DevelopmentWashington, DC

Diane MillerChiefScientific Communications BranchNational Institute on Alcohol Abuse

and AlcoholismKensington, Maryland

Harry B. Montoya, M.A.President/Chief Executive OfficerHands Across CulturesEspanola, New Mexico

Richard K. Ries, M.D.Director/ProfessorOutpatient Mental Health ServicesDual Disorder ProgramsHarborview Medical CenterSeattle, Washington

Gloria M. Rodriguez, D.S.W.Research ScientistDivision of Addiction ServicesNew Jersey Department of Health

and Senior ServicesTrenton, New Jersey

Everett Rogers, Ph.D.Center for Communications ProgramsJohns Hopkins UniversityBaltimore, Maryland

Jean R. Slutsky, P.A., M.S.P.H.Senior Health Policy AnalystAgency for Healthcare Research & QualityRockville, Maryland

Nedra Klein Weinreich, M.S.PresidentWeinreich CommunicationsCanoga Park, California

Clarissa WittenbergDirectorOffice of Communications and Public LiaisonNational Institute of Mental HealthKensington, Maryland

Consulting MembersPaul Purnell, M.A.Social Solutions, L.L.C.Potomac, Maryland

Scott Ratzan, M.D., M.P.A., M.A.Academy for Educational DevelopmentWashington, DC

Thomas W. Valente, Ph.D.Director, Master of Public Health ProgramDepartment of Preventive MedicineSchool of MedicineUniversity of Southern CaliforniaAlhambra, California

Patricia A. Wright, Ed.D.Independent ConsultantBaltimore, Maryland

xii Expert Panel

xiii

Foreword

The Treatment Improvement Protocol (TIP) series supports SAMHSA’smission of building resilience and facilitating recovery for people with orat risk for mental or substance use disorders by providing best-practicesguidance to clinicians, program administrators, and payors to improve thequality and effectiveness of service delivery, and, thereby promote recov-ery. TIPs are the result of careful consideration of all relevant clinical andhealth services research findings, demonstration experience, and imple-mentation requirements. A panel of non-Federal clinical researchers, clin-icians, program administrators, and client advocates debates and discuss-es its particular areas of expertise until it reaches a consensus on bestpractices. This panel’s work is then reviewed and critiqued by fieldreviewers.

The talent, dedication, and hard work that TIPs panelists and reviewersbring to this highly participatory process have helped to bridge the gapbetween the promise of research and the needs of practicing clinicians andadministrators to serve, in the most scientifically sound and effective ways,people who abuse substances. We are grateful to all who have joined withus to contribute to advances in the substance abuse treatment field.

Charles G. Curie, M.A., A.C.S.W.AdministratorSubstance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAMDirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administration

xv

Executive Summary

This Treatment Improvement Protocol (TIP) is a revision of TIP 19,Detoxification From Alcohol and Other Drugs (Center for SubstanceAbuse Treatment 1995d). It provides clinicians with updated informa-tion and expands on the issues commonly encountered in the delivery ofdetoxification services. Like its predecessor, this TIP was created by apanel of experts (the consensus panel) with diverse experience in detoxi-fication services—physicians, psychologists, counselors, nurses, andsocial workers, all with particular expertise to share.

This diverse group agreed to the following principles, which served as abasis 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 abusetreatment

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 beappropriate to the patient’s needs.

4. All persons requiring treatment for substance use disorders shouldreceive treatment of the same quality and appropriate thoroughnessand should be put into contact with substance abuse treatmentproviders after detoxification.

5. Ultimately, insurance coverage for the full range of detoxification ser-vices is cost-effective.

6. Patients seeking detoxification services have diverse cultural and ethnicbackgrounds as well as unique health needs and life situations.Programs offering detoxification should be equipped to tailor treatmentto their client populations.

7. A successful detoxification process can be measured, in part, bywhether 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 detoxificationas one component in the continuum of healthcare services for sub-stance-related disorders. The TIP reinforces the urgent need for non-

traditional settings—emergency rooms, medi-cal and surgical wards in hospitals, acute careclinics, and others—to be prepared to partici-pate in the process of getting the patient whois in need of detoxification services into treat-ment as quickly as possible. Furthermore, itpromotes the latest strategies for retainingindividuals in detoxification while alsoencouraging the development of the therapeu-tic alliance to promote the patient’s entranceinto substance abuse treatment. The TIP alsoincludes suggestions on addressing psychoso-cial issues that may impact detoxificationtreatment, such as providing culturallyappropriate services to the patient popula-tion.

Matching patients to appropriate care repre-sents a challenge to detoxification programs.Given the wide variety of settings and theunique needs of the individual patient, estab-lishing criteria that take into account all thepossible needs of patients receiving detoxifica-tion and treatment services is an extraordi-narily complex task. Addiction medicine hassought to develop an efficient system of carethat matches patients’ clinical needs with theappropriate care setting in the least restric-tive and most cost-effective manner. Patientplacement criteria, such as those publishedby the American Society of AddictionMedicine (ASAM) in the Patient PlacementCriteria, Second Edition, Revised, representan effort to define how care settings may bematched to patient needs and special charac-teristics. These criteria—the five “AdultDetoxification” placement levels—define themost broadly accepted standard of care fordetoxification services. The five levels of careare

1. Level I-D: Ambulatory DetoxificationWithout Extended Onsite Monitoring

2. Level II-D: Ambulatory Detoxification WithExtended Onsite Monitoring

3. Level II.2-D: Clinically Managed ResidentialDetoxification

4. Level III.7-D: Medically MonitoredInpatient Detoxification

5. Level IV-D: Medically Managed IntensiveInpatient Detoxification

ASAM criteria are being adopted extensivelyon the basis of their face validity, thoughtheir outcome validity has yet to be clinicallyproven. The ASAM guidelines are to beregarded as a work in progress, as theirauthors readily admit. They are an importantset of guidelines that are of great help to clini-cians. For administrators, the standards pub-lished by such groups as the JointCommission on Accreditation of HealthcareOrganizations and the Commission onAccreditation of Rehabilitation Facilities pro-vide guidance for overall program operations.

Placement will depend in part on the sub-stance of abuse. The consensus panel suggeststhat for alcohol, sedative-hypnotic, and opi-oid withdrawal syndromes, hospitalization (orsome form of 24-hour medical care) is oftenthe preferred setting for detoxification, basedon principles of safety and humanitarian con-cerns. When hospitalization cannot be pro-vided, then a setting that provides a high levelof nursing and medical backup 24 hours aday, 7 days a week is desirable.

A further challenge for detoxification pro-grams is to provide effective linkages to sub-stance abuse treatment services. Patientsoften leave detoxification without followup tothe treatment needed to achieve long-termabstinence. Each year at least 300,000patients with substance use disorders or acuteintoxication obtain inpatient detoxification ingeneral hospitals, while additional numbersobtain detoxification in other settings. Only20 percent of people discharged from acutecare hospitals receive substance abuse treat-ment during that hospitalization. Only 15percent of people who are admitted to adetoxification program through an emergencyroom and then discharged go on to receivetreatment.

The consensus panel recognizes that medical-ly assisted withdrawal is not always necessaryor desirable. A nonmedical approach can behighly cost-effective and provide inexpensive

xvi Executive Summary

access to treatment for individuals seekingaid. Young individuals in good health, with nohistory of previous withdrawal reactions, maybe well served by management of withdrawalwithout medication. However, personnelsupervising in this setting should be trained toidentify life-threatening symptoms and solicithelp through the emergency medical system asneeded.

The consensus panel also agreed on severalguidelines for nonmedical detoxification pro-grams. Such programs should follow local gov-ernmental regulations regarding their licensingand inspection. In addition, it is desirable thatall such programs have an alcohol and drug-free environment as well as personnel who arefamiliar with the features of substance usewithdrawal syndromes, have training in basiclife support, and have access to an emergencymedical system that can transport patients toemergency departments and other sites for clin-ical care.

A major clinical question for detoxification isthe appropriateness of the use of medicationin the management of an individual in with-drawal. This can be a difficult matter becauseprotocols have not been firmly establishedthrough scientific studies or evidence-basedmethods. Furthermore, the course of with-drawal is unpredictable and currently avail-able techniques of screening and assessmentdo not predict who will experience life-threat-ening complications.

Although it is the philosophy of some treat-ment facilities to discontinue all medications,this course of action is not always in the bestinterest of the patient. Abrupt cessation ofpsychotherapeutic medications may causesevere withdrawal symptoms or the re-emer-gence of a psychiatric disorder. As a generalrule, therapeutic doses of medication shouldbe continued through any withdrawal if thepatient has been taking the medication as pre-scribed. Decisions about discontinuing themedication should be deferred until after theindividual has completed detoxification. If,however, the patient has been abusing the

medication or the psychiatric condition wasclearly caused by substance use, then therationale for discontinuing the medication isstrengthened. Finally, practitioners shouldconsider withholding medication that lowersthe seizure threshold (e.g., bupropion, con-ventional antipsychotics) during the acutealcohol withdrawal period or at least pre-scribing a loading dose or scheduled taper ofbenzodiazepine.

Further studies are needed to confirm theclinical experience that psychiatric symptoms(including anxiety, depression, and personali-ty disorders) respond to specific treatment ofthe addiction. For example, cognitive–behav-ioral techniques employed in the 12-Steptreatment approach have been effective in themanagement of anxiety and depression associ-ated with addiction. Although challenging,treatment of both addiction and co-occurringpsychiatric conditions has proven cost-effec-tive in some studies.

This TIP also provides medical informationon detoxification protocols for specific sub-stances as well as considerations for individu-als with co-occurring medical conditionsincluding mental disorders. While the TIP isnot intended to take the place of medicaltexts, it provides the practitioner with anoverview of common medical complicationsseen in individuals who use substances.Disorders of several systems are discussed insome detail: gastrointestinal (including thegastrointestinal tract, liver, and pancreas),cardiovascular system, hematologic (blood)abnormalities, pulmonary (lung) diseases, dis-eases of the central and peripheral nervoussystem, infectious diseases, and special mis-cellaneous disorders. The TIP presents a cur-sory overview of special conditions, modifica-tions in protocols, and the use of detoxifica-tion medications in patients with co-occurringmedical conditions or mental disorders.Overall treatment of specific conditions is notaddressed unless modification of such treat-ment is needed.

xviiExecutive Summary

The setting in which detoxification occurs isalso influenced by the existence of co-occur-ring medical disorders. It is highly desirablethat individuals undergoing detoxification beassessed by primary care practitioners (i.e.,physicians, physician assistants, nurse practi-tioners) with some experience in substanceabuse treatment. Such an assessment shoulddetermine whether the patient is currentlyintoxicated and the degree of intoxication; thetype and severity of the withdrawal syn-drome; information regarding past with-drawals; and the presence of co-occurringpsychiatric, medical, and surgical conditionsthat might require specialized care.Particular attention should be paid to thoseindividuals who have undergone multiplewithdrawals in the past and for whom eachwithdrawal appears worse than previousones. Subjects with a history of severe with-drawals, multiple withdrawals, deliriumtremens (a potentially fatal syndrome associ-ated with alcohol withdrawal), or seizures arenot good candidates for detoxification pro-grams in nonmedical settings.

The setting in which detoxification is carriedout should be appropriate for the medicaland psychological conditions present andshould be adequate to provide the degree ofmonitoring needed to ensure safety (e.g.,oximetry [a measurement of the amount ofoxygen present in the blood], greater fre-quency of taking vital signs, etc.). Acute, life-threatening conditions need to be addressedconcurrently with the withdrawal process andintensive care unit monitoring may be indicat-ed. Detoxification staff providing supportshould be familiar with the signs and symp-toms of common co-occurring medical disor-ders. Likewise, personnel at medical facilities(e.g., emergency rooms, physicians’ offices)should be aware of the signs of withdrawaland how it affects the treatment of the pre-senting medical conditions.

This TIP will also bring clinicians and admin-istrators up to date on administrative issuesrelated to detoxification, including how theservices themselves can be paid for. It is

unusual in a clinical treatment improvementprotocol to discuss issues related to how clini-cal services are reimbursed. In the field ofsubstance abuse and detoxification services,however, reimbursement issues have becomeso intertwined with the delivery of servicesthat the consensus panel deemed it necessaryto address the conflicts and misunderstand-ings that sometimes arise between the caresystems and the reimbursement systems.

Third-party payors sometimes prefer to man-age payment for detoxification separatelyfrom other phases of substance abuse treat-ment, thus treating detoxification as if itoccurred in isolation from that treatment.This “unbundling” of services can result inthe separation of services into scattered seg-ments. In other instances, reimbursement andutilization policies dictate that only detoxifi-cation can be authorized. This detoxificationoften does not cover the nonmedical counsel-ing that is an integral part of substance abusetreatment.

Finally, identifying and maintaining fundingsources is a major issue in detoxification.Substance abuse treatment in the UnitedStates is financed through a diverse mix ofpublic and private sources, with substantiallymore being spent by the public sector. Theexistence of diverse funding streams in sub-stance abuse treatment funding presents bothmanagement challenges and opportunities forprogram independence and stability.However, a program with only one majorfunding source is financially and clinicallyvulnerable to changes in its major source’sbudget and priorities. This situation shouldbe avoided. The TIP suggests ways to diversi-fy funding sources to create a steady streamof resources that can withstand the loss of oneparticular funding source.

This TIP also makes recommendations forfostering relationships with reimbursementorganizations, such as managed care organi-zations (MCOs). These positive working rela-tionships are vital to successfully link thepatient to the needed services. For example,

xviii Executive Summary

the MCO may use a wide variety of specificcriteria and protocols to determine whetheror not services may be authorized for sub-stance abuse, typically including the ASAMpatient placement criteria and other level ofcare or diagnosis-based criteria sets.Successfully addressing the needs of the staffat MCOs that are responsible for authorizingthe care provided to patients is a critical ele-ment in maintaining a relationship with anMCO and the program’s clinical and financialviability. To do so, staff should understandwhat MCO staff do, be well trained in con-ducting professional relationships over thetelephone, be familiar with the criteria andprotocols used by the MCOs with which theprogram has contracts, and have easy accessto the abundance of clinical and service infor-mation required by an MCO in order to helpthem complete a review and authorize ser-vices. Maintaining thorough, clear, and accu-rate records is essential to this process.Detoxification staff also should be familiar

with each MCO’s appeal or exceptions processfor those occasions when the outcome of afirst-level review is unsatisfactory.

Regardless of their role in providing detoxifi-cation services, all personnel should keep inmind that patients undergoing detoxificationare in the midst of a personal and medicalcrisis. For many patients, this crisis repre-sents a window of opportunity to acknowledgetheir substance abuse problem and becomewilling to seek treatment. Physicians, nurses,substance abuse counselors, and administra-tors are in a unique position, not only toensure a safe and humane withdrawal fromsubstances of dependency, but also to fosterthe path for the patient’s entry into substanceabuse treatment. This TIP suggests ways forclinicians and programs to prepare thepatient for treatment while addressing thecomplex psychosocial and medical variablesinvolved in detoxification.

xixExecutive Summary

1

1 Overview, EssentialConcepts, andDefinitions inDetoxificationIn This

Chapter…Purpose of the TIP

Audience

Scope

History of DetoxificationServices

Definitions

Guiding Principles inDetoxification andSubstance Abuse

Treatment

Challenges to ProvidingEffective Detoxification

Chapter 1 provides a brief historical overview of changes in the percep-tions and provision of detoxification services. It also introduces the coreconcepts of the detoxification field, discusses the primary goals of detoxifi-cation services, clarifies the distinction between detoxification and treat-ment, and highlights some of the broader issues involved with providingdetoxification within systems of care.

Purpose of the TIPThis TIP is a revision of TIP 19, Detoxification From Alcohol andOther Drugs (Center for Substance Abuse Treatment [CSAT] 1995d).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 forpatients with substance use disorders, and new issues in the managementof detoxification services within comprehensive systems of care

•Emerging issues regarding specific populations (e.g., women, culturalminorities, adolescents)

This TIP provides clinicians with up-to-dateinformation in these areas. It also expands onthe administrative, legal, and ethical issuescommonly encountered in the delivery ofdetoxification services and suggests perfor-mance measures for detoxification programs.Like its predecessor, this TIP was created bya panel of experts with diverse experience indetoxification services—physicians, psycholo-gists, counselors, nurses, and social workers,all with particular expertise to share.

AudienceThe primary audiences for this TIP includesubstance abuse treatment counselors; adminis-trators of detoxification programs; Single StateAgency directors; psychiatrists and otherphysicians working in the field; primary careproviders such as physicians, nurse practition-ers, physician assistants, nurses, psychologists,and other clinical staff members; staff of man-aged care and insurance carriers; policymak-ers; and others involved in planning, evaluat-ing, and delivering services for detoxifyingpatients from substances of abuse. Secondaryaudiences include public safety/police andcriminal justice personnel, educational institu-tions, those involved with assisting workers(e.g., Employee Assistance Programs), shel-ters/feeding programs, and managed care orga-nizations. The TIP also should prove useful toproviders of other services in comprehensivesystems of care (vocational counseling, occupa-tional therapy, and public housing/assisted liv-ing), administrators, and payors (public, pri-vate, and managed care).

ScopeAmong other issues covered in this TIP is theimportance of detoxification as one compo-nent in the continuum of healthcare servicesfor substance-related disorders. The TIPreinforces the urgent need for nontraditionalsettings—such as emergency rooms, medicaland surgical wards in hospitals, acute careclinics, and others that do not traditionally

provide detoxification services—to be pre-pared to participate in the process of gettingthe patient who is in need of detoxificationinto a program as quickly as possible topotentially avoid the myriad possible negativeconsequences associated with substance abuse(e.g., physiological and psychological distur-bances/disorders, criminal involvement,unemployment, etc.). Furthermore, it pro-motes the latest strategies for retaining indi-viduals in detoxification while also encourag-ing the development of the therapeuticalliance to promote the patient’s entrance intosubstance abuse treatment. This includes sug-gestions on addressing psychosocial issuesthat may affect detoxification services.

This TIP provides medical information ondetoxification protocols for specific sub-stances, as well as considerations for individ-uals with co-occurring medical conditionsincluding mental disorders. While the TIP isnot intended to take the place of medicaltexts, it provides the practitioner with anoverview of medical considerations.

This TIP will also bring clinicians and adminis-trators up-to-date on important aspects ofdetoxification, including how the services are tobe paid for. It is unusual in a clinical treatmentimprovement protocol to discuss issues relatedto how clinical services are reimbursed.However, in the field of substance abuse anddetoxification services, reimbursement issueshave become so intertwined with the delivery ofservices that the consensus panel deemed itnecessary to address the conflicts and misun-derstandings that sometimes arise between thecare systems and the reimbursement systems.

History ofDetoxification ServicesPrior to the 1970s, public intoxication wastreated as a criminal offense. People arrestedfor it were held in the “drunk tanks” of localjails where they underwent withdrawal withlittle or no medical intervention (Abbott et al.

2 Chapter 1

1995; Sadd and Young 1987). Shifts in themedical field, in perceptions of addiction, andin social policy changed the way that peoplewith dependency on drugs, including alcohol,were viewed and treated. Two notable eventswere particularly instrumental in changingattitudes. In 1958, the American MedicalAssociation (AMA) took the official positionthat alcoholism is a disease. This declarationsuggested that alcoholism was a medical prob-lem requiring medical intervention. In 1971,the National Conference of Commissioners onUniform State Laws adopted the UniformAlcoholism and Intoxication Treatment Act,which recommended that “alcoholics not besubjected to criminal prosecution because oftheir consumption of alcoholic beverages butrather should be afforded a continuum oftreatment in order that they may lead normallives as productive members of society”(Keller and Rosenberg 1973, p. 2). While thisrecommendation did not carry the weight oflaw, it made a major change in the legal impli-cations of addiction. With these changes camemore humane treatment of people with addic-tions.

Several methods of detoxification have evolvedthat reflect a more humanitarian view of peoplewith substance use disorders. In the “medicalmodel,” detoxification is characterized by theuse of physician and nursing staff and theadministration of medication to assist peoplethrough withdrawal safely (Sadd and Young1987). The “social model” rejects the use ofmedication and the need for routine medicalcare, relying instead on a supportive nonhospi-tal environment to ease the passage throughwithdrawal (Sadd and Young 1987). Today, it israre to find a “pure” detoxification model. Forexample, some social model programs use medi-cation to ease withdrawal but generally employnonmedical staff to monitor withdrawal andconduct triage (i.e., sorting patients accordingto the severity of their disorders). Likewise,medical programs generally have some compo-nents to address social/personal aspects ofaddiction.

Just as the treatment and the conceptualiza-tion of addiction have changed, so too havethe patterns of substance use and the accom-panying detoxification needs. The popularityof cocaine, heroin, and other substances hasled to the need for different kinds of detoxifi-cation services. Atthe same time, publichealth officials haveincreased invest-ments in detoxifica-tion services andsubstance abusetreatment, especiallyafter 1985, as ameans to inhibit thespread of HIV infec-tion and AIDSamong people whoinject drugs. Morerecently, people withsubstance use disor-ders are more likelyto abuse more thanone drug simultane-ously (i.e., polydrugabuse) (Office ofApplied Studies2005).

The AMA continuesto maintain its posi-tion that substancedependence is a dis-ease, and it encour-ages physicians and other clinicians, healthorganizations, and policymakers to base alltheir activities on this premise (AMA 2002).As treatment regimens have become moresophisticated and polydrug abuse more com-mon, detoxification has evolved into a com-passionate science.

Definitions Few clear definitions of detoxification andrelated concepts are in general use at thistime. Criminal justice, health care, substanceabuse, mental health, and many other sys-

3Overview, Essential Concepts, and Definitions in Detoxification

The AMA’s

position is that sub-

stance dependence

is a disease, and it

encourages physi-

cians and other

clinicians, health

organizations, and

policymakers to

base all their activi-

ties on this premise.

tems all define detoxification differently. ThisTIP offers a clear and uniform set of defini-tions for the various components of detoxifi-cation and substance abuse treatment thatmay prove useful to the field of detoxifica-tion.

DetoxificationDetoxification is a set of interventions aimedat managing acute intoxication and withdraw-al. It denotes a clearing of toxins from thebody of the patient who is acutely intoxicatedand/or dependent on substances of abuse.Detoxification seeks to minimize the physicalharm caused by the abuse of substances. Theacute medical management of life-threateningintoxication and related medical problemsgenerally is not included within the termdetoxification and is not covered in detail inthis TIP.

The Washington Circle Group (WCG), a bodyof experts organized to improve the qualityand effectiveness of substance abuse preven-tion and treatment, defines detoxification as“a medical intervention that manages an indi-vidual safely through the process of acutewithdrawal” (McCorry et al. 2000a, p. 9).The WCG makes an important distinction,however, in noting that “a detoxification pro-gram is not designed to resolve the long-standing psychological, social, and behavioralproblems associated with alcohol and drugabuse” (McCorry et al. 2000a, p. 9). The con-sensus panel supports this statement and has

taken special care to note that detoxificationis not substance abuse treatment and rehabil-itation. For further explanation, see the textbox below.

The consensus panel built on existing defini-tions of detoxification as a broad process withthree essential components that may takeplace concurrently or as a series of steps: • Evaluation entails testing for the presence

of substances of abuse in the bloodstream,measuring their concentration, and screen-ing for co-occurring mental and physicalconditions. Evaluation also includes a com-prehensive assessment of the patient’s medi-cal and psychological conditions and socialsituation to help determine the appropriatelevel of treatment following detoxification.Essentially, the evaluation serves as thebasis for the initial substance abuse treat-ment plan once the patient has been with-drawn successfully.

• Stabilization includes the medical and psy-chosocial processes of assisting the patientthrough acute intoxication and withdrawalto the attainment of a medically stable, fullysupported, substance-free state. This oftenis done with the assistance of medications,though in some approaches to detoxificationno medication is used. Stabilizationincludes familiarizing patients with what toexpect in the treatment milieu and theirrole in treatment and recovery. During thistime practitioners also seek the involvementof the patient’s family, employers, and

4 Chapter 1

Detoxification as Distinct From Substance Abuse Treatment

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Superviseddetoxification may prevent potentially life-threatening complications that might appear if the patientwere left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity ofa disorder) for those who want to become abstinent or who must observe mandatory abstinence as aresult 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 otherhand, involves a constellation of ongoing therapeutic services ultimately intended to promote recoveryfor substance abuse patients.

other significant people when appropriateand with release of confidentiality.

• Fostering the patient’s entry into treatmentinvolves preparing the patient for entry intosubstance abuse treatment by stressing theimportance of following through with thecomplete substance abuse treatment contin-uum of care. For patients who have demon-strated a pattern of completing detoxifica-tion services and then failing to engage insubstance abuse treatment, a written treat-ment contract may encourage entrance intoa continuum of substance abuse treatmentand care. This contract, which is not legallybinding, is voluntarily signed by patientswhen they are stable enough to do so at thebeginning of treatment. In it, the patientagrees to participate in a continuing careplan, with details and contacts establishedprior to the completion of detoxification.

All three components (evaluation, stabiliza-tion, and fostering a patient’s entry intotreatment) involve treating the patient withcompassion and understanding. Patientsundergoing detoxification need to know thatsomeone cares about them, respects them asindividuals, and has hope for their future.Actions taken during detoxification willdemonstrate to the patient that the provider’srecommendations can be trusted and fol-lowed.

Other Relevant Terms As defined by the Diagnostic and StatisticalManual of Mental Disorders, 4th edition,Text Revision (DSM-IV-TR) (AmericanPsychiatric Association [APA] 2000), a sub-stance-related disorder is a “disorder relatedto the taking of a drug of abuse (includingalcohol), to the side effects of a medication,and to toxin exposure” (APA 2000, p. 191).The term substance “can refer to a drug ofabuse, a medication, or a toxin” (APA 2000,p. 191). In this TIP, the term substance refersto alcohol as well as other drugs of abuse.

Substance-related disorders are divided intotwo groups: substance use disorders and sub-

stance-induced disorders. According to theDSM-IV-TR, substance use disorders includeboth “substance dependence” and “substanceabuse.” Substance dependence refers to “acluster of cognitive, behavioral, and physio-logical symptoms indicating that the individu-al continues use of the substance despite sig-nificant substance-related problems. There isa pattern of repeated self-administration thatcan result in tolerance, withdrawal, and com-pulsive drug-taking behavior” (APA 2000, p.192). Substance abuse refers to “a maladap-tive pattern of substance use manifested byrecurrent and significant adverse conse-quences related to the repeated use of sub-stances” (APA 2000, p. 198). It should benoted that for purposes of this TIP, the term“substance abuse” is sometimes used todenote both substance abuse and substancedependence as they are defined by the DSM-IV-TR.

This TIP also uses the DSM-IV-TR definitionsfor substance intoxication and substancewithdrawal. Substance intoxication is “thedevelopment of a reversible substance-specificsyndrome due to the recent ingestion of (orexposure to) a substance” whereas substancewithdrawal is “the development of a sub-stance-specific maladaptive behavioralchange, with physiological and cognitive con-comitants, that is due to the cessation of, orreduction in, heavy and prolonged substanceuse” (APA 2000, pp. 199, 201). Figure 1-1 (p. 6) defines these and other relevant terms.

Treatment/rehabilitation includes an ongoing,continual assessment of the patient’s physical,psychological, and social status, as well as ananalysis of environmental risk factors thatmay be contributing to substance use and theidentification of immediate relapse triggers aswell as prevention strategies for coping withthem. It also includes the delivery of primarymedical care and psychiatric care, if neces-sary, to help the patient abstain from sub-stance use and minimize the physical harmcaused by it. Ultimately, the goal of treat-ment/rehabilitation is to attain a higher levelof social functioning by reducing risk factors,

5Overview, Essential Concepts, and Definitions in Detoxification

enhancing protective factors, and thusdecreasing the possibility of relapse.

Maintenance includes the continuation ofcounseling and support specified in the treat-ment plan, refinement and strengthening ofstrategies to avoid relapse, and engagement inongoing relapse prevention, aftercare, and/ordomiciliary care (Lehman et al. 2000).

As a final note, in this TIP persons in need ofdetoxification services and subsequent sub-stance abuse treatment are referred to as

patients to emphasize that these persons arecoming into contact with physicians, nurses,physician assistants, and medical social work-ers in a medical setting in which the patientoften is physically ill from the effects of with-drawal from specific substances. In somesocial setting detoxification programs, theterms “client” or “consumer” may be used inplace of “patient.”

6 Chapter 1

Figure 1-1DSM-IV-TR Definitions of Terms

Term Definition

Substance A drug of abuse, a medication, or a toxin.

Substance-related disorders Disorders related to the taking of a drug of abuse (includingalcohol), to the side effects of a medication, and to toxin expo-sure.

Substance abuse (in this TIP, alsosometimes used to denote “substancedependence”)

A maladaptive (i.e., harmful to a person’s life) pattern of sub-stance use marked by recurrent and significant negative conse-quences related to the repeated use of substances.

Substance dependence (in this TIP,“substance abuse” is sometimes usedto include “dependence”)

A cluster of cognitive, behavioral, and physiological symptomsindicating that the individual is continuing use of the substancedespite significant substance-related problems. A person experi-encing substance dependence shows a pattern of repeated self-administration that usually results in tolerance, withdrawal, andcompulsive drug-taking behavior.

Substance intoxication The development of a reversible substance-specific syndrome asthe result of the recent ingestion of (or exposure to) a substance.

Substance withdrawal The development of a substance-specific maladaptive behavioralchange, usually with uncomfortable physiological and cognitiveconsequences, that is the result of a cessation of, or reduction in,heavy and prolonged substance use.

Source: APA 2000.

Guiding Principles inDetoxification andSubstance AbuseTreatmentThe consensus panel recognizes that the suc-cessful delivery of detoxification services isdependent on standards that are to some extent

empirically measurable and agreed upon by allparties. The consensus panel developed guide-lines (listed in Figure 1-2) that serve as thefoundation for the TIP.

7

Figure 1-2Guiding Principles Recognized by the Consensus Panel

1. Detoxification does not constitute substance abuse treatment but is one part of a continuum of care forsubstance-related 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 incompleteand inadequate by the consensus panel.

3. Detoxification can take place in a wide variety of settings and at a number of levels of intensity withinthese settings. Placement should be appropriate to the patient’s needs.

4. Persons seeking detoxification should have access to the components of the detoxification processdescribed 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 samequality 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 providedby the same program that provided them with detoxification services. There can be “no wrong doorto treatment” for substance use disorders (CSAT 2000a).

6. Ultimately, insurance coverage for the full range of detoxification services is cost-effective. If reim-bursement systems do not provide payment for the complete detoxification process, patients may bereleased 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 asunique health needs and life situations. Organizations that provide detoxification services need toensure that they have standard practices in place to address cultural diversity. It also is essential thatcare providers possess the special clinical skills necessary to provide culturally competent compre-hensive assessments. Detoxification program administrators have a duty to ensure that appropriatetraining is available to staff. (For more information on cultural competency training and specificcompetencies that clinicians need to be “culturally competent” see the forthcoming TIP ImprovingCultural Competence in Substance Abuse Treatment [CSAT 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 substanceabuse treatment/rehabilitation program after detoxification.

Overview, Essential Concepts, and Definitions in Detoxification

8

Challenges toProviding EffectiveDetoxificationIt is an important challenge for detoxificationservice providers to find the most effectiveway to foster a patient’s recovery. Effectivedetoxification includes not only the medicalstabilization of the patient and the safe andhumane withdrawal from drugs, includingalcohol, but also entry into treatment.Successfully linking detoxification with sub-stance abuse treatment reduces the “revolvingdoor” phenomenon of repeated withdrawals,saves money in the medium and long run, anddelivers the sound and humane level of carepatients need (Kertesz et al. 2003). Studiesshow that detoxification and its linkage to theappropriate levels of treatment lead toincreased recovery and decreased use ofdetoxification and treatment services in thefuture. In addition, recovery leads to reduc-tions in crime, general healthcare costs, andexpensive acute medical and surgical treat-ments consequent to untreated substanceabuse (Abbot et al. 1998; Aszalos et al. 1999).While detoxification is not treatment per se,its effectiveness can be measured, in part, bythe patient’s continued abstinence.

Another challenge to providing effectivedetoxification occurs when programs try todevelop linkages to treatment services. Astudy (Mark et al. 2002) conducted for theSubstance Abuse and Mental Health ServicesAdministration highlights the pitfalls of theservice delivery system. According to theauthors, each year at least 300,000 patientswith substance use disorders or acute intoxi-cation obtain inpatient detoxification in gen-eral hospitals while additional numbersobtain detoxification in other settings. Onlyabout one-fifth of people discharged fromacute care hospitals for detoxification receivesubstance abuse treatment during that hospi-talization. Moreover, only 15 percent of peo-ple who are admitted through an emergencyroom for detoxification and then dischargedreceive any substance abuse treatment.

Finally the average length of stay for peopleundergoing detoxification and treatment in1997 was only 7.7 days (Mark et al. 2002).Given that “research has shown that patientswho receive continuing care have better out-comes in terms of drug abstinence and read-mission rates than those who do not receivecontinuing care,” the report authors concludethat there is a pronounced need for betterlinkage between detoxification services andthe treatment services that are essential forfull recovery (Mark et al. 2002, p. 3).

Reimbursement systems can present anotherchallenge to providing effective detoxificationservices (Galanter et al. 2000). Third-partypayors sometimes prefer to manage paymentfor detoxification separately from other phas-es of addiction treatment, thus treating detox-ification as if it occurred in isolation fromaddiction treatment. This “unbundling” ofservices has promoted the separation of allservices into somewhat scattered segments(Kasser et al. 2000). In other instances, somereimbursement and utilization policies dictatethat only “detoxification” currently can beauthorized, and “detoxification” for that poli-cy or insurer does not cover the nonmedicalcounseling that is an integral part of sub-stance abuse treatment. Many treatment pro-grams have found substance abuse counselorsto be of special help with resistant patients,especially for patients with severe underlyingshame over the fact that their substance use isout of control. Yet some payors will not reim-burse for nonmedical services such as thoseprovided by these counselors, and thereforethe use of such staff by a detoxification ortreatment service may be impossible, in spiteof the fact that they are widely perceived asuseful for patients.

Payors are gradually beginning to understandthat detoxification is only one component of acomprehensive treatment strategy. Patientplacement criteria, such as those publishedby the American Society of AddictionMedicine (ASAM) in the Patient PlacementCriteria, Second Edition, Revised (ASAM2001), have come to the fore as clinicians and

Chapter 1

9

insurers try to reach agreements on the levelof treatment required by a given patient, aswell as the medically appropriate setting inwhich the treatment services are to be deliv-ered. Accordingly, the TIP offers suggestions

for resolving conflicts as well as clearly defin-ing terms used in patient placement and treat-ment settings as a step toward clearer under-standing among interested parties.

Overview, Essential Concepts, and Definitions in Detoxification

2 Settings, Levels ofCare, and PatientPlacement

In ThisChapter…

Role of VariousSettings in the

Delivery of Services

Other ConcernsRegarding Levels ofCare and Placement

Establishing criteria that take into account all the possible needs ofpatients receiving detoxification and treatment services is an extraordi-narily complex task. This chapter discusses the criteria for placingpatients in the appropriate treatment settings and offering the requiredintensity of services (i.e., level of care).

Role of Various Settings in theDelivery of ServicesAddiction medicine has sought to develop an efficient system of care thatmatches patients’ clinical needs with the appropriate care setting in theleast restrictive and most cost-effective manner. (For an explanation ofleast restrictive care, see the text box, p. 12.) Challenges to effectiveplacement matching for clients arise from a number of factors:

•Deficits in the full range of care settings and levels of care

•Limitations imposed by third-party payors (e.g., strict adherence tostandardized admission criteria)

•Clinicians’ lack of authority (and sometimes sufficient knowledge) todetermine the most appropriate care setting and level of care

•Insurance that does not have a substance use disorder benefit availableas 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

In spite of the impediments, some progress hasbeen made in developing comprehensivepatient placement criteria. Because the choiceof a treatment setting and intensity of treat-ment (level of care) are so important, theAmerican Society of Addiction Medicine(ASAM) created the Patient PlacementCriteria, Second Edition, Revised (PPC-2R) aconsensus-based clinical tool for matchingpatients to the appropriate setting and level ofcare. The ASAM PPC-2R represents an effortto define how care settings may be matched topatient needs and special characteristics. Thesecriteria currently define the most broadlyaccepted standard of care for the treatment ofsubstance use disorders. ASAM criteria areintended to provide flexible clinical guidelines;these criteria may not be appropriate for par-ticular patients or specific care settings.

The PPC-2R identifies six “assessment dimen-sions to be evaluated in making placementdecisions” (ASAM 2001, p. 4). They are asfollows:

1. Acute Intoxication and/or WithdrawalPotential

2. Biomedical Conditions and Complications

3. Emotional, Behavioral, or CognitiveConditions and Complications

4. Readiness to Change

5. Relapse, Continued Use, or ContinuedProblem Potential

6. Recovery/Living Environment

The ASAM PPC-2R describes both the settingsin which services may take place and the inten-sity of services (i.e., level of care) that patientsmay receive in particular settings. It is impor-tant to reiterate, however, that the ASAMPPC-2R criteria do not characterize all thedetails that may be essential to the success oftreatment (Gastfriend et al. 2000). Moreover,traditional assumptions that certain treatmentcan be delivered only in a particular settingmay not be applicable or valuable to patients.Clinical judgment and consideration of thepatient’s particular situation are required forappropriate detoxification and treatment.

In addition to the general placement criteriafor treatment for substance-related disorders,ASAM also has developed a second set of place-

12 Chapter 2

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 toparticipate in society.

2. Patients should be able to disagree with clinician recommendations for care. While this includes theright to refuse any care at all, it also includes the right to obtain care in a setting of their choice (aslong as considerations of dangerousness and mental competency are satisfied). It implies a patient’sright 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 donein collaboration with their healthcare providers.

4. Careful consideration of State laws and agency policies is required for patients who are unable toact in their own self-interests. Because the legal complexities of this issue will vary from State toState the TIP cannot provide definitive guidance here, but providers need to consider whether ornot the person is “gravely” incapacitated, suicidal, or homicidal; likely to commit grave bodilyinjury; or, in some States, likely to cause injury to property. In such cases, State law and/or caselaw may hold providers responsible if they do not commit the patient to care, but in other casesprograms may be open to lawsuits for forcibly holding a patient.

ment criteria, which are more important forthe purposes of this TIP—the five “AdultDetoxification” placement levels of care withinDimension 1 (ASAM 2001). These “AdultDetoxification” levels of care are

1. Level I-D: Ambulatory DetoxificationWithout Extended Onsite Monitoring (e.g.,physician’s office, home health care agen-cy). This level of care is an organized out-patient service monitored at predeter-mined intervals.

2. Level II-D: Ambulatory DetoxificationWith Extended Onsite Monitoring (e.g.,day hospital service). This level of care ismonitored by appropriately credentialedand licensed nurses.

3. Level III.2-D: Clinically ManagedResidential Detoxification (e.g., nonmedi-cal or social detoxification setting). Thislevel emphasizes peer and social supportand is intended for patients whose intoxi-cation and/or withdrawal is sufficient towarrant 24-hour support.

4. Level III.7-D: Medically MonitoredInpatient Detoxification (e.g., freestandingdetoxification center). Unlike LevelIII.2.D, this level provides 24-hour medi-cally supervised detoxification services.

5. Level IV-D: Medically Managed IntensiveInpatient Detoxification (e.g., psychiatrichospital inpatient center). This level pro-vides 24-hour care in an acute care inpa-tient settings.

As described by the ASAM PPC-2R, thedomain of detoxification refers not only to thereduction of the physiological and psychologi-cal features of withdrawal syndromes, butalso to the process of interrupting the momen-tum of compulsive use in persons diagnosedwith substance dependence (ASAM 2001).Because of the force of this momentum andthe inherent difficulties in overcoming it evenwhen there is no clear withdrawal syndrome,this phase of treatment frequently requires agreater intensity of services initially to estab-lish participation in treatment activities andpatient role induction. That is, this phase

should increase the patient’s readiness forand commitment to substance abuse treat-ment and foster a solid therapeutic alliancebetween the patient and care provider.

It is important to note that ASAM PPC-2Rcriteria are only guidelines, and that thereare no uniform protocols for determiningwhich patients are placed in which level ofcare. For further information on patientplacement, readers are advised to consultTIP 13, The Role and Current Status ofPatient Placement Criteria in the Treatmentof Substance Use Disorders (Center forSubstance Abuse Treatment [CSAT] 1995h).

Because this TIP is geared to audiences thatmay or may not be familiar with the ASAMPPC-2R levels of care, this section discussesthe services and staffing specific to the caresettings that are familiar to a broad audience.

Physician’s OfficeIt has been estimated that nearly one half ofthe patients who visit a primary care providerhave some type of problem related to sub-stance use (Miller and Gold 1998). Indeed,because the physician may be the first pointof contact for these people, initiation of treat-ment often begins in the family physician’soffice (Prater et al. 1999). Physicians shoulduse prudence in determining which patientsmay undergo detoxification safely on an out-patient basis. As a general rule, outpatienttreatment is just as effective as inpatienttreatment for patients with mild to moderatewithdrawal symptoms (Hayashida 1998).

For physicians treating patients with sub-stance use disorders, preparing the patient toenter treatment and developing a therapeuticalliance between patient and clinician shouldbegin as soon as possible. This includes pro-viding the patient and his family with infor-mation on the detoxification process and sub-sequent substance abuse treatment, in addi-tion to providing medical care or referrals ifnecessary. Staffing should include certifiedinterpreters for the deaf and other language

13Settings, Levels of Care, and Patient Placement

interpreters if the program is serving patientsin need of those services. Physicians shouldbe able to accommodate frequent followupvisits during the management of acute with-drawal. Medications should be dispensed inlimited amounts.

Level of care Ambulatory detoxification withoutextended onsite monitoringThis level of detoxification (ASAM’s Level I-D) is an organized outpatient service, whichmay be delivered in an office setting, health-care or addiction treatment facility, or in apatient’s home by trained clinicians who pro-vide medically supervised evaluation, detoxi-fication, and referral services according to apredetermined schedule. Such services areprovided in regularly scheduled sessions.These services should be delivered under adefined set of policies and procedures or med-ical protocols (ASAM 2001). Ambulatorydetoxification is considered appropriate onlywhen a positive and helpful social supportnetwork is available to the patient. In thislevel of care, outpatient detoxification ser-vices should be designed to treat the patient’slevel of clinical severity, to achieve safe andcomfortable withdrawal from mood-alteringdrugs, and to effectively facilitate thepatient’s transition into treatment and recov-ery.

Ambulatory detoxification withextended onsite monitoringEssential to this level of care—and distin-guishing it from Ambulatory DetoxificationWithout Extended Onsite Monitoring—is theavailability of appropriately credentialed andlicensed nurses (such as registered nurses[RNs] or licensed practical nurses [LPNs])who monitor patients over a period of severalhours each day of service (ASAM 2001).Otherwise, this level of detoxification(ASAM’s Level II-D) also is an organized out-patient service. Like Level I-D, in this level ofcare detoxification services are provided inregularly scheduled sessions and delivered

under a defined set of policies and proceduresor medical protocols. Outpatient services aredesigned to treat the patient’s level of clinicalseverity and to achieve safe and comfortablewithdrawal from mood-altering drugs, includ-ing alcohol, and to effectively facilitate thepatient’s entry into ongoing treatment andrecovery (ASAM 2001).

StaffingAlthough they need not be present in thetreatment setting at all times, physicians andnurses are essential to office-based detoxifica-tion. In States where physician assistants,nurse practitioners, or advance practice clini-cal nurse specialists are licensed as physicianextenders, they may perform the duties ordi-narily carried out by a physician (ASAM2001).

Because detoxification is conducted on anoutpatient basis in these settings, it is impor-tant for medical and nursing personnel to bereadily available to evaluate and confirm thatdetoxification in the less supervised setting issafe. All clinicians who assess and treatpatients should be able to obtain and inter-pret information regarding the needs of thesepersons, and all should be knowledgeableabout the biomedical and psychosocial dimen-sions of alcohol and illicit drug dependence.Requisite skills and knowledge base includethe following:

•Understanding how to interpret the signs andsymptoms of alcohol and other drug intoxica-tion and withdrawal

•Understanding the appropriate treatmentand monitoring of these conditions

•The ability to facilitate the individual’s entryinto treatment

It is essential that medical consultation isreadily available in emergencies. It is desir-able that medical staff link patients to treat-ment services, although this may be an unrea-sonable expectation that cannot be met in abusy office setting. Linkage to treatment ser-vices may be provided by the physician or by

14 Chapter 2

designated counselors, psychologists, socialworkers, and acupuncturists who are avail-able either onsite or through the healthcaresystem (ASAM 2001).

Freestanding Urgent CareCenter or EmergencyDepartmentThere are several distinctions between urgentcare facilities and emergency rooms (ERs).Urgent care often is used by patients whocannot or do not want to wait until they seetheir doctor in his or her office, whereasemergency rooms are utilized more often bypatients who perceive themselves to be in acrisis situation. Unlike emergency depart-ments, which are required to operate 24hours a day, freestanding urgent care centersusually have specific hours of operation.Staffing for urgent care centers generally ismore limited than for an ER. Standardstaffing includes only a physician, an RN, atechnician, and a secretary. Despite these dis-tinctions, in actual practice there is consider-able overlap between the two—the ER will seemedical problems that could be handled byvisits to offices, and urgent care facilities willhandle some cases of emergency medicine.

A freestanding urgent care center or emergen-cy department reasonably can be expected toprovide assessment and acute biomedical(including psychiatric) care. However, thesesettings often are unable to provide satisfacto-ry psychosocial stabilization or completebiomedical stabilization (which includes boththe initiation and taper of medications used inthe treatment of substance withdrawal syn-dromes). Appropriate triage and successfullinkage to ongoing detoxification services isessential. The ongoing detoxification servicesmay be provided in an inpatient, residential,or outpatient setting. Patients with more thanmoderate biomedical or psychosocial compli-cations are more likely to require treatmentin an inpatient setting. Care in these settingscan be quite costly and should be accessed

only when there are serious concerns about apatient’s safety.

A timely and accurate assessment in an emer-gency department is of the highest impor-tance. This will permit the rapid transfer ofthe patient to a setting where complete carecan be provided.Ideally, personnel inthe emergencydepartment will haveat least a smallamount of experi-ence and expertise inidentifying criticallyill substance-usingpatients who may beabout to experienceor are already expe-riencing withdrawalsymptoms. Threeessential rules applyto emergency depart-ments and their han-dling of intoxicatedpatients and patientswho have begun toexperience with-drawal:

•Emergency depart-ments and theirclinicians shouldnever simplyadminister medications to intoxicated personsand then send them home.

•No intoxicated patient should ever be allowedto leave a hospital setting. All such personsshould be referred to the appropriate detoxi-fication setting if possible, although there arelegal restrictions that forbid holding personsagainst their will under certain conditions(Armenian et al. 1999).

•A clear distinction must be made betweenacute intoxication on the one hand and with-drawal on the other. Acute intoxication, itmust be remembered, creates special issuesand challenges that need to be addressed.The risk of suicidality in patients who pre-sent in a state of intoxication needs to be

15Settings, Levels of Care, and Patient Placement

Although they

need not be

present in the

treatment setting

at all times,

physicians and

nurses are

essential to

office-based

detoxification.

carefully assessed. Because of their volatilityand often risky behavior, patients who areintoxicated, as well as those patients whohave begun to experience withdrawal, meritspecial attention. For more on treating intox-icated patients, see chapter 3.

Level of care Care is provided topatients whose with-drawal signs andsymptoms are suffi-ciently severe torequire primarymedical and nursingcare services. Theservices are deliv-ered under adefined set of physi-cian-managed pro-cedures or medicalprotocols. Both set-tings provide medi-cally directed assess-ment and acute carethat includes the ini-tiation of detoxifica-tion for substanceuse withdrawal.Neither setting islikely to offer satis-factory biomedicalstabilization or 24-

hour observation. Generally speaking, triage toinpatient care can easily be facilitated fromeither setting.

Freestanding urgent care centers and emer-gency departments are outpatient settingsthat are uniquely designed to address theneeds of patients in biomedical crisis. Forpatients with substance use disorders, care inthese settings is not complete until successfullinkage is made to treatment that is focusedspecifically on the substance use disorder. Toaccomplish this, a comprehensive assessment,taking into account psychosocial as well as

biomedical issues, is recommended whereverpossible.

Appreciation of the value of multidimensionalpatient assessment is central to the clinician’sability to decide which triage (linkage) optionsare least restrictive and most cost-effectivefor a given patient.

StaffingBoth emergency departments and freestandingurgent care units are staffed by physicians.The same rules regarding who may providecare apply here as they did in the discussion ofstaffing of office-based detoxification (ASAM2001). An RN or other licensed and creden-tialed nurse is available for primary nursingcare and observation. Psychologists, socialworkers, addiction counselors, and acupunc-turists usually are not available in these set-tings. The physician or attending nurse usuallyfacilitates linkage to substance abuse treat-ment.

Freestanding Substance AbuseTreatment or Mental HealthFacilityFreestanding substance abuse treatment facili-ties may or may not be equipped to provideadequate assessment and treatment of co-occurring psychiatric conditions and biopsy-chosocial problems, as the range of servicesvaries considerably from one facility to anoth-er. Inpatient mental health facilities, on theother hand, are able generally to provide treat-ment for substance use disorders and co-occur-ring psychiatric conditions. Nonetheless, likesubstance abuse treatment facilities, the rangeof available services varies from one mentalhealth facility to another.

General guidelines for considering patientplacement in either of these settings are pro-vided below; however, it should be empha-sized that a clear understanding of the specif-ic services that a given setting provides is

16 Chapter 2

Inpatient

detoxification

provides 24-hour

supervision,

observation, and

support for

patients who are

intoxicated or

experiencing

withdrawal.

indispensable to identifying the least restric-tive and most cost-effective treatment optionthat may be available. Concern for safety isof primary importance, and the final decisionregarding placement always rests with thetreating physician.

Level of careMedically Monitored InpatientDetoxificationInpatient detoxification provides 24-hoursupervision, observation, and support forpatients who are intoxicated or experiencingwithdrawal. Since this level of care is relativelymore restrictive and more costly than a resi-dential treatment option, the treatment missionin this setting should be clearly focused andlimited in scope. Primary emphasis should beplaced on ensuring that the patient is medicallystable (including the initiation and tapering ofmedications used for the treatment of sub-stance use withdrawal); assessing for adequatebiopsychosocial stability, quickly intervening toestablish this adequately; and facilitating effec-tive linkage to and engagement in other appro-priate inpatient and outpatient services.

Inpatient settings provide medically managedintensive inpatient detoxification. At this levelof care, physicians are available 24 hours perday by telephone. A physician should beavailable to assess the patient within 24 hoursof admission (or sooner, if medically neces-sary) and should be available to provideonsite monitoring of care and further evalua-tion on a daily basis. An RN or other quali-fied nursing specialist should be present toadminister an initial assessment. A nurse willbe responsible for overseeing the monitoringof the patient’s progress and medicationadministration on an hourly basis, if needed.Appropriately licensed and credentialed staffshould be available to administer medicationsin accordance with physician orders.

Clinically Managed ResidentialDetoxificationResidential settings vary greatly in the level ofcare that they provide. Those with intensivemedical supervision involving physicians, nursepractitioners, physician assistants, and nursescan handle all but the most demanding compli-cations of intoxication and withdrawal. On theother hand, some residential settings have min-imally intensive medical oversight. Residentialdetoxification in settings with limited medicaloversight often is referred to as “social detoxifi-cation.” (Though the “social detoxification”model is not limited to residential facilities.)Facilities with lower levels of care should haveclear procedures in place for implementing andpursuing appropriate medical referral andlinkage, especially in the case of emergencies.For example, a patient who is in danger ofseizures or delirium tremens needs to bereferred to the appropriate medical facility foracute care of presenting symptoms, possiblymedicated, and then returned to a social detox-ification setting for continuing monitoring andobservation. The establishment of this kind ofcollaborative relationship between institutionsprovides a good example of a cost-effective wayto provide adequate care to patients.

Residential detoxification programs provide24-hour supervision, observation, and sup-port for patients who are intoxicated or expe-riencing withdrawal. They are characterizedby an emphasis on peer and social support(ASAM 2001). Standards published by suchgroups as the Joint Commission onAccreditation of Healthcare Organizations(JCAHO) and the Commission onAccreditation of Rehabilitation Facilities(CARF) provide further information on quali-ty measures for residential detoxification.Additional information is available on theJCAHO Web site (www.jcaho.org) and theCARF Web site (www.carf.org).

17Settings, Levels of Care, and Patient Placement

StaffingInpatient detoxification programs employlicensed, certified, or registered clinicians whoprovide a planned regimen of 24-hour, profes-sionally directed evaluation, care, and treat-ment services for patients and their families.An interdisciplinary team of appropriatelytrained clinicians (such as physicians, RNs andLPNs, counselors, social workers, and psychol-ogists) should be available to assess and treatthe patient and to obtain and interpret infor-mation regarding the patient’s needs. The num-ber and disciplines of team members should beappropriate to the range and severity of thepatient’s problems (ASAM 2001).

Residential detoxification programs arestaffed by appropriately credentialed person-nel who are trained and competent to imple-ment physician-approved protocols forpatient observation and supervision. Thesepersons also are responsible for determiningthe appropriate level of care and facilitatingthe patient’s transition to ongoing care.Medical evaluation and consultation shouldbe available 24 hours a day, in accordancewith treatment/transfer practice guidelines.All clinicians who assess and treat patientsshould be able to obtain and interpret infor-mation regarding the needs of these personsand should be knowledgeable about thebiomedical and psychosocial dimensions ofalcohol and other drug dependence. Suchknowledge includes awareness of the signsand symptoms of alcohol and other drugintoxication and withdrawal, as well as theappropriate treatment and monitoring ofthose conditions and how to facilitate theindividual’s entry into ongoing care. Staffshould ensure that patients are taking medi-cations according to their physician’s ordersand legal requirements (ASAM 2001).

Some residential detoxification programs arestaffed to supervise self-administered medica-tions for the management of withdrawal. Allsuch programs should rely on establishedclinical protocols to identify patients who

have biomedical needs that exceed the capaci-ty of the facility and to identify which pro-grams will likely have a need for transferringsuch patients to more appropriate treatmentsettings.

Intensive Outpatient andPartial HospitalizationProgramsAn intensive outpatient program (IOP) or par-tial hospitalization program (PHP) is appropri-ate for patients with mild to moderate with-drawal symptoms. Thorough psychosocialassessment and intervention should be avail-able in addition to biomedical assessment andstabilization. Many of these programs haveclose clinical and/or administrative ties to hos-pital centers. When needed, triage to a higherlevel of care should be easy to accomplish.Outpatient treatment should be delivered inconjunction with all components of detoxifica-tion.

Level of care This level of detoxification is an organized out-patient service that requires patients to be pre-sent onsite for several hours a day. It is thussimilar to a physician’s office in that ambulato-ry detoxification with extended onsite monitor-ing is provided. Unlike the physician’s office, inthe IOP and PHP it is standard practice tohave a multidisciplinary team available to pro-vide or facilitate linkage to a range of medicallysupervised evaluation, detoxification, andreferral services.

Detoxification services also are provided inregularly scheduled sessions and deliveredunder a defined set of policies and proceduresor medical protocols. These outpatient ser-vices are designed to treat the patient’s levelof clinical severity, to achieve safe and com-fortable withdrawal from mood-altering drugs(including alcohol), and to effectively facili-

18 Chapter 2

tate the patient’s engagement in ongoing treat-ment and recovery (ASAM 2001).

A partial hospitalization program may occupythe same setting (i.e., physical space) as anacute care inpatient treatment program.Although occupying the same space, the levelsof care provided by these two programs aredistinct yet complementary. Acute care inpa-tient programs provide detoxification servicesto patients in danger of severe withdrawaland who therefore need the highest level ofmedically managed intensive care, includingaccess to life support equipment and 24-hourmedical support. In contrast, partial hospital-ization programs provide services to patientswith mild to moderate symptoms of withdraw-al that are not likely to be severe or life-threatening and that do not require 24-hourmedical support. The transition from anacute care inpatient program to either a par-tial hospitalization or intensive outpatientprogram sometimes is referred to as a “step-down.” Typically, whether these programsshare space and staff with an acute care inpa-tient program or are physically distinct froma hospital structure, they have close clinicaland/or administrative ties to hospital centers.Collaborative working relationships are indis-pensable in pursuing the goal of providingpatients with the most appropriate level ofcare in the most cost-effective setting.

StaffingIOPs and PHPs should be staffed by physi-cians who are available daily as active mem-bers of an interdisciplinary team of appropri-ately trained professionals and who medicallymanage the care of the patient. An RN orother licensed and credentialed nurse shouldbe available for primary nursing care andobservation during the treatment day.Addiction counselors or licensed or registeredaddiction clinicians should be available toadminister planned interventions according tothe assessed needs of the patient. The multi-disciplinary professionals (such as physicians,nurses, counselors, social workers, psycholo-gists, and acupuncturists) should be available

as an interdisciplinary team to assess andcare for the patient with a substance-relateddisorder, as well as patients with both a sub-stance use disorder and a co-occurringbiomedical, emotional, or behavioral condi-tion. Successful linkage to treatment for thesubstance use disorder (in addition tobiomedical stabilization) is central to the mis-sion of an intensiveoutpatient or partialhospitalization pro-gram (ASAM 2001).For more informa-tion, see the TIPSubstance Abuse:Clinical Issues inIntensive OutpatientTreatment [CSAT indevelopment d].

Acute CareInpatientSettings There are severaltypes of acute careinpatient settings.They include

•Acute care generalhospitals

•Acute care addic-tion treatment unitsin acute care gener-al hospitals

•Acute care psychi-atric hospitals

•Other appropriatelylicensed chemicaldependency special-ty hospitals

These settings share the ready availability ofacute care medical and nursing staff, life sup-port equipment, and ready access to the fullresources of an acute care general hospital orits psychiatric unit. This level of care providesmedically managed intensive inpatient detoxifi-cation (ASAM 2001).

19Settings, Levels of Care, and Patient Placement

Successful linkage

to treatment for

the substance use

disorder (in

addition to

biomedical

stabilization) is

central to the

mission of an

intensive out-

patient or partial

hospitalization

program.

Level of careAcute inpatient care is an organized servicethat provides medically monitored inpatientdetoxification that is delivered by medical andnursing professionals. Medically supervisedevaluation and withdrawal management in apermanent facility with inpatient beds is pro-vided for patients whose withdrawal signs andsymptoms are sufficiently severe to require 24-hour inpatient care. Services should be deliv-ered under a set of policies and procedures orclinical protocols designated and approved by aqualified physician (ASAM 2001). Additionalinformation on acute inpatient programs isavailable on the JCAHO Web site(www.jcaho.org) and the CARF Web site(www.carf.org).

StaffingAcute care inpatient detoxification programstypically are staffed by physicians who areavailable 24 hours a day as active members ofan interdisciplinary team of appropriatelytrained professionals and who medically man-age the care of the patient. In some States,these duties may be performed by an RN orphysician assistant. An RN or LPN, as usual, isavailable for primary nursing care and obser-vation 24 hours a day. Facility-approved addic-tion counselors or licensed or registered addic-tion clinicians should be available 8 hours aday to administer planned interventionsaccording to the assessed needs of the patient.An interdisciplinary team of appropriatelytrained clinicians (such as physicians, nurses,counselors, social workers, and psychologists)should be available to assess and treat thepatient with a substance-related disorder, or apatient with co-occurring substance use,biomedical, psychological, or behavioral condi-tions (ASAM 2001).

Other ConcernsRegarding Levels ofCare and PlacementIn part because of the need to keep costs to aminimum and in part as the result of researchin the field, outpatient detoxification is becom-ing the standard for treatment of symptoms ofwithdrawal from substance dependence inmany locales. Most alcohol treatment programshave found that more than 90 percent ofpatients with withdrawal symptoms can betreated as outpatients (Abbott et al. 1995).Careful screening of these patients is essentialto reserve for inpatient treatment those clientswith possibly complicated withdrawal; forexample, patients with subacute medical orpsychiatric conditions (that in and of them-selves would not require hospitalization) andthose in danger of seizures or delirium tremensshould receive inpatient care. Inpatient addic-tion treatment programs will vary in the levelof acute medical or psychiatric care that can beprovided. Figure 2-1 presents an overview ofissues to consider in deciding between inpatientand outpatient detoxification.

ASAM criteria are being adopted extensivelyon the basis of their “face validity,” thoughtheir outcome validity has yet to be clinicallyproven. Early studies of more versus lessrestrictive and intensive treatment settings onrandomized samples generally have failed toshow group differences, and studies continueto show this pattern (Gastfriend et al. 2000).Whether patients undergoing detoxificationwill have better results as outpatients ratherthan as inpatients remains to be established(Hayashida 1998).

Another consideration is that ASAM place-ment guidelines are not always the best guideto placing a patient in the proper setting atthe proper level. For example, what is theclinician to do with the patient who qualifiesfor outpatient treatment according to theASAM guidelines but is homeless in sub-zerotemperatures? No provision is made for suchcases. The ASAM guidelines are to be regard-

20 Chapter 2

ed as a “work in progress,” as their authorsreadily admit (ASAM 2001, p. 19).Nevertheless, they are an important set ofguidelines that are of great help to clinicians.For administrators, the standards publishedby such groups as JCAHO and CARF offerguidance for overall program operations.Additional information is available on theJCAHO Web site (www.jcaho.org) and theCARF Web site (www.carf.org).

It has become clear that detoxificationinvolves much more than simply medicallywithdrawing a patient from alcohol or other

drugs. Detoxification, whether done on aninpatient, residential, or outpatient basis, fre-quently is the initial therapeutic encounterbetween patient and clinician. Irrespective ofthe substance involved, a detoxificationepisode should provide an opportunity forbiomedical (including psychiatric) assess-ment, referral for appropriate services, andlinkage to treatment services. Chapter 3 pro-vides an overview of the psychosocial andbiomedical issues relevant to detoxification,strategies to engage the patient, and anoverview of providing adequate linkage to fol-low up treatment and services.

21Settings, Levels of Care, and Patient Placement

Figure 2-1Issues 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-al seizures

Contraindication to outpatient detoxification:recurrence likely; specific situation may suggestthat 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 ifunable to follow recommendations

Co-occurring medical conditions Unstable medical conditions such as diabetes,hypertension, or pregnancy: all relatively strongcontraindications to outpatient detoxification

Supportive person to assist Not essential but advisable for outpatient detoxifi-cation

Source: Consensus Panelist Sylvia Dennison, M.D.

3 An Overview ofPsychosocial andBiomedical IssuesDuring Detoxification In This

Chapter…Evaluating and

AddressingPsychosocial andBiomedical Issues

Strategies forEngaging and

Retaining Patientsin Detoxification

Referrals andLinkages

Regardless of setting or level of care, the goals of detoxification are toprovide safe and humane withdrawal from substances and to fosterthe patient’s entry into long-term treatment and recovery.Detoxification presents a unique opportunity to intervene during aperiod of crisis and move a client to make changes in the direction ofhealth and recovery. Hence, a primary goal of the detoxification staffshould be to build the therapeutic alliance and motivate the patient toenter treatment. This process should begin even as the patient is beingmedically stabilized (Onken et al. 1997).

Psychological dependence, co-occurring psychiatric and medical con-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 duringdetoxification significantly increases the likelihood that the patientwill 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 areturn 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 mayaffect detoxification and ensuing treatment. It highlights evaluation pro-cedures for patients undergoing detoxification, discusses strategies forengaging and retaining patients in detoxification and preparing them fortreatment, and presents an overview for providing linkages to other services.

23

Evaluating andAddressingPsychosocial andBiomedical IssuesPatients entering detoxification are undergoingprofound personal and medical crisis.Withdrawal itself can cause or exacerbate cur-rent emotional, psychological, or mental prob-lems. The detoxification staff needs to beequipped to identify and address potentialproblems.

Considerations for Conductingthe Initial EvaluationAn initial evaluation will help detoxificationstaff foresee any variables that might compli-cate a safe and effective withdrawal. Figure 3-1lists the biomedical and psychosocial domainsthat can affect the stabilization of the patient.

The following sections include some generalguidelines and important considerations tofollow when providing detoxification services.

General Guidelines forAddressing ImmediateMedical ConcernsBecause substance abuse affects all systems ofthe body and is associated with lack of self-care, it is not unusual for detoxification to becomplicated by medical problems. Health pro-fessionals should screen for medical problemsthat may put the client at risk for a medical cri-sis or expose other clients or staff to contagiousdiseases. This section outlines important con-siderations for both nonmedical and medicalstaff. Chapter 5 provides a clinical overview ofco-occurring medical conditions and is gearedprimarily toward medical personnel.

Co-occurring medical conditionsThe initial consultation should include an eval-uation of the expected signs, symptoms, andseverity of the withdrawal. Detoxification is notan exact science, but any significant deviationfrom the expected course of withdrawal shouldbe observed closely. Figure 3-2 (p. 26) provides

24 Chapter 3

Overarching Principles for Care During Detoxification Services

•Detoxification services do not offer a “cure” for substance use disorders. They often are a first steptoward 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 privacyand confidentiality is encouraged.

•Patients are treated with due consideration for individual background, culture, preferences, sexual orien-tation, disability status, vulnerabilities, and strengths.

a list of signs and symptoms of conditions thatrequire immediate medical attention. All staffmembers who work with patients should beaware of these and seek medical consultationfor the patients as necessary.

Seizures are of special concern. Practitionersshould interview the patient and family aboutseizure disorders and seizure history. In addi-tion, nonmedical staff should be aware of signsof impending seizures such as tremors,

25An Overview of Psychosocial and Biomedical Issues During Detoxification

Figure 3-1 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 ofpsychosis or destructive thoughts?

•General physical assessment with neurological exam—This will ascertain the patient’s general healthand identify any medical or psychiatric disorders of immediate concern.

•Temperature, pulse, blood pressure—These are important indicators and should be monitoredthroughout 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 ofprevious 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 haveadequate employment and income?

•Dependent children—Is the patient able to care for children, provide adequate child care, andensure the safety of children?

•Legal status—Is the patient a legal resident? Are there pending legal matters? Is treatment courtordered?

•Physical, sensory, or cognitive disabilities—Does the client have disabilities that require considera-tion?

increased blood pressure, overactive reflexes,and high temperature and pulse. It is essentialthat nonmedical staff be trained in protocols toprevent injury in the event of a seizure.Competence in carrying out these protocolsshould be evaluated by a physician or nurseclinician. For more information on seizures,see chapter 4.

All staff working with patients should befamiliar with medical disorders that are asso-ciated with various addictive substances orroutes of administration. Alcoholism has mul-tiple organ effects involving the liver, pan-creas, central nervous system, cardiovascularsystem, and endocrine system. Cocaine pro-duces many of its medical complicationsthrough vasoconstriction (i.e., narrowing ofthe blood vessels), including myocardialinfarction (heart attack), stroke, renal dis-ease, spontaneous abortion, and even bowelinfarction (death of tissue). Cocaine also cancause seizures and cardiac arrhythmia (irreg-ular heartbeat). A heroin overdose can leadto a fatal respiratory depression. Intravenousdrug use is particularly likely to increase therisk of infectious complications, including

HIV, viral hepatitis, abscesses, and sepsis (thespreading of infection from its original site inthe body). Intrapulmonary (within the lungs)administration can cause lung disorders(Dackis and Gold 1991). Nonmedical detoxifi-cation staff also should be aware of the medi-cations used in detoxification, medications forcommon medical and psychiatric disorders,and signs of common medication reactionsand interactions.

Infectious diseaseStandard precautions should be used with allpatients to protect the staff and patients againstthe transmission of infectious diseases, includ-ing HIV and hepatitis A, B, and C. All openwounds should be cultured and treated to pre-vent the spread of infections. Providers shoulduse HIV/blood and respiratory infection pre-cautions until HIV and respiratory infectiousstatus are known. Patients with respiratoryinfections should be carefully evaluated. Thepanel suggests that tuberculin testing be per-formed or recent test results obtained on allpatients to screen for active tuberculosis. Achest x-ray is recommended if indicated by the

26 Chapter 3

Figure 3-2Symptoms 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 thepotential for seizures

patient’s history and physical assessments.Nonmedical detoxification staff should betrained to watch for the signs of common infec-tious diseases passed through casual contact,including infestation with scabies and lice.

General Guidelines forAddressing Immediate MentalHealth Needs The following section provides general guide-lines for treating patients who have immediatemental health needs. For more detailed infor-mation on the treatment of patients with co-occurring psychiatric conditions see TIP 42,Substance Abuse Treatment for Persons WithCo-Occurring Disorders (Center forSubstance Abuse Treatment [CSAT] 2005c).

SuicideThose who are users of multiple illicit sub-stance are more likely to experience psychiatricdisorders, and the risk is highest among thosewho use both opiates and benzodiazepinesand/or alcohol (Marsden et al. 2000).Depression is more common among those whoabuse a combination of these substances, andwomen are at higher risk than men. Amongthose patients who are positive for depression,the risk of suicide is high. Marsden and col-leagues’ 2000 study of 1,075 clients enteringtreatment showed that 29 percent reported sui-cidal ideation in the past 3 months.

During acute intoxication and withdrawal, itis important to provide an environment thatminimizes the opportunities for suicideattempts. As a precaution, locations notclearly visible to staff should be free of itemsthat might be used for suicide attempts.Frequent safety checks should be implement-ed; the frequency of these checks should beincreased when signs of depression, shame,guilt, helplessness, worthlessness, and hope-lessness are present. When feasible, patientsat risk for suicide should be placed in areasthat are easily monitored by staff. Mostimportant, when interacting with patients at

risk for suicide, staff should avoid harsh con-frontation and judgment and instead focus onthe treatable nature of substance use disor-ders and the rehabilitation options available.These interactions offer an opportunity tostart a dialog with the patient regarding theimpact of substance use on mental illness andvice versa.

Anger and aggressionAlcohol, cocaine, amphetamine, and hallu-cinogen intoxication may be associated withincreased risk of violence. Symptoms associ-ated with this increased risk for violenceinclude hallucinations, paranoia, anxiety, anddepression. As a precaution, all patients whoare intoxicated should be considered poten-tially violent (Miller et al. 1994). Programsshould have in place well-developed plans topromote staff and patient safety, includingprotocols for response by local law enforce-ment agencies or security contractors. Staffworking in detoxification programs should betrained in techniques to de-escalate anger andaggression. In many cases, aggressive behav-iors can be defused through verbal and envi-ronmental means (Reilly and Shopshire2002). For the protection of the staff and thepatient, physical restraint should be used as alast resort and programs should be aware oflocal laws and regulations pertaining to physi-cal restraint. Figure 3-3 (p. 28) lists some use-ful ways of managing patients who are angryand aggressive. Readers may refer to thestandards published by such groups as theJoint Commission on Accreditation ofHealthcare Organizations (JCAHO) and theCommission on Accreditation ofRehabilitation Facilities (CARF) for furtherguidance. Additional information is availableon the JCAHO Web site (www.jcaho.org) andthe CARF Web site (www.carf.org). TheSubstance Abuse and Mental Health ServicesAdministration (SAMHSA) also has publishedguidelines on the use of seclusion andrestraint, which call for the reduction andpossible elimination of their use (SAMHSA2002).

27An Overview of Psychosocial and Biomedical Issues During Detoxification

Co-occurring mental disordersWith the patient’s consent, a review of thepatient’s mental health history with the patientand family is useful in identifying co-occurringpsychiatric conditions. Mental health profes-sionals caring for the client should be consult-ed. If a pharmacy profile on the patient isavailable, it should be copied for review (withinthe confines of State and Federal confidentiali-ty laws).

Diagnosis of co-occurring substance-relateddisorders and mental conditions is difficultduring acute intoxication and withdrawalbecause it often is impossible to be precise untilthe clinical picture allows for the full assess-ment of both the effects of substance use and ofthe symptoms of mental disorders. As the indi-vidual moves from severe to moderate with-drawal symptoms, attention to differentialdiagnosis of substance use disorders and otherpsychiatric disorders becomes a priority (Firstet al. 2002). The American PsychiatricAssociation (APA) and the American Society ofAddiction Medicine (ASAM) guidelines recom-mend a period of 2 to 4 weeks of abstinencebefore attempting to diagnose a psychiatric dis-order (APA 2000; ASAM 2001).

General Guidelines forAddressing NutritionalConcernsMalnutrition is a major concern for patientsentering detoxification because the nutrientdeficiencies associated with substance abusecan interfere with or even prolong the detoxifi-cation process (Nazrul Islam et al. 2001).Longstanding irregular eating habits and poordietary intake only exacerbate the problem(Pelican et al. 1994). The detoxification processitself is stressful to the body and may result inincreased nutrient requirements. Proper nutri-tion during recovery improves to a significantextent the adverse effects of the substanceabuse (Nazrul Islam et al. 2001).

Nutritional evaluationAn evaluation of nutritional status should be acore component of detoxification. It should benoted, however, that for patients who abusealcohol, the administration of fluids to addressdehydration should be the first step, withnutritional evaluation occurring after thepatient is adequately hydrated.

28 Chapter 3

Figure 3-3 Strategies for De-escalating 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.

The nutritional evaluation should consist oflaboratory and anthropometric indices, adetailed nutritional history, and nutritioncounseling (Simko et al. 1995). The interven-tion begins in the initial acute phase of with-drawal and continues through detoxificationand subsequent substance abuse treatment. Ifthe patient consents, family members or signifi-cant others may be included in the nutritionalevaluation and counseling.

Weight is an important consideration in deter-mining the nutritional status of the person witha substance use disorder. Substance abuse mayresult in a reduction in food intake and disrup-tion in the patient’s metabolism that may inturn have caused an eating disorder, weightloss, and malnutrition. Conversely, weight gainmay be related to inactivity and an excessiveintake of highly refined carbohydrates (Zadoret al. 1996). Patients should be asked whetherthere have been any recent changes in theirweight. While a patient may appear to be ade-quately nourished, a skinfold caliper (aninstrument that measures the thickness of afold of skin with its underlying layer of fat) candetermine body density (the relationship of thebody’s mass to its volume), though the bodymass index may be a better indicator of nutri-tional status (Simko et al. 1995).

Other questions to ask during the initial evalu-ation concern appetite, eating patterns, foodpreferences, snacking habits, food allergies,food intolerance, special diets, and foods to beavoided because of cultural or religious beliefs.A food frequency questionnaire, food diary, or24-hour food recall may be of use.

Many drug addictions are associated withabnormal glucose (sugar) metabolism. Thisabnormality means that the body is unable tomaintain a stable concentration of glucose inthe blood. Abnormally high or low blood sugarlevels easily can be confused with the signs andsymptoms of alcohol intoxication or withdraw-al; consequently, a check of blood glucose levelis particularly important in patients with a his-tory of blood sugar abnormalities. Hypogly-cemia (low levels of blood sugar) in the person

with a substance use disorder may lead to dras-tic mood changes. When blood glucose levelsdrop below a certain threshold, these patientsusually feel depressed, anxious, or moody andmay experience cravings for their drug ofchoice.

Nutritional deficits associated with specific substancesAs noted, the abuse of drugs can interfere withnutrient utilization and storage. Detoxificationpersonnel should be familiar with the nutrition-al deficits associated with specific substances.Opioids are known to decrease calcium absorp-tion and to increase cholesterol and bodypotassium levels. Magnesium deficiency often isseen in chronic alcohol dependence. Othernutrient deficiencies seen in alcohol abuseinclude protein, fat, zinc, calcium, iron, vita-mins A and E, and the water-soluble vitaminspyridoxine, thiamine, folate, and vitamin B12(Nazrul Islam et al. 2001). Alcohol also con-tains calories (7 kcal/gm) that when consumedin excessive amounts may displace nutrient-dense foods. Cocaine is an appetite suppressantand may interfere with the absorption of calci-um and vitamin D. Laboratory tests for pro-tein, vitamins, and iron and the other elec-trolytes are recommended to determine theextent of liver function as well as supplementa-tion (Fontaine et al. 2001). Caution should beexercised when using supplements because oftheir potential interactions with other drugsand treatments.

Addressing nutritionaldeficits Detoxification should include efforts to addressnutritional deficits and to begin the patient ona course of improved eating habits. It is crucialto switch the paradigm from ingesting sub-stances harmful to the body to taking in foodsthat heal the body (Nebelkopf 1981, 1987,1988). The regularity of meal times, taste, andpresentation are important considerations.

29An Overview of Psychosocial and Biomedical Issues During Detoxification

Attractively arranged, pleasant-tasting foodmay inspire the patient to consume vital nutri-ents and adequate calories. It is important thatduring the detoxification process, the patientavoid substituting one addiction for another.Consuming excessive amounts of caffeine orsugar can compromise the process and lead torelapse. Patients should be offered only decaf-feinated beverages and healthful snacks insteadof refined carbohydrates such as sugar-basedsweets like candy, cookies, or donuts. Freshfruits, vegetables, and other whole foods cancontribute to the individual’s health and well-ness.

Gastrointestinal disturbances (i.e., nausea,vomiting, and diarrhea) may accompany thefirst phase of detoxification. Such distur-bances can worsen dehydration and may dis-turb blood chemistry balance, which in turncan lead to mental status changes, neurologi-cal or heart problems, and other potentiallydangerous medical conditions. Patients withgastrointestinal disturbances may only beable to tolerate clear liquids. When solidfoods are tolerated, balanced meals consistingof low-fat foods, with an increased intake ofprotein (meat, dairy products, legumes), com-plex carbohydrates (whole grain bread andcereals), and dietary fiber are recommended(Duyff 1996). Patients undergoing detoxifica-tion may also experience constipation.Increasing the fiber content of the diet willhelp to alleviate this discomfort.

Considerations for patientswith special dietary requirementsPatients with special dietary requirements needadditional nutrition therapy. A person withdiabetes, for example, should follow the dietaryguidelines of the American DiabetesAssociation, which emphasizes individualizedmeal planning (American Diabetes Association2004). A patient who is a vegetarian may haveadditional nutritional deficiencies, especially ifshe or he is a vegan (i.e., a person who avoidseating all foods derived from animals, including

milk products and eggs). If a vegan entersdetoxification with marginal or low nutrientstores, his or her diet should be augmentedwith legumes, meat analogs, textured vegetableprotein, nuts, and seeds. Many other medicalconditions (e.g., ulcers, heart disease, foodallergies, etc.) may require special diets. Atintake, any special dietary considerationsshould be noted.

Considerations forIntoxication and Withdrawalin AdolescentsGenerally, detoxification is the same for adoles-cents as it is for adult clients. However, thereare a few important and unique considerationsfor adolescent patients. For one, adolescentsare more likely than adults to drink largequantities of alcohol in a short period of time,making it is especially important that detoxifi-cation providers be alert to escalating bloodalcohol levels in these patients. Moreover, ado-lescents are more likely than adults to usedrugs they cannot identify, to combine multiplesubstances with alcohol, to ingest unidentifiedsubstances, and to be unwilling to disclose druguse (Westermeyer 1997). As a result, the con-sensus panel recommends routinely screeningadolescent patients for illicit drug intoxication.It also is important for staff to be trained inhow to assess for the use of PCP, which canpresent with psychosis-like symptoms. Staffshould ask the adolescent directly whether hehas used PCP within the 12-hour period beforeentering the clinic or treatment center.

Adolescents should be placed in a secure,clean environment with observation and sup-portive care. If alcohol, heroin, or otherdrugs associated with vomiting are suspected,protecting the individual’s airway and posi-tioning the patient on his or her side to avoidaspiration (inhaling) of stomach contents arecritical. In severe cases of ingestion of respi-ratory depressants, respiratory support maybe needed. If the individual is severely com-bative or belligerent, physical restraint maybe needed as a last resort when allowed and

30 Chapter 3

appropriate. In milder cases, observation in aquiet, secure room with compassionate reas-surance may be sufficient. Additionally, ado-lescents served in adult settings should beseparated from the adult population andobserved closely to ensure that they are notvictimized (i.e., verbally, physically, or sexu-ally) by adult clients. Finally, adolescents indetoxification settings should always bescreened carefully for suicide potential andco-occurring psychiatric problems.

It sometimes is challenging to establish rap-port with adolescents, as their experiencewith adults may be marked by adverse conse-quences. Asking open-ended questions andusing street terminology for drugs and otherexpressions commonly used by teenagers canbe helpful both in establishing rapport and inobtaining an accurate substance use history.For more information on working with ado-lescents, see TIP 31, Screening and AssessingAdolescents for Substance Use Disorders(CSAT 1999d), and TIP 32, Treatment ofAdolescents With Substance Use Disorders(CSAT 1999f).

Considerations for PatientsWho Are Parents WithDependent ChildrenFor parents—especially women—enteringdetoxification programs, the safety of childrenoften is a concern and one of the biggest barri-ers to retention. Even if women do not havecustody of their children they often are theones who continue to care for them. Some chil-dren may show extreme need for their motherwhile separated from her, and their demandscould trigger unauthorized leave from detoxifi-cation. Thus, ensuring that children have asafe place to stay while their mothers are indetoxification is of vital importance. Workingwith women and men to identify supportivefamily or friends may identify temporary child-care resources. A consult or referral to thetreatment facility’s social services while thepatient is being detoxified is indicated when thecare of children is uncertain.

Considerations for Victims ofDomestic Violence While both men and women are victims ofdomestic abuse, women’s substance use is asso-ciated with increased risk of intimate partnerviolence (Cunradi et al. 2002). Staff shouldknow the signs of domestic violence and be pre-pared to follow proce-dures to ensure thesafety of the patient.

If a patient disclosesa history of domesticviolence, trainedstaff can help thevictim create a long-term safety plan ormake a proper refer-ral. If a safety planis made or phonenumbers for domes-tic violence help areprovided, relatedinformation shouldbe labeled carefullyso as not to discloseits purpose (e.g., list-ed as women’s healthresources) since theabuser may gothrough all personalbelongings. All print-ed information about domestic violence alsoshould be disguised and none should be keptby the patient when she leaves the safe facili-ty. If the victim needs to press charges orobtain a restraining order, this should bedone from a safe setting (e.g., inpatient detox-ification). If at all possible, the victim shouldbe escorted to a safety shelter. It may beimportant that the abused person, whethermale or female, not be allowed to talk to theabuser while in detoxification. Parents whoare victims of domestic violence may needhelp with parenting skills and securing coun-seling and childcare. Therefore, it is impor-tant for detoxification providers to be famil-iar with local childcare resources. For more

31An Overview of Psychosocial and Biomedical Issues During Detoxification

Ensuring that

children have a

safe place to stay

while their

mothers are in

detoxificaton is of

vital importance.

information see TIP 25, Substance AbuseTreatment and Domestic Violence (CSAT1997b).

Considerations for CulturallyDiverse PatientsIn providing psychosocial supports for cultur-ally diverse patients, cultural sensitivity is oftremendous importance. Clients’ expectations

of detoxification, their feelings about thehealthcare system generally, and their socialand community support structures varyaccording to their cultural backgrounds. Inworking with any specific population, the prac-titioner should avoid defining the patient interms of his culture, since over- or underem-phasizing the patient’s race or ethnicity can bedetrimental (Clark et al. 1998). Figure 3-4 pro-

32 Chapter 3

Figure 3-4Questions 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 aboutyour 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 yourfamily 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)? Orwhat 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 thecommunity?

•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 substanceuse)?

•What concerns or fears do you have about this treatment?

Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.

vides clinicians with some helpful questions toguide their discussions.

Considerations for ChronicRelapsersA patient who recently relapsed after a periodof extended abstinence may feel especiallyhopeless and vulnerable (an abstinence viola-tion effect). In this situation, clinicians canacknowledge progress that had been madeprior to relapse and reassure the patient thatthe internal gains from past recovery workhave not all been lost (despite the feeling at themoment that they have), perhaps reframing theseverity of emotional pain as an indicator ofhow important recovery is to the patient.

Strategies forEngaging andRetaining Patients inDetoxification It is essential to keep patients who enter detoxi-fication from “falling through the cracks”(Kertesz et al. 2003). Successful providersacknowledge and show respect for the patient’spain, needs, and joys, and validate thepatient’s fears, ambivalence, expectation ofrecovery, and positive life changes. It is essen-tial that all clinicians who have contact withpatients in withdrawal continually offer hopeand the expectation of recovery. An atmo-sphere that conveys comfort, relaxation, clean-liness, availability of medical attention, andsecurity is beneficial to patients experiencingthe discomforts of the withdrawal process.Throughout the detoxification experience,detoxification staff should be unified in theirmessage that detoxification is only the begin-ning of the substance abuse treatment processand that rehabilitation and maintenance activi-ties are critical to sustained recovery.

Educate the Patient on theWithdrawal ProcessDuring intoxication and withdrawal, it is usefulto provide information on the typical with-drawal process based on the particular drug ofabuse. Usually withdrawal includes symptomsthat are the opposite of the effects of the partic-ular drug. This rebound effect can cause anxi-ety and concern for patients. Providing infor-mation about the common withdrawal symp-toms of the specific drugs of abuse may reducediscomfort and the likelihood that the individu-al will leave detoxification services prematurely(for a list of withdrawal symptoms, see chapter4). Settings that routinely encounter individu-als in withdrawal should have written materialsavailable on drug effects and withdrawal fromspecific drugs, and have staff who are wellversed in the signs and symptoms of withdraw-al. An additional consideration is providingsuch information to non–English-speakingpatients and their families.

Interventions that assist the client in identify-ing and managing urges to use also may behelpful in retaining the client in detoxificationand ensuring initiation of rehabilitation.These interventions may include cognitive–behavioral approaches that help the individu-al identify thoughts or urges to use, the devel-opment of an individualized plan to resistthese urges, and use of medications such asnaltrexone to reduce craving (Anton 1999;Miller and Gold 1994).

Use Support SystemsThe use of client advocates to intervene withclients wishing to leave early often can be aneffective strategy for promoting retention indetoxification. Visitors should be instructedabout the importance of supporting the individ-ual in both detoxification and substance abusetreatment. If available, and if the patient is sta-ble, he or she can attend onsite 12-Step orother support group meetings while receivingdetoxification services. These activities rein-force the need for substance abuse treatment

33An Overview of Psychosocial and Biomedical Issues During Detoxification

and maintenance activities and may provide acritical recovery-oriented support system oncedetoxification services are completed.

Maintain a Drug-FreeEnvironmentMaintaining a safe and drug-free environmentis essential to retaining clients in detoxifica-tion. Providers should be alert to drug-seek-ing behaviors, including bringing alcohol orother drugs into the facility. Visiting areasshould be easy for the staff to monitor closely,and staff may want to search visiting areasand other public areas periodically to reducethe opportunities for acquiring substances. Itis important to note, however, that personnelshould be respectful in their efforts to main-tain a drug-free environment. It is importantto explain to patients (prior to treatment) andvisitors why substances are not allowed in thefacility.

Consider AlternativeApproachesAlternative approaches such as acupunctureare safe, inexpensive, and increasingly popularin both detoxification and substance abusetreatment. Although the effectiveness of alter-native treatments in detoxification and treat-ment has not been validated in well-controlledclinical trials, if an alternative therapy bringspatients into detoxification and keeps themthere, it may have utility beyond whatever spe-cific therapeutic value it may have(Trachtenberg 2000). Other treatments thatreside outside the Western biomedical system,typically grouped together under the heading ofComplementary or Alternative Medicine, alsomay be useful for retaining patients. Indeed,given the great cultural diversity in the UnitedStates, other culturally appropriate practicesshould be considered.

Enhancing MotivationMotivational enhancements are particularlywell-suited to accomplishing the detoxification

services goal of promoting initiation in reha-bilitation and maintenance activities. Use ofthese techniques in the detoxification settingincreases the likelihood that patients will seektreatment by helping them understand theadverse consequences of continued substanceuse. It also establishes a supportive and non-judgmental relationship between the sub-stance abuse counselor and the patient—thistherapeutic alliance is an important factor inthe patient’s choice to seek treatment services(Miller and Rollnick 2002). TIP 35,Enhancing Motivation for Change inSubstance Abuse Treatment (CSAT 1999c),covers specific interventions and techniquesto increase motivation to change substance-related behaviors. TIP 35 also includes somebasic principles common to motivationalinterventions (CSAT 1999c, p. xvii):

•Focus on the patient’s strengths.

•Show respect for a patient’s decisions andautonomy; respect should be maintained at all times, even when the patient is intoxicated.

•Avoid confrontation.

•Individualize treatment.

•Do not use labels that depersonalize thepatient, such as “addict” or “alcoholic.”

•Empathize with the patient, making anattempt to understand the patient’s perspec-tive and accept his or her feelings.

•Accept treatment goals that involve smallsteps toward ultimate goals.

•Assist the patient in developing an awarenessof discrepancies between her or his goals orvalues and current behavior.

•Listen reflectively to the patient’s immediateconcerns and ask open-ended questions.

In addition, the detoxification team can lever-age the relationship the patient has with sig-nificant others. Using interventions such asCommunity Reinforcement and FamilyTraining (CRAFT) (Miller et al. 1999), thedetoxification team can help significant othersin the patient’s life capitalize on momentswhen the patient is ready for change and

34 Chapter 3

assist the patient in preparing for change in anonthreatening, nonconfrontational manner.The consensus panel does not recommendthat clinicians use direct confrontation inhelping a person with a substance use disor-der begin the process of detoxification andsubsequent substance abuse treatment.Techniques that involve purposefully con-fronting patients about their substance usebehavior, such as the Johnson Intervention,where significant others are taught to con-front the individuals using substances(Liepman 1993), have been shown to be high-ly effective when significant others implementthem. However, subsequent studies of clini-cians, groups, and programs that rely on con-frontational techniques have yielded pooroutcomes (Miller et al. 1995). Moreover, thevast majority of significant others do not wishto use these techniques, and for that reasonthese techniques are not recommended (Milleret al. 1999).

Care should be taken to ensure that any sig-nificant other who is involved in motivatingthe patient for therapy is appropriate for thistask. Only significant others who have beenappropriately introduced to the interventionby a clinician should participate. The pres-ence of a trained facilitator is recommended,either for coaching or for facilitating theintervention. It also is important to have therecommended treatment option readily avail-able so if the patient agrees, admission can beswift and seamless. Those individuals selectedto intervene should support the patient’sabstinence from substances of abuse.Furthermore, if the patient places consider-able value on her or his relationships withthese significant others, success is more likely(Longabaugh et al. 1993).

Tailoring MotivationalIntervention to Stage ofChangePerhaps the most well-known and empiricallyvalidated model of “readiness to change” thathas been applied to substance abuse is the

transtheoretical model, also known as thestages of change model (DiClemente andProchaska 1998). The interventions toincrease patient motivation for substanceabuse treatment described in TIP 35,Enhancing Motivation for Change inSubstance AbuseTreatment (CSAT1999c) are based onthis model.

According to themodel, a client isconsidered to be atone of five stages ofreadiness to changehis substance-abus-ing behavior, eachstage being progres-sively closer to sus-tained recovery.Those stages are pre-contemplation, con-templation, prepara-tion, action, andmaintenance. Themodel assumes thatindividuals maymove back and forthbetween differentstages over time. Acorollary to thisassumption is that anindividual’s level of motivation is definitelynot a permanent characteristic. Rather, moti-vation to change can be influenced by others,including detoxification treatment staff.

In general, the basic concept is to try to movepatients to the next stage of change. The clini-cian needs to identify any potential obstaclesthat might hinder the patient’s progressthrough the stages of change. The transtheo-retical model is illustrated in Figure 3-5 (p. 36) and the details of each stage aredescribed in the text below.

35An Overview of Psychosocial and Biomedical Issues During Detoxification

Clinicians,

groups, and

programs that

rely on

confrontational

techniques have

yielded poor

outcomes.

In the precontemplation stage, the individualis not considering any change in substance-using behavior in the foreseeable future.Typically, a patient in this stage either isunaware that his substance use is a problemor is unwilling or too discouraged to make achange. Often, a person in the precontempla-tion stage has not experienced serious conse-quences from substance use. During the pre-contemplation stage, the clinician should beattentive for and seize upon any ambivalence

expressed by the patient toward substance-related behaviors. Such ambivalence may bemore likely to emerge during initial detoxifi-cation, before the patient has returned to arelative zone of comfort and greater denial.For patients who are determined to remain inthe precontemplation stage, the main goal isto get the patient to begin to consider chang-ing. To accomplish this, the clinician mightexpress concern, listen to the patient’s per-

36 Chapter 3

Figure 3-5 The Transtheoretical Model (Stages of Change)

Source: DiClemente and Prochaska 1998.

spective, and keep the door open for furthercommunication regarding treatment options.

In the contemplation stage, the individual hassome awareness that substance use presents aproblem. In this stage, the patient mayexpress a desire or willingness to change, buthas no definite plans to do so in the nearfuture, which generally is considered to bethe next 2 to 6 months. Whether it is explicit-ly stated or not, it is thought that most indi-viduals in this stage are ambivalent aboutchanging. That is, side-by-side with anydesire to change is a desire to continue thecurrent behavior. For patients in the contem-plation stage, clinicians are advised to use“decisional balancing strategies” to help thepatient move to the action stage (Carey et al.1999). In this approach, the clinician helpsthe patient to consider the positive and nega-tive aspects of her substance abuse and hasthe patient weigh them against each otherwith the expectation that the scale of balancetips in favor of adopting new behavior.Psychoeducation on the interaction of sub-stance abuse with other problems, includinghealth, legal, employment, parenting, andmental illness, can be part of this procedure.Helping the patient understand that ambiva-lent feelings about changing substance usebehaviors are normal and expected can beparticularly useful at this stage.

In the preparation stage, the patient is awarethat his substance use presents a significantproblem and desires change. Moreover, thepatient has made a conscious decision to com-mit himself to a behavior change. This stage isdefined as one in which the individual pre-pares for the upcoming change in specificways, such as deciding whether a formaltreatment program is needed and, if so, whichone. This stage is characterized by goal set-ting and making commitments to stop using,such as informing coworkers, friends, andfamily of treatment plans. For patients in thepreparation stage, clinicians should elicit thepatient’s goals and strategies for change andbe on the alert for signs that the patient isready to move into the action stage. It is criti-

cal that the clinician respond quickly to anyrequests for treatment to capitalize on thismotivation before it wanes. One of the mostcritically important roles the clinician canplay in this stage is to assist the patient indeveloping a plan of action or a behavioralcontract, taking into account the individualneeds of the patient. As part of this processthe clinician should help the patient enlistsocial support. Exploring the patient’s expec-tations regarding treatment and her role in itis important. Finally, because of the common-ly experienced difficulty in accessing treat-ment, the clinician should discuss with thepatient ways of maintaining motivation forchange during a possible wait for entry into atreatment program, should the patient beplaced, for example, on a waiting list.

In the action stage, the patient is takingactive steps to change substance use behav-iors. This includes making modifications tohis habits and environment, such as notspending time in places or with people associ-ated with drug taking behavior. Thesechanges may even continue to be made 3 to 6months after substance abuse has ceased.

In the maintenance stage, the patient is work-ing to maintain the changes initiated in theaction phase.

Fostering a TherapeuticAllianceThe therapeutic alliance refers to the quality ofthe relationship between a patient and his careproviders and is the “nonspecific factor” thatpredicts successful therapy outcomes across avariety of different therapies (Horvath andLuborsky 1993). A therapeutic alliance shouldbe developed in the context of an ability toform an alliance to a group of helping individu-als—such as a healthy support network ortherapeutic community. A clinically appropri-ate relationship between the clinician andpatient that is supportive, empathic, and non-judgmental is the hallmark of a strong thera-peutic alliance.

37An Overview of Psychosocial and Biomedical Issues During Detoxification

Readiness to change predicts a positive thera-peutic alliance (Connors et al. 2000). Strongalliances, in turn, have been associated withpositive outcomes in patients who are depen-dent on alcohol (Connors et al. 1997), as wellas patients involved in methadone mainte-nance, on such measures as illicit drug use,employment status, and psychological func-tioning. In addition, the practitioner’s exper-tise and competence instill confidence in thetreatment and strengthen the therapeuticalliance. Emphasis also should be given to thealliance with a social support network, whichcan be a powerful predictor of whether thepatient stays in treatment (Luborsky 2000).

Given the importance of the therapeuticalliance and the fact that detoxification oftenis the entry point for patients into substanceabuse treatment services, work on establish-ing a therapeutic alliance ideally will beginupon admission. Many of the guidelines listedabove for enhancing motivation apply toestablishing this rapport. Newman (1997)makes some additional recommendations fordeveloping the therapeutic alliance, such asdiscussing the issue of confidentiality withpatients and acknowledging that the road to

recovery is difficult. He also advises beingconsistent, dependable, trustworthy, andavailable, even when the patient is not. Theclinician should remain calm and cool even ifthe patient becomes noticeably upset.Practitioners should be confident yet humbleand should set limits in a respectful mannerwithout engaging in a power struggle. SeeFigure 3-6 for a list of characteristics mostvaluable to a clinician in strengthening thetherapeutic alliance.

Referrals and LinkagesOnce an individual passes through the mostsevere of the withdrawal symptoms and is safeand medically stable, the focus of the psychoso-cial interventions shifts toward actively prepar-ing her for substance abuse treatment andmaintenance activities. These interventionsinclude (1) assessment of the patient’s charac-teristics, strengths, and vulnerabilities that willinfluence recommendations for substanceabuse treatment; (2) preparing the patient toparticipate in treatment; and (3) successfullylinking the patient to treatment as well as otherneeded services and resources.

38 Chapter 3

Figure 3-6Clinician’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 self-expression on the part of the client

Ensuring that patients with substance use dis-orders enter substance abuse treatment fol-lowing detoxification often is difficult. Manypatients believe that once they have eliminat-ed the substance or substances of abuse fromtheir bodies, they have achieved abstinence.Moreover, some insurance policies may notcover treatment, or only offer partial cover-age. The patient may have to go through cum-bersome channels to determine if treatment iscovered, and if so, how much.

Preparation should focus on eliminatingadministrative barriers to entering substanceabuse treatment prior to discussing treatmentoptions with the patient. Discussions with thepatient should be consistent with the patient’simproving ability to process and assess infor-mation in such a way that the patient appearsto be acting with his or her own interests inmind.

Evaluation of the Patient’sRehabilitation Needs To make appropriate recommendations forongoing treatment and recovery activities,detoxification staff need to determine theindividual characteristics of clients and theirenvironments that are likely to influence thelevel of care, setting, and specialized servicesneeded for recovery. ASAM’s PatientPlacement Criteria, Second Edition, Revised(PPC-2R) (ASAM 2001) provides one widelyused model for determining the level of ser-vices needed to address substance-related dis-orders. The levels of treatment services rangefrom community-based early interventiongroups to medically managed intensive inpa-tient services. As noted in chapter 2,providers need to make a placement decisionbased on six dimensions:

1. Acute Intoxication and/or WithdrawalPotential

2. Biomedical Conditions and Complications

3. Emotional, Behavioral, or CognitiveConditions or Complications

4. Readiness to Change

5. Relapse, Continued Use, or ContinuedProblem Potential

6. Recovery/Living Environment

Due to the limited time patients stay in detoxifi-cation settings, it is challenging for programs toconduct a complete assessment of the rehabili-tation needs of the individual. With this inmind, detoxification programs should focus onthose areas that are essential to make anappropriate linkage to substance abuse treat-ment services. The assessment of the psychoso-cial needs affecting the rehabilitation processitself may have to be left to the professionalsproviding substance abuse treatment. Otherassessment considerations include

•Special needs, such as co-occurring psychi-atric and medical conditions that may com-plicate treatment or limit access to availablerehabilitation services

•Pregnancy, physical limitations, and cogni-tive impairments that limit the settings suit-able for the individual

•Support system issues such as family sup-port, domestic violence, and isolation thatinfluence recommendations about residen-tial versus outpatient settings

•The needs of dependent children

•The need for gender-specific treatment (formore information see the forthcoming TIPsSubstance Abuse Treatment: Addressingthe Specific Needs of Women [CSAT indevelopment e] and Substance AbuseTreatment: Men’s Issues [CSAT in develop-ment g]).

Figure 3-7 (p. 40) outlines the areas the consen-sus panel recommends for assessment to deter-mine the most appropriate rehabilitation plan.

Appendix C lists a variety of instruments use-ful in characterizing the addiction and relateddisorders (for example, the AddictionSeverity Index [ASI]), measuring motivation-al willingness to change (Stages of ChangeReadiness and Treatment Eagerness Scale[SOCRATES] and University of Rhode IslandChange Assessment [URICA]), and evaluatingco-occurring psychiatric conditions and social

39An Overview of Psychosocial and Biomedical Issues During Detoxification

40 Chapter 3

Figure 3-7 Recommended Areas for Assessment To Determine Appropriate

Rehabilitation Plans

Domain Description

Medical Conditions andComplications

Infectious illnesses, chronic illnesses requiring intensive or specialized treat-ment, pregnancy, and chronic pain

Motivation/Readiness toChange

Degree to which the client acknowledges that substance use behaviors are aproblem and is willing to confront them honestly

Physical, Sensory, orMobility Limitations

Physical conditions that may require specially designed facilities or staffing

Relapse History andPotential

Historical relapse patterns, periods of abstinence, and predictors of absti-nence; client awareness of relapse triggers and craving

SubstanceAbuse/Dependence

Frequency, amount, and duration of use; chronicity of problems; indicators ofabuse or dependence

Developmental andCognitive Issues

Ability to participate in confrontational treatment settings, and benefit fromcognitive interventions and group therapy

Family and SocialSupport

Degree of support from family and significant others, substance-free friends,involvement in support groups

Co-Occurring PsychiatricDisorders

Other psychiatric symptoms that are likely to complicate the treatment of thesubstance use disorder and require treatment themselves, concerns aboutsafety in certain settings (note that assessment for co-occurring disordersshould include a determination of any psychiatric medications that the patientmay be taking for the condition)

Dependent Children Custody of dependent children or caring for noncustodial children andoptions 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 toseek culturally specific rehabilitation programs, culturally driven strengths orobstacles 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 aninterpreter familiar with substance abuse

and family factors. Administering theseinstruments requires varying degrees ofsophistication on the part of the clinician. Allinstruments should be considered for theircultural, linguistic, level of cognitive compre-hension, and developmental appropriatenessfor each patient. For further information onpatient placement see TIP 13, The Role andCurrent Status of Patient Placement Criteriain the Treatment of Substance Use Disorders(CSAT 1995h).

Settings for TreatmentJust as with settings for detoxification, set-tings where substance abuse treatment is pro-vided often are confused with the level ofintensity of the services. It is increasinglyclear that although level of intensity of ser-vices and setting are both critical to success-ful recovery, they are two separate dimen-sions to be considered when linking clients totreatment. This process has been called “de-linking” or “unbundling” and generallyinvolves determining the need for social ser-vices independently from the clinical intensity(Gastfriend and McLellan 1997; McGee andMee-Lee 1997).

Treatment and maintenance activities areoffered in a variety of settings. These includesettings specifically designed to deliver sub-stance abuse treatment, such as freestandingsubstance abuse treatment centers, as well assettings operating for other purposes, includ-ing mental health centers, jails and prisons,and community corrections facilities.Descriptions of these settings appear below:

•Inpatient programs for treatment of sub-stance abuse generally are delivered in hos-pitals and freestanding clinics and provide24-hour nursing care in addition to inten-sive treatment for substance-related prob-lems.

•Residential treatment programs normallyprovide 24-hour supervision by nonmedicalstaff and the availability of medical staffmay be limited. These programs deliver

highly intensive substance abuse counselingand clients may participate in the upkeep offacilities. Peer support is critical to thetreatment delivered. As a general rule,patients will stay at a residential treatmentfacility for 7 to 30 days.

•Therapeutic communities (TCs) usuallyhave 24-hour supervision by nonmedicalstaff or clients who have sustained recov-ery. They tend to provide highly intensivecounseling services and rely on peer sup-port and confrontation to shape behaviorsof clients. The TC is based on concepts ofself-help. Residence in a TC is longer than apatient’s stay in a residential program—patients usually stay for a period of at least30 days and often 6 months to a year. Insome special situations, such as a criminaljustice setting, TC residence can last 2years or more.

•Transitional residential programs andhalfway houses ordinarily have 24-hoursupervision from nonmedical staff or clientswho have sustained recovery. Patients inthese programs often are working and par-ticipate in counseling and peer support dur-ing the evening and weekend hours.

•Partial hospitalization and day treatmentprograms use a combination of medical andnonmedical staff to deliver a high intensityof counseling services during daytimehours. Patients return home in theevenings.

•Intensive outpatient programs usually aredelivered by nonmedical staff in a cliniclocation. Patients receive 6 to 9 hours ofcounseling services each week in two orthree contacts.

•Traditional outpatient services typically aredelivered by counselors in a clinic or officesetting and provide fewer hours of servicesthan the “intensive outpatient” programs.

•Recovery maintenance activities are nottreatment but are highly valuable for ongo-ing sobriety maintenance. They include 12-Step and other support groups aimed atmaintaining the gains accomplished in treat-

41An Overview of Psychosocial and Biomedical Issues During Detoxification

ment settings. Oxford House establishmentsand other “clean and sober” living environ-ments are among the resources that clini-cians should explore and perhaps incorpo-rate in maintenance activities.

Provide Linkage to Treatmentand Maintenance ActivitiesApproximately half of those making anappointment for treatment do not appear fortheir first appointment and another 20 per-cent or more fail to appear for the secondappointment (Gottheil et al. 1997; Parker2002). As patients near completion of detoxi-fication, whether they take the next step andenter treatment is dependent on a number ofvariables. Patients who are employed, aremotivated beyond the precontemplation stage,and have family and social support, as well asthose with co-occurring psychiatric condi-tions, are more likely to initiate treatment.Conversely, those who have severe drugdependence and those who are older are lesslikely to follow through and enter treatment(Kirchner et al. 2000; Weisner et al. 2001).Women are more likely to initiate treatmentafter detoxification than men, and individualswho have health insurance that features a

behavioral health carve-out and lower cost-sharing requirements are more likely to entertreatment than those who do not (Mark et al.2003b). Kleinman and associates (2002) fol-lowed 279 opioid- and cocaine-dependentpatients who had been in detoxification pro-grams to determine how many had enteredsubstance abuse treatment 30 days after leav-ing the detoxification program. They foundthat those who were on parole, homeless, orwho had been using drugs for less than 20years were more likely than others to haveentered treatment.

Research indicates that patients are morelikely to initiate and remain in rehabilitationif they believe the services will help them withspecific life problems (Fiorentine et al. 1999).Figure 3-8 suggests strategies that detoxifica-tion personnel can use with their patients topromote the initiation of treatment and main-tenance activities.

Provide Access to WraparoundServicesPatients are more likely to engage in treatmentif they believe the full array of their problems

42 Chapter 3

Figure 3-8Strategies 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.

will be addressed, including those needs typi-cally addressed by wraparound services (e.g.,housing, vocational assistance, childcare,transportation) (Fiorentine et al. 1999).Moreover, patients receiving neededwraparound services remain in substanceabuse treatment longer and improve more thanpeople who do not receive such services (Hseret al. 1999).

As the individual passes through acute intoxi-cation and withdrawal, it is important toensure that the basic needs of the patient aremet after discharge. These needs includeaccess to a safe, stable, and drug-free livingenvironment if possible; physical safety; foodand clothing; ongoing health and prenatalcare; financial assistance; and childcare.Ensuring access to these basic needs may beproblematic, and staff must be flexible andcreative in finding the means to meet thebasic needs of the patient.

Clearly, services planning should extendbeyond the issues of substance dependence toother areas that may affect compliance withrehabilitation. Detoxification providersshould be familiar with available resourcesfor legal assistance, dental care, supportgroups, interpreters, housing assistance,trauma treatment, recovery-sensitive parent-ing groups, spiritual and cultural support,employment assistance, and other assistanceprograms for basic needs. Family and othersupport systems also can be helpful to thepatient in accessing services and should takepart in the services planning as often as possi-ble, always with the patient’s consent.

To address the needs of homeless and indigentpatients, detoxification providers should befamiliar with emergency shelters, cash assis-tance, and food programs in their communi-ties and should have established referral rela-tionships. Assessing women, teenagers, olderadults, and other vulnerable individuals forvictimization by another member of thehousehold also is important. Patients shouldbe linked with prenatal and primary healthcare for domestic violence. Ideally, linkage to

these programs includes more than a phonenumber; detoxification staff should assistpatients in scheduling initial appointmentsand arranging for transportation.

Linkage to primary health and prenatal careas well as to community resources is essentialfor individuals with substance use disorders.Linkages can be an effective mechanism toassist the patient in accessing these services ifthey are not available as a part of the detoxi-fication program. Formalized referralarrangements through contracts or memoran-da of understanding can be useful to specifyorganizational obligations (D’Aunno 1997).

Minimize Access BarriersAn integral part of the process of linking anindividual with rehabilitation and treatmentresources is to address access barriers.Transportation, child care during treatment,the potential for relapse between detoxificationdischarge and treatment admission, housingneeds, and safety issues such as possibledomestic violence should be addressed throughan individualized plan prior to discharge.

The problem of a patient’s placement on awaiting list presents a special barrier to treat-ment. The solution lies in developing strate-gies to maintain motivation for treatment dur-ing the waiting period.

For pregnant women and patients with depen-dent children, the threat of Child ProtectiveServices removing their children for abuseand neglect due to drug use can be a barrierto entering a treatment program.

Additionally, interacting with hostile orunfriendly practitioners and encounteringresistance from family, partners, or friendscan be barriers to treatment entry.

Detoxification staff should be knowledgeableabout State laws regarding drug use duringpregnancy and definitions of child abuse andneglect in order to be able to reassure andencourage women to enter treatment.

43An Overview of Psychosocial and Biomedical Issues During Detoxification

People who identify as having a physical orcognitive disability also face special barriersto treatment. The reader is referred to TIP29, Substance Use Disorder Treatment forPeople With Physical and CognitiveDisabilities (CSAT 1998g) and TIP 36,Substance Abuse Treatment for Persons WithChild Abuse and Neglect Issues (CSAT2000d), for more information on these topics.

For racial/ethnic minorities, access barrierscan be compounded by language, cultural,and financial factors. The ability of programsto develop culturally specific interventions,train staff and interpreters to respond to thespecific needs of these individuals, and beaware of cultural differences in the manifesta-tion of symptoms is critical to improvingaccess to care. Supervision of staff and train-ing in cross-cultural issues is equally impor-tant to all programs serving diverse patientpopulations. The forthcoming TIP ImprovingCultural Competence in Substance AbuseTreatment (CSAT in development a) containsmore information on this topic.

Use Case ManagementCase management presents an opportunity totailor services to individual client needs andto minimize barriers to these services(Gastfriend and McLellan 1997). Case man-agement is a set of services managed to assistthe client in accessing needed resources. It isa useful strategy to ensure that access towraparound services such as employment,housing, health care, and basic needs are metalong with minimizing barriers to accessingsubstance abuse treatment. As outlined inTIP 27, Comprehensive Case Management forSubstance Abuse Treatment (CSAT 1998a),the common functions of case managementare defined as assessment, planning, linkage,monitoring, and advocacy. Case managerscan facilitate the critical linkage betweendetoxification services and rehabilitation byproviding transportation to the rehabilitationfacility, arranging for childcare, or assistingwith housing needs. Additionally, case man-agement is a widely used strategy to integrate

mental health and substance abuse treatmentfor those with co-occurring conditions (Drakeand Mueser 2000).

Linkage to OngoingPsychiatric ServicesAlthough it is important to make referrals forongoing psychiatric attention, the presence ofpsychological symptoms should not preventdetoxification staff from referring patients tosubstance abuse treatment. Individuals withco-occurring psychiatric conditions appear tobe able to initiate and benefit from substanceabuse treatment like individuals without psy-chiatric conditions (Joe et al. 1995).

Since some psychiatric illnesses may affectdrug cravings in patients who are substancedependent, it is important to ensure that boththe psychiatric condition and the substanceuse disorder are addressed in rehabilitation(Anton 1999). Individuals who are taking psy-chotropic medications should be counseledabout the importance of continuing on thesemedications. Whenever possible, dischargefrom the detoxification services should becoordinated with the patient’s mental healthprovider in the community, and the patientshould have an appointment scheduled at thetime of discharge from the detoxificationfacility. Detoxification providers shouldrequest that the patient sign appropriatereleases of information to provide assessmentand other material to the mental healthprovider to promote continuity of care. Thisshould only occur when the patient is medi-cally stabilized and is in such a state of mindthat he or she can make coherent decisions inthis regard (e.g., while intoxicated, patientsshould not be permitted to sign releases).

For individuals with serious co-occurring psy-chiatric conditions, integrated treatment forsubstance use disorders and mental illness isrecommended. Case management services asdescribed above may be especially importantfor individuals with severe mental illnessimpeding their ability to access services ontheir own. Increasingly, substance abuse and

44 Chapter 3

mental health providers are implementingmodels using clinicians trained to deliver bothsubstance abuse and mental health treatmentconcurrently (Drake and Mueser 2000). Formore information, see TIP 42, SubstanceAbuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).

Linkage to Followup Medical CareThe patient’s consent should be sought toinvolve her or his primary healthcare providerin the coordination of care. Patients withchronic medical conditions and those in need offollowup care should have an appointmentmade for followup medical care before leavingthe detoxification setting (Luborsky et al.1997).

Considerations for IndividualsWith Chronic SubstanceDependence For individuals with substance abuse prob-lems who detoxify regularly but have limitedperiods of abstinence, traditional treatment

approaches may not be effective. In somecases, addressing other needs may provide anavenue to engage the individual with chronicsubstance dependence in treatment. Casemanagement approaches can be successful ataddressing the need for housing, health care,and basic needs even though the individual isnot yet willing to confront the issue of drink-ing or other drug use (Cox et al. 1998). TIP27, Comprehensive Case Management forSubstance Abuse Treatment (CSAT 1998a),provides additional information about deliv-ery of case management services to homelessindividuals with substance use disorders andthose with other complex problems.Documentation of repetitive inappropriateuse of voluntary detoxification services mayhelp pave the way for civil commitment toinvoluntary treatment where this is an option,and, where detoxification resources are limit-ed, treatment systems need to be creative indesigning care plans for patients seeking fre-quent detoxification without evidence of anytherapeutic benefit.

45An Overview of Psychosocial and Biomedical Issues During Detoxification

4 PhysicalDetoxificationServices forWithdrawal FromSpecific Substances

In ThisChapter…Psychosocial and

BiomedicalScreening and

Assessment

AlcoholIntoxication and

Withdrawal

Opioids

Benzodiazepinesand OtherSedative-Hypnotics

Stimulants

Inhalants/Solvents

Nicotine

Marijuana andOther Drugs

Containing THC

Anabolic Steroids

Club Drugs

Management ofPolydrug Abuse:

An IntegratedApproach

AlternativeApproaches

Considerations forSpecific

Populations

This chapter highlights specific treatment regimens for specific sub-stances and provides guidance on the medical, nursing, and social ser-vices aspects of these treatments. It also includes considerations for spe-cific populations. Although it is written principally for healthcare profes-sionals, some professionals without medical training may find it of use.To accommodate a broad audience, the chapter includes definitions fortechnical terms that may be unfamiliar to some readers—for example,“the patient was afebrile (without fever).”

Psychosocial and BiomedicalScreening and AssessmentThis section covers more complex psychosocial and biomedical assess-ments that may occur after initial contact as an individual undergoesdetoxification. Psychosocial and biomedical screening and services areclosely associated: neither is likely to succeed without the other, as thecase study below illustrates.

Although the medical issues in this case indicate that the patient couldsuccessfully be managed as an outpatient, careful assessment of psy-chosocial and biomedical aspects of the patient’s condition, includinglack of transportation, the risk of violence, and his inability to carry outroutine medical instructions, strongly indicated that the patient remainin a 24-hour supervised setting such as a residential detoxification ortreatment program. For an illustration of some of the fundamental

47

aspects of the patient’s health and psychosocialstatus that should be covered in screening andassessment, see Figure 3-1, p. 25.

Figure 4-1 lists several instruments useful incharacterizing the intensity of specific with-drawal states (see appendix C for more infor-mation on these instruments and how to obtainthem).

Biochemical Markers andTheir UseThis section focuses on biochemical laborato-ry tests that detect the presence or absence ofalcohol or another substance of abuse, maybe able to quantify the level of present use, ormay be able to quantify cumulative use overthe past few weeks. Tests in all of these areasare reasonably well developed and validatedfor alcohol. This is not the case for mostother substances of abuse. Biochemical mark-ers are not adequate screening or assessmentinstruments alone, but rather are used tosupport a more comprehensive clinical assess-ment. Common uses of these biochemicalmarkers are:

1. In the initial screening setting to supportor refute other information that leads toproper diagnosis, assessment, and manage-ment.

2. For forensic purposes (e.g., evaluating adriver after an automobile accident).

3. In detecting occult (secretive or hidden)use of alcohol and other substances intherapeutic settings where abstinence,

rehabilitation, and treatment are beingpromoted.

Clinicians also can use the presentation ofinformation from biochemical markers topatients as an effective tool in motivationalenhancement. For example, informationregarding liver transaminases (specific kindsof enzymes that perform chemical reactionswithin the liver) helps provide the patientwith objective information on the level ofrecent alcohol use and potential acute hepaticdamage. This may help the patient move fromcontemplating treatment to actually beginningtreatment. For a more detailed discussion ofbiological markers in substance abuse, seeJavors and colleagues (1997).

Blood alcohol contentBlood alcohol content (BAC) can be determinedby highly sensitive laboratory procedures thatgenerally are available in most emergencydepartments, hospitals, and clinical chemistrylaboratories. Alcohol elimination undergoes,for the most part, zero-order kinetics (decreas-ing a set amount per unit of time rather than aset percentage), so the concept of half-life is notreally accurate. However, first-order kineticsand half-life do occur when BAC is low (i.e.,below 10mg percent), and the half-life is on theorder of about 15 minutes at that point.Though disappearance rates of 15mg percentper hour are probably average for moderatedrinkers, higher values were seen in a group ofSwedish drivers apprehended for driving whileintoxicated (19mg/dL/hr) (Jones and Andersson

48 Chapter 4

Case Study

A 44-year-old Caucasian male with a fifth-grade education presented to an emergency clinic in mild alcoholwithdrawal 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 ClinicalInstitute Withdrawal Assessment for Alcohol (CIWA-Ar) (see below) score = 12, indicating mild withdrawal.A treatment plan was recommended that called for an outpatient 3-day fixed-dose taper of lorazepam (abenzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to returndaily for brief assessment by nursing personnel. The social worker assigned to this client pointed out thatthere was no reliable transportation to the clinic, there had been domestic violence on the parts of bothspouses, and the patient’s ability to carry out routine medical instructions was questionable.

1996). The rate of metabolism of alcoholincreases with dependence—some alcoholicscan metabolize 20–25mg/dL/hr (Jones andAndersson 1996), and Jones and Sternebring(1992) have found that alcohol-dependentpatients may metabolize 22mg/dL/hr duringdetoxification.

When knowledge of BAC is combined withclinical information, the healthcare providercan make some predictions regarding theacuteness of withdrawal. For example, in anindividual whose blood alcohol level is 200mgpercent but who is already showing tremu-lousness (shakiness of the hands), briskreflexes, tachycardia (rapid heart rate),diaphoresis (excessive sweating), and perhapsa CIWA-Ar score in the moderate or high

range (about 15 or higher), the clinician canreasonably predict that the withdrawal will berelatively severe. As noted, however, the rateof metabolism of alcohol increases withdependence. The diagnosis of alcohol intoxi-cation is a clinical diagnosis and not basedsimply on a BAC. A person with a BAC of200mg percent could be in withdrawal, intoxi-cated (showing related signs and symptoms),or showing no signs and symptoms of eitherintoxication or withdrawal. A BAC above100mg percent does not necessarily indicateclinical intoxication. Like all laboratory pro-cedures, the blood alcohol levels test has limi-tations. Usually, patient permission must beobtained prior to testing, the testing itself canbe expensive, and forensic testing may besubject to specific legal procedures.

49Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol

and Specific Illicit Drugs

Drug of Dependence Instrument Reference Notes

Alcohol CIWA-Ar Sullivan etal. 1989

10 items that take 2 to 5 minutes to com-plete; scores 0–67, with 10 or greater asclinically significant; requires training toadminister

Cocaine Cocaine SelectiveSeverityAssessment (CSSA)

Kampman etal. 1998

18 items that take 10 minutes to com-plete; high scores correlated with pooroutcome

Opioids Subjective OpiateWithdrawal Scale(SOWS)

Handelsmanet al. 1987

16-item questionnaire; using a scale of0–4, respondents rate to what extentthey are currently experiencing each of16 characteristics; higher scores indicatemore severe withdrawal

Objective OpiateWithdrawal Scale(OOWS)

Handelsmanet al. 1987

Rater observes patient for about 10 min-utes and indicates if any of 13 manifesta-tions of withdrawal are present; scorescan range from 0 to 13, with higherscores indicating more severe withdraw-al; staff must be familiar with withdraw-al signs

Breath alcohol levelsAlthough the initial cost of small breath alcoholinstruments may be relatively high, the recur-ring costs (of disposable mouthpieces and peri-odic recalibration) are low. The technique isless invasive than blood testing and healthproviders can follow breath alcohol levelsrepeatedly at low expense during the course ofassessment and detoxification. The detection ofrapidly rising, high levels of alcohol over ashort period of time may indicate alcohol poi-soning overdose. Breath alcohol levels provideuseful guidance in determining whether to hos-pitalize these patients.

Limitations on breath alcohol determinationsare that patient cooperation is required andthat some patients with lung diseases are notable to muster a sufficient tidal volume (force-ful breath) to give an accurate reading to themachine. On occasion, patients whose breathalcohol levels indicate recent alcohol use willassert that they have recently gargled withmouthwash that contained alcohol. Having thepatient rinse his mouth with water severaltimes and then making another breath alcoholdetermination in 15 to 30 minutes usually willresolve whether the patient’s assertion is valid.

Urine drug screensUrine drug screens vary widely in their meth-ods of detection, sensitivity and specificity,expense, and availability. The healthcareprovider assessing patients for detoxificationshould be familiar with the type of assay (testmeasurement) being used; some examples areenzyme multiple assay techniques, thin layerchromatography, high performance liquid

chromatography, urine alcohol concentration,and gas chromatography-mass spectrometry.

Informed clinicians also should be aware ofwhich drugs are screened for by the laboratorythey use, the relative time window of detection(a substance’s metabolic half-life, or approxi-mately how long a drug can be detected onceingested), and whether cross-reactivity withother interfering substances may alter out-comes. Many laboratories perform more specif-ic confirmation testing on positive screeningtests, which can largely eliminate false-posi-tives. It is important to clarify which type oftest result is being reported. Interfering andcross-reactive substances leading to false-posi-tive tests frequently are discussed in bulletinsand publications periodically published by theNational Institute on Drug Abuse (NIDA) andthe Centers for Disease Control and Prevention(CDC). Usually, the senior laboratory supervi-sor has up-to-date information in this area andoften can be consulted via e-mail or telephonein an emergency. Limitations of urine drugscreening include consent and privacy issues,expense, the inability to screen for some drugsof abuse, and the inability of urine drugscreens to provide information on the currentlevel of intoxication.

Urine testing should at a minimum test for thepresence of

•Benzodiazepines

•Barbiturates

•Cocaine

•Amphetamines

•Opioids

•PCP

50 Chapter 4

Reading Blood Alcohol Concentrations

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. Thisfigure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BACof .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.

Source: Center for Substance Abuse Treatment (CSAT) 1995a.

It also should be noted that current testing foropioids primarily refers to “organic” drugs thatare derived from opium (i.e., heroin, codeine,and morphine). Synthetic opioids likehydrocodone and methadone are not detectedby the usual tests; this is true of oxycodone aswell. If the use of these drugs is suspected, spe-cial tests can be ordered. Most important, eachprogram should tailor its urine screening teststo reflect the substance use patterns prevalentin the community.

Gamma-glutamyltransferase(GGT)GGT has been measured in serum (the portionof the blood that has neither red nor whiteblood cells) for many years as a marker forliver damage. More recently, GGT has beenadvocated as a measure of cumulative alcoholuse (Dackis 2001). Sensitivity of the test is inthe 60 to 70 percent range and specificity (itsability not to misidentify or confuse alcohol usewith other disorders) is in the 40 to 50 percentrange. In general, both sensitivity and specifici-ty are lower in females than males. GGT doescorrelate with alcohol intake but often requiresheavy drinking (more than six drinks per day)to elevate it, and only about half of individualswill show elevations. The half-life of elevatedserum GGT after the onset of abstinence is saidto be 2 to 3 weeks with alcoholic liver disease.Chlorpromazine, phenobarbital, andacetaminophen can all raise serum GGT levels.

GGT is limited by its expense and its relative-ly low specificity, which sometimes leads tofalse-positive evaluations. GGT is helpful as amotivational enhancer in patients with a highdegree of denial during detoxification.Evidence of liver damage, as measured by theGGT, provides patients with objective feed-back concerning the consequences of theiralcohol use and thus plays a very importantrole in enhancing motivation.

Hepatitis is a general term that refers toinflammation of the liver with damage to livercells (hepatocytes). Hepatitis may be due toviruses (such as in hepatitis A, B, C) or

insults to the liver from toxins (such as chemi-cals, alcohol, prescribed or over-the-countermedications). In any form of hepatitis, GGTmay be elevated, indicating damage to livercells. Therefore, GGT elevation does notautomatically mean liver damage from alcoholuse, although this is certainly one of the mostcommon reasons for elevated GGT levels inpatients hospitalized in North America. Theuse of GGT levels along with carbohydrate-deficient transferrin (CDT) levels is a rela-tively sensitive and specific indicator of alco-hol use. The CDT test is discussed below.

Carbohydrate-deficient transferrinCDT has been developed over the past 20 yearsas a marker of cumulative alcohol consumptionbut is just now becoming widely available as aclinical tool. Sensitivities appear to be in the 70to 80 percent range, and specificities of greaterthan 90 percent have been found. Sensitivityand specificity are somewhat lower amongfemales than males. Most therapeutic drugs ordrugs of abuse do not appear to affect CDTlevels. When CDT and GGT levels are com-bined, sensitivity and specificity rise to morethan 90 percent (Anton 2001). CDT testing islimited by its relatively high cost, lack of clini-cal availability in some laboratories, and false-positive results in abstaining individuals whohave endstage liver disease from causes otherthan alcohol use (DiMartini et al. 2001).

Mean corpuscular volume (MCV)Erythrocyte (red blood cell) size is measured ina Coulter counter and often is part of a com-plete blood count; therefore, it is widely avail-able to clinicians. Sensitivity and specificity arein the 30 to 50 percent range. Hence, cautionshould be exercised when interpreting an ele-vated MCV in relation to drinking behavior.This lab test should be considered complemen-tary to other biological markers that are morespecific and sensitive, such as GGT or CDT.Advanced age, nutritional status, cigarette

51Physical Detoxification Services for Withdrawal From Specific Substances

smoking, and co-occurring disease states with-out the presence of alcoholism may make testresults abnormal.

Alcohol Intoxicationand Withdrawal

Intoxication Signs andSymptomsThe clinical presentation of intoxication fromalcohol varies widely depending in part onblood alcohol level and level of previouslydeveloped tolerance. At alcohol concentrationsbetween 20mg percent and 80mg percent, lossof muscular coordination, changes in mood,personality alteration, and [increases in motoractivity] begin. At levels from 80 to 200mg per-cent, more progressive neurologic impairmentoccurs with ataxia (inability to coordinate mus-cular activity) and slurring of speech beingprominent. A variety of cognitive functions alsoare impaired. At blood alcohol levels between200 and 300mg percent nausea and vomitingmay occur, which along with sedation mayplace patients at grave risk for aspiration ofstomach contents. At levels greater than 300mgpercent, hypothermia (low body temperature)with impairment of level of consciousness islikely except in all but the most tolerant indi-viduals. Coma begins to be seen at levels of 400to 600mg percent, but this is variable, againdepending on tolerance. Although exceptionsare found, BACs between 600 and 800mg per-cent are fatal. At this point, respiratory, car-diovascular, and body temperature controlsfail. See Figure 4-2 for more symptoms of alco-hol intoxication.

Since the elimination rate of alcohol from thebody generally is 10 to 30mg percent per hour,the goals for the treatment of alcohol intoxica-tion are to preserve respiration and cardiovas-cular function until alcohol levels fall into asafe range. Patients who are severely intoxicat-ed and comatose as the result of alcohol useshould be managed in the same manner as allcomatose patients, with particular care taken

in monitoring vital functions, protecting respi-ration, and observing aspiration, hypo-glycemia, and thiamin deficiency. Screening forother drugs that may contribute to the coma,as well as other sources of coma induction,should be done. Agitation is best managed withinterpersonal and nursing approaches ratherthan additional medications, which may onlycomplicate and delay the elimination of thealcohol.

Withdrawal Signs andSymptomsHippocrates, writing around 400 B.C., gave usour first written clinical picture of alcohol with-drawal when he wrote that if the patient is “inthe prime of life and if from drinking he hastrembling hands,” it may well be the case thatthe patient is showing withdrawal signs andsymptoms. To this day, alcohol withdrawalremains underrecognized and undertreated.The signs and symptoms of acute alcohol with-drawal generally start 6 to 24 hours after thepatient takes his last drink. Alcohol withdrawalmay begin when the patient still has significantblood alcohol concentrations. The signs andsymptoms may include the following:•Restlessness, irritability, anxiety, agitation

•Anorexia (lack of appetite), nausea, vomiting

•Tremor (shakiness), elevated heart rate,increased blood pressure

•Insomnia, intense dreaming, nightmares

•Poor concentration, impaired memory andjudgment

•Increased sensitivity to sound, light, and tac-tile sensations

•Hallucinations (auditory, visual, or tactile)

•Delusions, usually of paranoid or persecutoryvarieties

•Grand mal seizures (grand mal seizures rep-resent a severe, generalized, abnormal elec-trical discharge of the major portions of thebrain, resulting in loss of consciousness, briefcessation of breathing, and muscle rigidityfollowed by muscle jerking; a brief period of

52 Chapter 4

sleep, awakening later with some mild to evensevere confusion, generally occurs)

•Hyperthermia (high fever)

•Delirium with disorientation with regard totime, place, person, and situation; fluctua-tion in level of consciousness

For a discussion of seizures and delirium,including delirium tremens, see below under

the heading Management of Delirium andSeizures (p. 63).

Mild alcohol withdrawal generally consists ofanxiety, irritability, difficulty sleeping, anddecreased appetite. Severe alcohol withdrawalusually is characterized by obvious tremblingof the hands and arms, sweating, elevation ofpulse (above 100) and blood pressure (greater

53Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-2Symptoms 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 bloodpressure

•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 bloodalcohol level).

Source: Consensus Panelist Robert Malcolm, M.D.

than 140/90), nausea (sometimes with vomit-ing), and hypersensitivity to noises (which seemlouder than usual) and light (which appearsbrighter than usual). Brief periods of hearingand seeing things that are not present (auditoryand visual hallucinations) also may occur. Afever greater than 101° F also may be seen,though care should be taken to determinewhether the fever is the result of an infection.Seizures and true delirium tremens, as dis-cussed elsewhere, represent the most extremeforms of severe alcohol withdrawal. Moderatealcohol withdrawal is defined more vaguely,but represents some features of both mild andsevere withdrawal.

The course of these symptoms is extremelyvariable. An individual may progress partial-ly through some of the symptoms noted aboveand then have a slow improvement. Otherindividuals may have mild to moderate symp-toms with almost abrupt resolution. Yetanother group may present with a grand malseizure or with hallucinations. Some peoplewith alcohol dependence, regardless of theirpattern of drinking or the extent of drinking,appear to develop minor symptoms or showno symptoms of withdrawal. Infrequent bingedrinkers seem less likely to have withdrawalsymptoms than individuals who are heavyregular users of alcohol who then abruptlycease their alcohol use, but this is not wellsubstantiated. As previously discussed in theassessment section, the use of a standardizedclinical rating instrument for withdrawal suchas the CIWA-Ar is valuable because it guidesthe clinician through multiple domains ofalcohol withdrawal and allows for semi-quan-titative assessment of nausea, tremor, auto-nomic hyperactivity, anxiety, agitation, per-ceptual disturbances, headache, and disorien-tation. Age, general health, nutritional fac-tors, and possible co-occurring medical orpsychiatric conditions all appear to play arole in increasing the severity of the symp-toms of alcohol withdrawal.

The most useful clinical factors to assess thelikelihood and the extent of a current with-drawal is the patient’s last withdrawal and

the number of previous withdrawals (treatedor untreated) experienced, with three or fourbeing a particularly significant number forthe appearance of severe withdrawal reac-tions unless adequate medical care is provid-ed. This assumption that this phenomenonwill manifest itself, which has been referredto as the “kindling hypothesis,” is well-estab-lished in the research literature (Booth andBlow 1993; Wojnar et al. 1999).Uncomplicated or mild to moderate with-drawal is characterized by restlessness, irri-tability, anorexia (lack of appetite), tremor(shakiness), insomnia, impaired cognitivefunctions, and mild perceptual changes.Complicated or severe medical withdrawalhas one or more elements of delirium, halluci-nations, delusions, seizures, and disturbancesof body temperature, pulse, and blood pres-sure.

Medical Complications ofAlcohol Withdrawal: PossibleFatal Outcomes Seizures; delirium tremens (severe deliriumwith trembling); and dysregulation of bodytemperature, pulse, and blood pressure areoutcomes in severe alcohol dependence that canlead to fatal consequences. Other medical com-plications of alcohol withdrawal include infec-tions, hypoglycemia, gastrointestinal (GI)bleeding, undetected trauma, hepatic failure,cardiomyopathy (dilation of the heart withineffective pumping), pancreatitis (inflamma-tion of the pancreas), and encephalopathy(generalized impaired brain functioning). Thesuspicion of impending complications or theirappearance will require hospitalization of theclient and possible intensive care unit level ofmanagement. Consultation with internists spe-cializing in infectious disease, pulmonary care,and hepatology; surgeons; neurologists; psychi-atrists; anesthesiologists; and other specialistsalso may be warranted, depending on thenature of the complications.

54 Chapter 4

Management of WithdrawalWithout Medication The management of an individual in alcoholwithdrawal without medication is a difficultmatter because the indications for this have notbeen established firmly through scientific stud-ies or any evidence-based methods.Furthermore, the course of alcohol withdrawalis unpredictable and currently available tech-niques of screening and assessment do notallow us to predict with confidence who will orwill not experience life-threatening complica-tions. Severe alcohol withdrawal may be associ-ated with seizures due to relative impairment ofgamma-aminobutyric acid (GABA) and relativeover-activity of N-methyl-D-aspartate systems(a subtype of the excitatory glutamate receptorsystem) (Moak and Anton 1996). The failure totreat incipient convulsions is a deviation fromthe established general standard of care.

Positive aspects of the nonmedicationapproach are that it is highly cost-effectiveand provides inexpensive access to detoxifica-tion for individuals seeking aid. Observationis generally better than no treatment, butpeople in moderate to severe withdrawal willbe best served at a higher level of care. Youngindividuals in good health, with no history ofprevious withdrawal reactions, may be wellserved by management of withdrawal withoutmedication. However, personnel supervisingin this setting should possess assessment abili-ties and be able to summon help through theemergency medical system. Methods of with-drawal management without medicationinclude frequent interpersonal support, pro-vision of adequate fluids and food, attentionto hygiene, adequate sleep, and the mainte-nance of a no-alcohol/no-drug environment.

Social DetoxificationSocial detoxification programs are defined asshort-term, nonmedical treatment services forindividuals with substance use disorders. Asocial detoxification program offers room,board, and interpersonal support to intoxicat-ed individuals and individuals in substance use

withdrawal. The consensus panel has foundthat in actual practice, social detoxificationprograms vary greatly in their approach andscope. Some programs offer some medical andnursing onsite supervision, while others pro-vide access to medicaland nursing evalua-tion through clinics,urgent care pro-grams, and emergen-cy departments.Some social detoxifi-cation programs onlyoffer basic room andboard for a “coldturkey” detoxifica-tion, while other pro-grams offer super-vised use of medica-tions. Sometimesmedications are pre-scribed at the onset ofwithdrawal by health-care professionals inan outpatient setting,while the staff in thesocial detoxificationprogram supervisesthe administration ofthese medications.Whatever the partic-ular situation mightbe, there shouldalways be medicalsurveillance, includ-ing monitoring ofvital signs, as part of every social detoxificationprogram.

The consensus panel agrees that for alcohol,sedative-hypnotic, and opioid withdrawal syn-dromes, hospitalization (or some form of 24-hour medical care) is generally the preferredsetting for detoxification, based on principles ofsafety and humanitarian concerns. When hos-pitalization cannot be provided, a setting thatprovides a high level of nursing and medicalbackup 24 hours a day, 7 days a week is desir-able. The panel readily acknowledges thatsocial detoxification programs are, for some

55Physical Detoxification Services for Withdrawal From Specific Substances

For alcohol,

sedative-hypnotic,

and opioid with-

drawal syndromes,

hospitalization (or

some form of

24-hour medical

care) is generally the

preferred setting for

detoxification, based

on principles of

safety and humani-

tarian concerns.

communities, the only available resources foruninsured, homeless individuals. Social detoxi-fication is preferable to detoxification in unsu-pervised settings such as the street, shelters, orjails. The panel also notes that in some largeurban areas, social detoxification programshave longstanding, excellent reputations of pro-viding high-quality supervision and nurturance

for their clients.Social detoxificationprograms are orga-nized and funded bya variety of sources,including faith-basedorganizations, com-munity charities,and municipal andother local govern-ments.

The genesis of socialdetoxification iscomplex. Often,these programs grewout of communityneeds when no otheralternatives wereavailable. Earlyreports (Whitfield etal. 1978) indicatedthat many individu-als in alcohol with-drawal could bemanaged successful-

ly without medications in a social detoxificationsetting. Subsequent reviews that have revisitedthe topic (Lapham et al. 1996) have reachedsimilar conclusions. Critical analysis of thesereports by the consensus panel indicates thatsome of the scientific issues were oversimplifiedand misleading. A number of these studies, infact, excluded many seriously ill clients fromtheir surveys prior to referral to social detoxifi-cation. Some of these surveys had a very highstaff-to-client ratio during social detoxification,thus providing an unusually high level of psy-chological support. This level of staffing is notfrequently found today in social detoxificationprograms.

The consensus panel acknowledges that, for asubstantial group of individuals, substanceuse withdrawal syndromes do not lead to fataloutcomes or even significant morbidity.Determining which individuals will havebenign outcomes often is difficult, and in factthis determination prior to social detoxifica-tion referral frequently is not made. Someincorrect beliefs have sprung up in the con-text of social detoxification: Individualsundergoing opioid withdrawal often are con-sidered to require hospitalization to alleviatesuffering, while individuals undergoing alco-hol withdrawal sometimes are, for a variety ofreasons, denied hospital-level treatment fordetoxification, even though alcohol withdraw-al produces suffering and may have fatal con-sequences.

The consensus panel agreed on several guide-lines for social detoxification programs:

•Such programs should follow local govern-mental regulations regarding their licensingand inspection.

•It is highly desirable that individuals enteringsocial detoxification be assessed by primarycare practitioners (physicians, physicianassistants, nurse practitioners) with someexperience in substance abuse treatment.

•Such an assessment should determinewhether the patient currently is intoxicatedand the degree of intoxication, the type ofwithdrawal syndrome, severity of the with-drawal, information regarding past with-drawals, and the presence of co-occurringpsychiatric, medical, and surgical conditionsthat might well require specialized care (seechapter 3, Figure 3-1, p. 25).

•Particular attention should be paid to thoseindividuals who have undergone multiplewithdrawals in the past and for whom eachwithdrawal appears to be worse than previ-ous ones—this is the so-called “kindlingeffect” (Ballenger and Post 1978; Booth andBlow 1993; Malcolm et al. 2000; Shaw et al.1998; Wojnar et al. 1999; Worner 1996).Subjects with a history of severe with-drawals, multiple withdrawals, delirium

56 Chapter 4

For a substantial

group of

individuals,

substance use

withdrawal

syndromes do not

lead to fatal

outcomes or even

significant

morbidity.

tremens, or seizures are not good candidatesfor social detoxification programs.

•All social detoxification programs shouldhave an alcohol- and drug-free environment,have personnel who are familiar with the fea-tures of substance use withdrawal syn-dromes, have training in basic life support,and have access to an emergency medical sys-tem that can provide transportation to emer-gency departments and other sites of clinicalcare.

Management of WithdrawalWith MedicationsOver the last 15 years several reviews and posi-tion papers (Fuller and Gordis 1994; Lejoyeuxet al. 1998; Mayo-Smith 1997; Nutt et al. 1989;Shaw 1995) have asserted that only a minorityof patients with alcoholism will in fact go intosignificant alcohol withdrawal requiring medi-cations. Identifying that significant minoritysometimes is problematic, but there are signsand symptoms of impending problems that canalert the caretaker to seek medical attention.

Deciding on whether to use medical manage-ment for the treatment of alcohol withdrawalrequires that patients be separated into threegroups. The first and most obvious groupcomprises those clients who have had a previ-ous history of the most extreme forms of with-drawal, that of seizures and/or delirium. Thisgroup is discussed in more detail below, butin general, the medication treatment of thisgroup in early abstinence, whether or notthey have had the initiation of withdrawalsymptoms, should proceed as quickly as pos-sible.

The second group of patients requiring imme-diate medication treatment includes thosepatients who are already in withdrawal anddemonstrating moderate symptoms of with-drawal.

The third group of patients includes thosewho may still be intoxicated and thereforehave not had time to develop withdrawalsymptoms or who have, at the time of admis-

sion, been abstinent for a few hours and havenot developed signs or symptoms of withdraw-al. A decision regarding medication for thisgroup should be in part based on age, num-ber of years of alcohol dependence, and thenumber of previously treated or untreatedsevere withdrawals (three or four appears tobe a significant threshold in predicting futureserious withdrawal) (Shaw 1995). If there isan opportunity to observe the patient in theemergency department of the clinic or similarsetting over the next 6 to 8 hours, then it ispossible to delay a decision regarding treat-ment and periodically reevaluate a client ofthis category. If this is not possible, then thereturn of the patient to a setting in whichthere is some supervision by family, signifi-cant others, or in a social detoxification pro-gram is desirable.

The decision as to whether to give the patienta single medication dose prior to dischargeand perhaps provide one or two additionalmedication doses to be administered in thereferral setting rests on adequacy of supervi-sion, the probability of whether the patientwill drink while undergoing treatment, andwhether the patient can or will return forassessments the following day. In some cir-cumstances, no treatment may be safer thantreatment with medication. Mayo-Smith(1997) has shown that benzodiazepines conferprotection against alcohol withdrawal seizuresand thus patients with previous seizuresshould be treated early. The same applies todelirium. Both of these topics will be exploredin greater detail in the next section.Extremely heavy drinking in the weeks priorto complete cessation also predicts moresevere withdrawal (Lejoyeux et al. 1998), butconfirming such a history often is difficult.

A less accepted and more controversial posi-tion on the indications for medication treat-ment for alcohol withdrawal springs fromstudies that attempt to measure oxidativestress, which is the formation of oxidativefree radicals (chemicals that damage pro-teins), and stress hormones during alcoholwithdrawal (Dupont et al. 2000; Tsai et al.

57Physical Detoxification Services for Withdrawal From Specific Substances

1998). These studies have asserted that indi-viduals who are undergoing mild withdrawalwithout treatment still have the formation oftoxic oxidative products which have the hypo-thetical potential of producing neuronal dam-age and perhaps some cell death. Lendingsupport to this argument is the fact that alco-hol withdrawal appears to be progressive inthat it worsens with each successive episode(Malcolm et al. 2000) and that some patientsdependent on alcohol develop evidence ofdementia over time. On the other hand, age,nutritional status, trauma, co-occurring con-ditions, and other unspecified events alsoprobably contribute to this process.

The decision to treat a patient in alcoholwithdrawal or at potential risk for alcoholwithdrawal will in great part rest on the clini-cal judgment of the practitioner, relying onthe factors noted above in addition to theissue of whether treatment may in fact actual-ly do more harm than good. This topic is dis-cussed below under the heading Limitationsof Benzodiazepines in Outpatient Treatment(p. 60). For more information about medica-tion-assisted treatment, see TIP 43,Medication-Assisted Treatment for OpioidAddiction in Opioid Treatment Programs(CSAT 2005d).

Benzodiazepine treatment ofalcohol withdrawalDepending upon the clinical setting and thepatient circumstances, there are several accept-able regimens for treating alcohol withdrawalthat make use of benzodiazepines. These drugsremain the medication class of choice for treat-ing alcohol withdrawal. The early recognitionof alcohol withdrawal and prompt administra-tion of a suitable benzodiazepine usually willprevent the withdrawal reaction from proceed-ing to serious consequences. Patients suspectedof alcohol withdrawal should be seen promptlyby a primary care provider (physician, nursepractitioner, physician assistant) who has expe-rience in diagnosing and managing alcoholwithdrawal. Practitioners are reminded that

benzodiazepines have side effects and limita-tions. These limitations are far more prominentwhen treating alcohol withdrawal in an outpa-tient setting.

Loading dose of a benzodiazepine Medical or nursing administration of a slowlymetabolized benzodiazepine, frequently intra-venously, but sometimes orally, may be carriedout every 1 to 2 hours until significant clinicalimprovement occurs (such as reducing theCIWA-Ar score to 10 or less) or the patientbecomes sedated (Sellers and Naranjo 1985).Patients at grave risk for the most severe com-plications of alcohol withdrawal or who arealready experiencing severe withdrawal shouldbe hospitalized and can be treated with thisregimen. In general, patients with severe with-drawal may receive 20mg of diazepam or100mg of chlordiazepoxide every 2 to 3 hoursuntil improvement or sedation prevails.Oversedation, ataxia (lack of muscular coordi-nation), and confusion, particularly in elderlypatients, may occur with this protocol. Thetreatment staff should closely monitor hemody-namic (blood pressure and pulse) and respira-tory features. They should particularly be pre-pared to detect and rapidly treat apnea (nobreathing) with assisted ventilation. Havingexperienced staff with adequate time to fre-quently monitor the patient and provide intra-venous medication is necessary.

Symptom-triggered therapy Using the CIWA-Ar or similar alcohol with-drawal rating scales, medical personnel can betrained to recognize signs and symptoms ofalcohol withdrawal, make a rating, and basedon that rating administer benzodiazepines totheir patients only when signs and symptomsreach a particular threshold score. Studieshave demonstrated that appropriate training ofnurses in the application of the CIWA-Ar dra-matically reduces the number of patients whoneed to receive symptom-triggered medication(Saitz et al. 1994; Wartenberg et al. 1990). Thisregimen has been used successfully with short,intermediate, and long half-life benzodi-azepines.

58 Chapter 4

The training of staff in a standardized proce-dure of administering rating scales is impor-tant and periodic retraining to ensure contin-ued reliability among raters is essential. Atypical routine of administration of symptom-triggered therapy is as follows: Administer50mg of chlordiazepoxide (Librium) forCIWA-Ar > 9 and reassess in 1 hour.Continue administering 50mg chlordiazepox-ide every hour until CIWA-Ar is < 10. Dosageamount and frequency can be modifieddepending on the individual clinical situationas determined by the medical provider.Patients with a history of withdrawal seizuresshould receive scheduled doses of a long-act-ing benzodiazepine (e.g., diazepam [Valium],20mg every 6 hours for 3 days) regardless ofCIWA-Ar score, and should receive addition-al doses if indicated by elevated CIWA-Arscore. It must be noted here that symptom-triggered therapy is not recommended foroutpatient detoxification. Symptom-triggeredtherapy requires monitoring and decision-making by a healthcare professional.

Gradual, tapering doses Before beginning any tapering regimen, thepatient must be fully stabilized; that is, all signsand symptoms of withdrawal must beimproved. Without proper stabilization, notapering scheme will succeed. Once the patienthas been stabilized, oral benzodiazepines canbe administered on a predetermined dosingschedule for several days and graduallytapered over time. This is a commonly usedregimen.

Dosing protocols vary widely among treat-ment facilities based on the needs of thepatient population. One example is thatpatients might receive 50mg of chlordiazepox-ide or 10mg of diazepam every 6 hours duringthe first day of treatment and 25mg of chlor-diazepoxide or 5mg of diazepam every 6hours on the second and third days. Thisapproach to dosing, that is, every 6 hours, isnot as accurate in tailoring medications tocounter symptoms; a more precise dosing reg-imen is titrating (adjusting dosage in light of

drug response) according to severity of symp-toms. An alternative regimen might be theadministration of 1 to 2mg lorazepam two orthree times a day the first day, followed bygradual reduction over the next 3 to 5 days.The general approach to tapering is to estab-lish an acute dose in the first 24 hours, thento reduce it over the next three days: forexample, 400 chlordiazepoxide total on day 1,then 300, 200, 100,and off on day 5.This has to beextended iflorazepam is used.Doses of withdrawalmedication are omit-ted if the patient issleeping soundly,showing signs ofoversedation, orexhibiting markedataxia.

The use of gradual,tapering doses isappealing in settingswhere trained nurs-ing or medicalobservations cannotbe made frequently;however, this initself is a pitfall.Under- or overmedication with this regimencan occur depending on benzodiazepine toler-ance; the presence of chronic cigarette smok-ing, which induces benzodiazepinemetabolism; liver function; age; and the pres-ence of co-occurring medical or psychiatricconditions. The use of this regimen may beproblematic in the outpatient settings inwhich it frequently is applied. Supplying thepatient with 4 to 5 days of a benzodiazepineand facing the probability that the patientmay drink and take the benzodiazepine is ahazard. It is important to enforce strict limi-tations on driving automobiles, climbing, oroperating hazardous machinery.

59Physical Detoxification Services for Withdrawal From Specific Substances

Benzodiazepines

remain the

medication class

of choice for

treating alcohol

withdrawal.

Single daily dosing protocolJauhar and Anderson (2000) compared singledaily dosing of diazepam to multiple daily dos-ing of chlordiazepoxide in inpatients beingtreated for alcohol withdrawal. Patients in thediazepam single daily dose group did as well asthe chlordiazepoxide multiple dosing group.The authors suggest that this regimen might beattractive in community or social detoxificationsettings, particularly if patients could be moni-tored between administered doses. Furtherstudy with a larger group of patients is needed.

The choice of the specific benzodiazepine forany particular regimen depends on a numberof factors, but the most significant factor is thatthe clinician administer one that she has themost experience using. Despite 30 years ofresearch, no single benzodiazepine has emergedas the number one drug of choice in treatingalcohol withdrawal. All benzodiazepines stud-ied have worked better than placebo but havebeen roughly equivalent with each other. Manyclinicians prefer long half-life benzodiazepinessuch as chlordiazepoxide and diazepam, desir-ing less frequent daily dosing, relatively steadyserum levels, and the ability of these drugs toself-taper based on their long half-lives.

Diazepam and chlordiazepoxideBoth diazepam and chlordiazepoxide haveexcellent rapid oral absorption and are avail-able for intravenous (IV) use. Intramuscularuse of these drugs is to be discouraged sincemuscle absorption is erratic. One study sug-gests that if chlordiazepoxide (Librium) istaken in overdose with alcohol, it is less likelyto be fatal than diazepam (Valium) (Serfatyand Masterton 1993). Detractors of the use ofthese two drugs point out that they have longhalf-lives (although some clinicians see this asan advantage because it prevents the emer-gence of withdrawal symptoms between doses),have multiple active metabolites, and gothrough many oxidative metabolic steps in theliver. Older patients or patients with liver dis-ease are likely to accumulate these medicationsquickly without being able to metabolize them.Possible consequences include oversedation or

ataxia, and on rare occasions, confusion mayensue.

LorazepamLorazepam (Ativan) has an intermediate half-life of about 8–15 hours, and although it usual-ly is administered in multiple doses each day, itcan be given approximately twice per day.Lorazepam, with its shorter half-life and lackof storage in adipose (fatty) tissue, actually hasto be given more frequently than the long-act-ing preparations, not less. It is absorbed easilyorally, intramuscularly, and intravenously.Older patients and patients with severe liverdisease tolerate it well and it is an effectiveanticonvulsant in blocking a second alcoholwithdrawal seizure (D’Onofrio et al. 1999).However, it has been suggested that seizuresmay occur late in detoxification with short-act-ing benzodiazepines such as lorazepam andoxazepam (Shaw 1995).

OxazepamOxazepam (Serax) often is favored by internistsand hepatologists treating alcohol withdrawalin patients with severe liver failure. It has a rel-atively short half-life of 6 to 8 hours. Itsmetabolism is very simple and it has nometabolites. The agent is relatively limited inthat its oral absorption is quite slow comparedto other benzodiazepines, it must be giventhree to four times a day, and is only availablein the United States in an oral form.

Ultimately, the experience of the treating clini-cian, characteristics of the patient, and the set-ting in which he will be treated will determinethe choice of drug. Although all benzodi-azepines are now generic in the United States,costs vary and this too may be a factor inchoice.

Limitations of benzodiazepines inoutpatient treatmentAlthough benzodiazepines remain the mainstayof treatment for alcohol withdrawal, they havelimitations that are particularly pronouncedwhen treating outpatients. Benzodiazepines’potential interactions with alcohol can lead tocoma and respiratory suppression, motor inco-

60 Chapter 4

ordination (leading to falls and automobileaccidents), and abuse of the medications.Abuse usually is in the context of the concur-rent use of alcohol, opioids, or stimulants.

There are two other limitations of benzodi-azepines that may be relevant in some clinicalsettings for some patients. First, although ben-zodiazepines have been studied for more than30 years and are effective for suppressing alco-hol withdrawal symptoms at any one episode,their ability to halt the progressive worseningof each successive alcohol withdrawal reactionis in question. There are now at least nine stud-ies that have found that an ever-increasingnumber of previous alcohol withdrawalsincreases the severity of withdrawal, particu-larly seizures and delirium tremens, anddecreases responsiveness to benzodiazepines(Ballenger and Post 1978; Booth and Blow1993; Brown et al. 1988; Gross et al. 1972;Lechtenberg and Worner 1990, 1992; Malcolmet al. 2000; Shaw et al. 1998; Worner 1996). Atenth study (Wojnar et al. 1999) found thatincreasing severity of alcohol withdrawal symp-toms was observed only in a minority (22 per-cent) of 418 repeatedly treated clients.However, within this group of one in five indi-viduals, seizures were three times more com-mon than in the larger, nonprogressive groupand premature age of death was 7 yearsyounger than for the nonprogressive group. In

the majority of these studies, patients weretreated with benzodiazepines, although in afew, phenobarbital was used.

A second, and at present more hypothetical,concern about benzodiazepine use to treat out-patients in alcohol withdrawal is that they may“prime” or reinstate alcohol use during theiradministration. Two preclinical studies supportthis premise (Deutsch and Walton 1977;Hedlund and Wahlstrom 1998). A recent ran-domized, blinded, clinical trial comparing car-bamazepine to lorazepam for the outpatienttreatment of alcohol withdrawal found that theoutpatients on lorazepam were three times aslikely to drink as those on carbamazepine. Thelorazepam group drank about twice as muchalcohol in the immediate post-detoxificationperiod than the carbamazepine group (Malcolmet al. 2002).

For a list of potential contraindications to usingbenzodiazepines to treat alcohol withdrawal incertain patients, see Figure 4-3.

Other medicationsBarbituratesBarbiturates have been used for nearly a cen-tury for the treatment of alcohol withdrawal.Most barbiturates, other than phenobarbital,have fallen into disfavor because of severe

61Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-3Potential Contraindications To Using Benzodiazepines To Treat

Alcohol Withdrawal

•Previous allergic reaction

•Previous paradoxical disinhibition (e.g., violence, agitation, self-harm)

•Previous serious adverse outcomes that could have medico-legal consequences if they re-occur (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.

lethal interactionswith alcohol, deathfrom overdose of theagents alone, rapidtolerance, and highabuse potential.Barbiturates arehighly addictive. Inclinical practice, themedication is effec-tive both for thetreatment of alcoholwithdrawal andsedative-hypnoticwithdrawal althoughfew controlled trialshave been conduct-ed with it (Wilbur

and Kulik 1981). Phenobarbital has a longhalf-life and may rapidly accumulate.Overdoses with phenobarbital also can be fatal.Members of the consensus panel recommend itsuse only in highly supervised settings.

AnticonvulsantsAnticonvulsants have been used in Europe fora quarter of a century for the treatment ofalcohol withdrawal. Carbamazepine (Atretol,Tegretol) has been shown in at least three trialsto be as effective as various benzodiazepines inmild to moderate alcohol withdrawal (Malcolmet al. 2001). Although less well studied, val-proic acid also has been shown to be effective(Reoux et al. 2001). Older, first-generationanticonvulsants have limitations in that theyonly have been studied in mild to moderatewithdrawal, can on rare occasions have serioushepatic and bone marrow toxicities, interactwith several other classes of medication, andare only available in oral forms. They are not,however, controlled substances, are notabused, and as previously noted, carba-mazepine may have the propensity to reducesome of the indices of drinking behavior imme-diately in the post-withdrawal treatment of out-patients. Newer drugs such as tiagabine, oxcar-bazepine, and gabapentin do not appear tohave these liabilities, but sufficient studies havenot been done to confirm their effectivenessand safety.

Other agentsBeta blockers and alpha adrenergic agonistssuch as clonidine have been used in the treat-ment of alcohol withdrawal. They do not pre-vent seizures in delirium and have only modestbenefits for ameliorating symptoms of with-drawal. However, some patients will havetachycardia (rapid heartbeat) and hyperten-sion (high blood pressure) that will not be con-trolled by benzodiazepines, and beta blockersand alpha adrenergic agonists can be of use inthese patients. Calcium channel antagonists willalso ameliorate some symptoms of alcohol with-drawal. As with beta blockers and clonidine,calcium channel antagonists should be consid-ered adjunctive therapy primarily to manageextreme hypertension during withdrawal.

AntipsychoticsAntipsychotics have long been used to controlextreme agitation, hallucinations, delusions,and delirium during alcohol withdrawal. Older,low-potency drugs such as chlorpromazine gen-erally are avoided since they can reduce theseizure threshold. High-potency drugs such ashaloperidol (Haldol) also can reduce theseizure threshold, but less commonly.Haloperidol and related agents are availablefor oral, intramuscular, and IV administration.Clinicians should note that since antipsychoticscan lower the seizure threshold, their use dur-ing alcohol withdrawal should be undertakenwith great care and close supervision of thepatient is required.

Relapse prevention agentsRelapse prevention agents such as naltrexoneand acamprosate are under consideration asadditional therapies during late withdrawaltreatment, although they are not effective foralcohol detoxification. Since one-third to one-half of outpatients detoxifying with benzodi-azepines will either drink or leave treatmentprematurely, naltrexone and acamprosate maybe valuable in assisting in reducing the proba-bility of the individual drinking during latedetoxification. High-dose naltrexone therapyhas been associated with some liver toxicity,but this has not been reported in individualstaking therapeutic doses to enhance relapse

62 Chapter 4

Delirium and

seizures are the

two most

pathological

responses seen in

alcohol

withdrawal.

prevention. Acamprosate may produce diar-rhea and this may be already present in someindividuals in alcohol withdrawal. Thus far nowell-controlled studies have been conducted toprovide guidelines as to when these medicationsshould be introduced during detoxification orwhether it would be better to wait until theearly phase of rehabilitation. For an extendedreview, see Kranzler and Jaffe (2003).

Other medicationsAbecarnil (Anton et al. 1997), and more recent-ly baclofen (Addolorato et al. 2002), have bothshown promise in the treatment of alcohol with-drawal. However, insufficient information hasbeen accumulated on these drugs, and there-fore they are not recommended for use in clini-cal patient settings. Their use in alcohol with-drawal should be considered experimental andpremature for the present.

Management of Delirium andSeizures Delirium and seizures are the two most patho-logic responses seen in alcohol withdrawal. Themajor goal of medical management is to avoidseizures and a special state of delirium calleddelirium tremens (DTs) with aggressive use ofthe primary detoxification drug (e.g., higherdoses of a benzodiazepine). Prevention isessential where DTs are concerned. DTs do notdevelop suddenly but instead progress fromearlier withdrawal symptoms. Properly admin-istered symptom-triggered medicationapproaches will prevent DTs and limit over-medication that can occur when high-dose ben-zodiazepines are administered without regardto clinical response. It can be challenging clini-cally to differentiate impending DTs versusbenzodiazepine toxicity on day 3 of detoxifica-tion. When in doubt, in most cases it is safer toovermedicate than to undertreat and allow DTsto develop. Flumazenil (Romazicon) can beused to reverse benzodiazepine overdose.

Death and disability may result from DTs orseizures without medical care. Several factorsare related to severity of alcohol withdrawal:high amounts of alcohol being consumed in the

weeks prior to treatment, the severity of thelast withdrawal episodes, and the number ofpreviously treated or untreated withdrawalepisodes. Other factors such as increasing age;the patient’s general health, including nutri-tional status; the presence of co-occurring med-ical, surgical, and psychiatric disorders; andthe use of medications (prescription, over-the-counter, or herbal) also can amplify severity ofwithdrawal symptoms. Early proper medicalmanagement of alcohol withdrawal reduces theprobability of these complications, assumingearly recognition.

For patients with a history of DTs or seizures,early benzodiazepine treatment is indicated atthe first clinical contact setting (e.g., doctor’soffice, clinic, urgent care, emergency depart-ment). Patients with severe withdrawal symp-toms, multiple past detoxifications (more thanthree), and co-occurring unstable medical andpsychiatric conditions should be managed simi-larly.

Once an initial clinical screening and assess-ment have been made, and the diagnosis is rea-sonably certain, medication should be given.Giving the patient a benzodiazepine should notbe delayed by waiting for the return of labora-tory studies, transportation problems, or theavailability of a hospital bed. Early thiamineand multivitamin administration also should bedone at this time. Once full DTs have devel-oped, they tend to run their course despitemedication management, and there is little evi-dence in the medical literature to suggest thatany medication treatment can immediatelyabort DTs.

Patients presenting in severe DTs should haveemergency medical transport to a qualifiedemergency department and generally willrequire hospitalization. If the DTs are severe,patients may need to be placed in an intensivecare unit (ICU), and in such settings continu-ous monitoring of cardiac rhythm, pulse, bloodpressure, oxygen saturation, temperature, andrespiration rates begins with the emergencymedical system and continues in the emergencydepartment and ICU.

63Physical Detoxification Services for Withdrawal From Specific Substances

Early care will depend on medical and surgicalcomplications and may involve protocols fromadvanced cardiac life support (ACLS) and/oradvanced trauma life support. Correction offluids and electrolytes (salts in the blood),hyperthermia (high fever), and hypertensionare vital. Loading doses (rapid administrationof initial high doses) of IV diazepam orlorazepam are recommended, as are IV thi-amine (prior to IV glucose) and multiple vita-mins. The physician should consider intramus-cular or intravenous haloperidol (Haldol andothers) to treat agitation and hallucinations.Nursing care is vital, with particular attentionto medication administration, patient comfort,soft restraints, and frequent contact with ori-enting responses and clarification of environ-mental misperceptions.

Alcohol withdrawal seizures represent anothermanagement challenge (Ahmed et al. 2000),since no large-scale clinical studies have beenconducted to establish firmly best treatmentpractices. The majority of alcohol withdrawalseizures occur within the first 48 hours aftercessation or reduction of alcohol, with peakincidence around 24 hours (Victor and Adams1953). Most alcohol withdrawal seizures aresingular, but if more than one occurs they tendto be within several hours of each other. Whilealcohol withdrawal seizures can occur severaldays out, a higher index of suspicion for othercauses is prudent. Someone experiencing analcohol withdrawal seizure is at greater risk forprogressing to DTs, whereas it is extremelyunlikely that a patient already in DTs will alsothen experience a seizure.

The occurrence of an alcohol withdrawalseizure happens quickly, usually without warn-ing to the individual experiencing the seizure oranyone around him. The patient loses con-sciousness, and if seated usually slumps over,but if standing will immediately fall to the floor.The patient’s body is rigid, and breathing ceas-es. This part of the seizure is called the tonicphase, which usually lasts for a few secondsand rarely more than a minute.

The next part of the seizure (more dramaticand generally remembered by witnesses) con-

sists of jerking of head, neck, arms, and legs.Breathing resumes during this clonic phase ofthe seizure but may be irregular. During theclonic phase, the lips, tongue, or inside of thecheeks may be bitten. Involuntary urination ora bowel movement may occur. Immediatelyafter the jerking ceases, the patient generallyhas a period of what appears to be sleep withmore regular breathing. Vomiting may occur atthis time. The period of sleep may be a few sec-onds with awakening or a few minutes. Rarely,the patient may appear not to waken at all andhave a second period of rigidity followed bymuscle jerking. This is known as status epilep-ticus. Upon awakening, the individual usuallyis mildly confused as to what has happened andmay be disoriented as to where she or he is.This period of post-seizure confusion generallylasts only for a few minutes but may persist forseveral hours in some patients. Headache,sleepiness, nausea, and sore muscles may per-sist in some individuals for a few hours. See thetext box on the next page for what to do in theevent of a seizure.

Patients who start to retch or vomit should begently placed on their side so that the vomitus(stomach contents vomited) may exit the mouthand not be taken into the lungs. Vomitus takeninto the lungs is a severe medical conditionleading to immediate difficulty breathing and,within hours, severe pneumonia.

Predicting who will have a seizure during alco-hol withdrawal cannot be accomplished withany great certainty. There are some factorsthat clearly increase the risk of a seizure, buteven in individuals with all of these factors,most patients will not have a seizure. Out of100 people experiencing alcohol withdrawalonly two or three of them will have a seizure.The best single predictor of a future alcoholwithdrawal seizure is a previous alcohol with-drawal seizure. Individuals who have had threeor more documented withdrawal episodes inthe past are much more likely to have a seizureregardless of other factors including age, gen-der, or overall medical health. However, cer-tain other factors may increase the risk ofseizures for all patients:

64 Chapter 4

•Having drunk for more than two decades

•Having poor general medical health and poornutritional status

•Having had previous head injuries

•Having had disturbances of serum calcium,sodium, potassium, or magnesium

Patients having a witnessed seizure can betreated with IV diazepam or lorazepam andACLS protocol procedures. This reduces butdoes not completely prevent the likelihood of asecond seizure (D’Onofrio et al. 1999). In therare patient with recurrent multiple seizures orstatus epilepticus (continuous seizures of sever-al minutes) an anesthesiology consultation maybe required for general anesthesia. Evaluationof electrolyte disturbances, central nervous sys-tem (CNS) trauma, and consideration of seda-tive-hypnotic withdrawal should be reviewed.

Patients who have had a single witnessed orsuspected alcohol withdrawal seizure shouldbe immediately given a benzodiazepine,

preferably with IV administration. The studyby D’Onofrio and colleagues (1999) indicatedthat a single dose of 1mg of IV lorazepamreduced recurrent seizure risk, reduced ratesof return to emergency departments, and low-ered hospitalization rates. Despite thisreport, the consensus panel agrees that hospi-talization for further detoxification treatmentis strongly advised to monitor and ameliorateother withdrawal symptoms, reduce suffering,and stabilize the patient for rehabilitationtreatment.

The addition of anti-epileptic drugs (AEDs)has not been established as effective (Chance1991; Hillbom and Hjelm-Jager 1984; Rathlevet al. 1994). This is primarily based on evalu-ations of phenytoin (Dilantin and others).Newer AEDs have not been studied extensive-ly for preventing alcohol withdrawal seizures.The consensus panel suggests that AED thera-py should be considered in alcohol withdraw-al patients with multiple past seizures (of anycause), a history of recent head injury, past

65Physical Detoxification Services for Withdrawal From Specific Substances

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 forthe clinic or hospital unit.

•While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attemptto prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s headand body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seenby anyone.

•In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head fromextreme head-banging by placing a soft object under the head and neck. Sometimes placing one’s hand orshoe 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 partiallyswallowed and obstruct the airway.

•Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomachcontents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is asevere 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 aseizure, it is strongly recommended that he be referred for medical evaluation.

•Individuals who awaken confused and disoriented should be given brief reassuring and soothing messagesto reorient them as to what happened and where they are.

meningitis, encephalitis, or family history ofseizures. Further evaluation of a first seizureoften warrants neurologic evaluation (com-puterized tomography and electroencephalo-gram), even if the seizure may be suspected tohave been due to alcohol withdrawal.

Patient Care and ComfortInterpersonal support and hygienic care alongwith adequate nutrition should be provided.Staff assisting patients in detoxification shouldprovide whatever assistance is necessary tohelp get patients cleaned up after entering thefacility and bathed thoroughly as soon as theyhave been medically stabilized. Attention to thetreatment of scabies, body lice, and other skinconditions should be given. Screening fortuberculosis should be done. Dental and oralcare should be made available. The patientshould be screened for physical trauma,including bruises and lacerations. Tetanusimmunization may be necessary. Patients withan altered mental status or altered level of con-sciousness should be seen in emergency depart-ments, evaluated, and possibly hospitalized.Staff should continue to observe patients forhead injuries after admission because somehead injuries, such as subdural hematomas,may not immediately be evident and cost con-siderations may preclude obtaining a brainscan in some settings.

Other Immediate ConcernsAlcohol may interact with several classes ofmedicine to produce serious CNS depression.Some examples include benzodiazepines, barbi-turates, meprobamate, and other sedative hyp-notic groups. Metoclopramide and sedatingantipsychotic medicines such as phenothiazinesalso can produce CNS suppression. A disulfi-ram-like (Antabuse) reaction characterized byflushing, sweating, tachycardia, nausea, andchest pain has been reported for metronidazoleand several antibiotics including, but not limit-ed to, cefamandole, cefoperazone, and cefote-tan. Acetaminophen in low doses may actacutely with alcohol to produce hepatotoxicity(liver damage). Clinicians also should deter-

mine whether the patient is using aspirin ornonsteroidal anti-inflammatory medications(for example, Motrin or Advil, both containingibuprofen) in conjunction with alcohol use.Antidiabetic agents in concert with alcohol mayproduce hypoglycemia (low blood sugar) andlactic acidosis (blood that has become tooacidic). The therapeutic efficacy and margin ofsafety for the use of anti-anxiety medications,antidepressants, and antipsychotic medicationis thought by some to be lessened by alcoholuse, but this is based largely on anecdotalinformation. Alcohol interacts with numerousother classes of medications that lead to lessserious results. Some important examples aresedatives, tranquilizers, antiseizure medica-tions, and anticoagulants (blood thinners) suchas Coumadin. Patients who may be taking suchmedications need to be carefully observed andhave their medications carefully monitored.

OpioidsOpioids are highly addicting, and their chronicuse leads to withdrawal symptoms that,although not medically dangerous, can be high-ly unpleasant and produce intense discomfort.All opioids (e.g., heroin, morphine, hydromor-phone, oxycodone, codeine, and methadone)produce similar effects by interacting withendogenous (produced by the body itself) opi-oid (:, *, and 6) receptors (that is, specific siteson cells where these substances bind to thecell). Opioid agonists stimulate these receptorsand opioid antagonists block them, preventingtheir action.

Opioid Withdrawal SymptomsAll opioid agents produce similar withdrawalsigns and symptoms with some variance inseverity, time of onset, and duration of symp-tomatology, depending on the agent used, theduration of use, the daily dose, and the intervalbetween doses. For instance, heroin withdrawaltypically begins 8 to 12 hours after the lastheroin dose and subsides within a period of 3to 5 days. Methadone withdrawal typicallybegins 36 to 48 hours after the last dose, peaks

66 Chapter 4

after about 3 days, and gradually subsides overa period of 3 weeks or longer. Physiological,genetic, and psychological factors can signifi-cantly affect intoxication and withdrawal sever-ity. Figure 4-4 summarizes many of the com-mon signs and symptoms of opioid intoxicationand withdrawal.

The clinician uses intoxication and withdraw-al measures as guides to avoid under- or over-medicating patients during medically super-vised detoxification; the number and intensityof signs determine the severity of opioid with-drawal. It is important to appreciate thatuntreated opioid withdrawal gradually buildsin severity of signs and symptoms and thendiminishes in a self-limited manner. Repeatedassessments should be made during detoxifi-cation to determine whether symptoms areimproving or worsening. Repeated assess-ments also should address the effectiveness ofpharmacological interventions. Detoxificationstrategies should aim to establish control over

the opioid withdrawal syndrome, after whichdose reductions can be made gradually.

Medical complications associated with opioidwithdrawal can develop and should be quick-ly identified and treated. Unlike alcohol andsedative withdrawal, uncomplicated opioidwithdrawal is not life-threatening. Rarely,severe gastrointestinal symptoms produced byopioid withdrawal, such as vomiting or diar-rhea, can lead to dehydration or electrolyteimbalance. Most individuals can be treatedwith oral fluids, especially fluids containingelectrolytes, and some might require intra-venous therapies. In addition, underlyingcardiac illness could be made worse in thepresence of the autonomic arousal (increasedblood pressure, increased pulse, sweating)that is characteristic of opioid withdrawal.Fever may be present during opioid with-drawal and typically will respond to detoxifi-cation. Other causes of fever should be evalu-ated, particularly with intravenous users,

67Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal

Opioid Intoxication Opioid Withdrawal

SignsBradycardia (slow pulse)Hypotension (low blood pressure)Hypothermia (low body temperature)SedationMeiosis (pinpoint pupils)Hypokinesis (slowed movement)Slurred speechHead nodding

SymptomsEuphoriaAnalgesia (pain-killing effects)Calmness

SignsTachycardia (fast pulse)Hypertension (high blood pressure)Hyperthermia (high body temperature)InsomniaMydriasis (enlarged pupils)Hyperreflexia (abnormally heightened reflexes)Diaphoresis (sweating)Piloerection (gooseflesh) Increased respiratory rate Lacrimation (tearing), yawningRhinorrhea (runny nose)Muscle spasms

SymptomsAbdominal cramps, nausea, vomiting, diarrheaBone and muscle painAnxiety

Source: Consensus Panelist Charles Dackis, M.D.

because HIV infec-tion, viral hepati-tis, abscesses,infected injectionsites, and pneumo-nia occur common-ly in this popula-tion and alwaysrequire medicalattention. Anxietydisorders, especial-ly those involvingpanic anxiety, alsomight showincreased intensityduring opioid with-drawal. Finally,any conditioninvolving pain islikely to worsenduring opioid with-drawal because of areduced painthreshold and thelack of analgesia(pain relief) afford-ed by opioid use.

This phenomenon is particularly commonwith dental pain and chronic back pain.

Management of WithdrawalWithout MedicationsIt is not recommended that clinicians attemptto manage significant opioid withdrawal symp-toms (causing discomfort and lasting severalhours) without the effective detoxificationagents discussed below. Even mild levels of opi-oid use commonly produce uncomfortable lev-els of withdrawal symptomatology.Management of this syndrome without medica-tions can produce needless suffering in a popu-lation that tends to have limited tolerance forphysical pain.

Management of WithdrawalWith MedicationsThe management of opioid withdrawal withmedications is most commonly achievedthrough the use of methadone (in addition toadjunctive medications for nausea, vomiting,diarrhea, and stomach cramps). Federal regu-lations restrict the use of methadone for opioidwithdrawal to specially licensed programs,except in cases where the patient is hospitalizedfor treatment of another acute medical condi-tion. Methadone is the most frequently usedagent approved for detoxification by the Foodand Drug Administration (FDA), and a newmedication, buprenorphine (discussed below),has been approved for use. Methadone can beused for detoxification from heroin and all opi-oid agonists.

Another commonly used agent is clonidine(Gold et al. 1984), an α-adrenergic agonistthat relieves most opioid withdrawal symp-toms without producing opioid intoxication ordrug reward. However, since clonidine detox-ification is less effective against many opioidwithdrawal symptoms, adjunctive medicinesoften are necessary to treat insomnia, musclepain, bone pain, and headache. Adjunctiveagents should not be used in the place of anadequate detoxification dosage. Additionalopioid agonists could be used theoretically fordetoxification but would have to be adminis-tered “off label,” because the FDA hasapproved only methadone for this purpose.Off-label use (prescribing an agent approvedfor another condition) could be difficult tojustify, given the efficacy of methadone inreversing opioid withdrawal.

Detoxification is indicated for treatment-seek-ing persons who display signs and symptomssufficient to warrant treatment with medica-tions and for whom maintenance is declinedor for some reason is not indicated or practi-cal. In addition, individuals dependent onopioids sometimes are hospitalized for otherhealth problems and may require hospital-based detoxification even though they are not

68 Chapter 4

Methadone is the

most frequently

used agent

approved for

detoxification by

the FDA, and a

new medication,

buprenorphine,

has been

approved for use.

seeking substance abuse treatment. Suchpatients also can be maintained on methadoneduring the course of hospitalization for anycondition other than opioid addiction. Thehospital does not have to be a registered opi-oid treatment program, as long as the patientwas admitted for a detoxification treatmentfor some substance other than opioids. Onthe other hand, some persons may not haveused sufficient amounts of opioids to developwithdrawal symptoms, and for others suffi-cient time may have elapsed since their lastdose to extinguish withdrawal and eliminatethe need for detoxification.

Methadone This section discusses methadone as an agentfor detoxification. For detailed informationon methadone maintenance, readers arereferred to TIP 43 Medication-AssistedTreatment for Opioid Addiction in OpioidTreatment Programs (CSAT 2005d). Whilemethadone is one of the more common medi-cations for opioid detoxification, its use ishighly regulated and it can only be prescribedfor withdrawal by a doctor at a SubstanceAbuse and Mental Health ServicesAdministration (SAMHSA)-certifiedmethadone clinic or if the patient is beinghospitalized for another medical condition.(Detoxification programs may become certi-fied to prescribe methadone by undergoingthe process described in TIP 43.) Federal reg-ulations allow for the use of methadone inboth a short-term detoxification treatment ofless than 30 days and a long-term treatmentof 30 to 180 days. The regulations also specifythat if a patient has failed two detoxificationattempts in a 12-month period he or she mustbe evaluated for a different course of treat-ment (e.g., ongoing opioid substitution therapy).

Methadone is a long-acting agonist at the :-opi-oid receptor site that, in effect, displaces hero-in (or other abused opioids) and restabilizes thesite, thereby reversing opioid withdrawal symp-toms. If maintained for long enough, this stabi-lizing effect can even reverse the immunologic

and endocrinologic defects caused by long-termheroin addiction. This is one of many impor-tant reasons to consider conversion to mainte-nance during most methadone detoxificationadmissions.

Once the dose requirement for methadone hasbeen established, methadone can be givenonce daily and generally tapered over 3 to 5days in 5 to 10mg daily reductions. The initialdose requirement is determined by estimatingthe amount of opioid use and gauging thepatient’s response to administeredmethadone. Clinicians should take care not tounderdose patients with methadone; adequatedosage is vitally important. Patients some-times exaggerate their daily consumption toreceive greater dosages of methadone. Forthis reason, history is no substitute for aphysical examination that screens for signs ofopioid withdrawal. Treating clinicians shouldnot only be familiar with the intoxication andwithdrawal signs that are set forth in Figure4-4 (p. 67), but also should be skilled in dis-cerning these features of opioid withdrawal.Avoidance of overmedicating is crucial duringmethadone detoxification because excessivedoses of this agent can produce overdose,whereas opioid withdrawal does not constitutea medical danger in otherwise healthy adults.For more information on methadone andother medications used to treat opioid addic-tion, see TIP 43, Medication-AssistedTreatment for Opioid Addiction in OpioidTreatment Programs (CSAT 2005d).

Patients with significant opioid dependencemay require a starting dose of 30 to 40mg perday; this dose range should be adequate foreven the most severe withdrawal. If thedegree of dependence is unclear, withdrawalsigns and symptoms can be reassessed 1 to 2hours after giving a dose of 10mg ofmethadone. The practice of giving a dose ofmethadone and later assessing its effect (alsotermed a challenge dose) is an importantintervention of detoxification. Sedation orintoxication signs after a methadone challengedose indicate a lower starting dose. Similarly,intoxication at any point of the detoxification

69Physical Detoxification Services for Withdrawal From Specific Substances

signals the need to hold or more rapidly wean(reduce to a zero dose) the methadone. Careshould be taken to avoid giving methadone tonewly admitted patients with signs of opioidintoxication, since overdose could result.Note that methadone stabilization is the treat-ment of choice for patients who are pregnantand opioid dependent.

Clonidine (Catapres)Clonidine was originally marketed andapproved for the treatment of high blood pres-sure but also has been used for opioid detoxifi-cation since 1978. While clonidine is not FDAapproved for treatment of opioid withdrawal, itis widely used “off label” for this purpose(Alling 1992) because the research literaturesubstantiates its effectiveness for this condition.Advantages of clonidine over methadone in thetreatment of opioid withdrawal are as follows:

•Clonidine does not produce opioid intoxica-tion and is not reinforcing.

•The FDA does not classify clonidine as havingabuse potential. Yet some abuse has beenreported. (See p. 107 under the section onpregnant women and opioids.)

•Since clonidine does not interact with the :-opioid receptor, detoxification occurs without opioids.

•No special licensing is required for the dis-pensing of this medication.

One disadvantage to methadone detoxificationwith naltrexone (an opioid antagonist), com-pared with clonidine, is that naltrexone, whenit is prescribed for abstinence, can precipitateopioid withdrawal if given too soon after thelast methadone dose. This problem does notexist with clonidine, making this agent particu-larly beneficial in a drug-free treatment pro-gram or a therapeutic community.

Nevertheless, patients addicted to opioidsgenerally prefer methadone over clonidinedetoxification. Although clonidine alleviatessome symptoms of opioid withdrawal, it usu-ally is relatively ineffective for insomnia,

muscle aches, and drug craving. Completionrates for opioid detoxification using clonidinehave been low (ranging from 20 to 40 per-cent); those patients who complete the proce-dure are more likely to be dependent on opi-oids other than heroin, have private healthinsurance, and report lower levels of subjec-tive withdrawal symptoms than those who donot complete (Strobbe et al. 2003).

An appropriate protocol for clonidine is0.1mg administered orally as a test dose. Adose of 0.2mg might be used initially forpatients with severe signs of opioid withdraw-al or for those patients weighing more than200 pounds. The sublingual (under thetongue) route of administration also may beused. Clinicians should check the patient’sblood pressure prior to clonidine administra-tion and clonidine should be withheld if sys-tolic blood pressure is lower than 90 or dias-tolic blood pressure is below 60. Theseparameters can be relaxed to 80/50 in somecases if the patient continues to complain ofwithdrawal and is not experiencing symptomsof orthostatic hypotension (a sudden drop inblood pressure caused by standing).Clonidine (0.1 to 0.2mg orally) can then begiven every 4 to 6 hours on an as-neededbasis. Clonidine detoxification is best con-ducted in an inpatient setting, as vital signsand side effects can be monitored more close-ly in this environment. In cases of severewithdrawal, a standing dose (given at regularintervals rather than purely “as needed”) ofclonidine might be advantageous (Alling1992). The daily clonidine requirement isestablished by tabulating the total amountadministered in the first 24 hours, and divid-ing this into a three or four times per daydosing schedule. Total clonidine should notexceed 1.2mg the first 24 hours and 2.0mgafter that, with doses being held in accor-dance with parameters noted above. Thestanding dose is then weaned over severaldays. Clonidine must be tapered to avoidrebound hypertensions.

The clonidine transdermal (administeredthrough the skin) patch, FDA approved in

70 Chapter 4

1986 for the treatment of hypertension (highblood pressure), also is used in opioid detoxi-fication. However, the safety of the patch fortreatment of opioid withdrawal has not beensufficiently studied in controlled clinical tri-als. The transdermal route of administrationhas the disadvantage of continued clonidineaction even after the patch has been removed.Blood pressure effects of clonidine can there-fore be prolonged, leading to undesirable andpersistent reductions of blood pressure. Forthis reason, it has been recommended that thepatch be used only if the patient’s blood pres-sure is monitored regularly (Alling 1992).

The clonidine patch is available in three sizes that deliver a total daily oral equivalentclonidine dose of 0.2mg (3.5 cm2), 0.4mg (7.0cm2), or 0.6mg (10.5 cm2). The patch suppliesclonidine for up to 7 days and one patchapplication usually is sufficient. The conve-nience of one application allows the clinicianto avoid the disruption that multiple dosingmight have during rehabilitative program-ming. In particular, patients can focus onrehabilitative treatment without being dis-tracted by the need to ask repeatedly for oralclonidine doses. Vital signs should be moni-tored at least four times daily to assess persis-tent signs and symptoms of withdrawal orundesirable effects of clonidine on blood pres-sure.

BuprenorphineBuprenorphine, a partial α-opioid agonist thatis FDA approved in an injectable form(Buprenex) for the treatment of pain, hasrecently been approved as a detoxificationagent and for opioid maintenance treatment asan alternative to methadone maintenance. Anumber of clinical trials have reported it to beeffective for heroin detoxification (Becker et al.2001; Bickel et al. 1988; Diamant et al. 1998),and the medication should play an importantrole in gradually removing patients frommethadone maintenance (Amass et al. 2004;Banys et al. 1994; Johnson et al. 2000).

Buprenorphine is available in oral form asSubutex, which contains only buprenorphine,and is meant for patients who are startingtreatment for drug dependence. Anotherform, Suboxone, contains buprenorphine andnaloxone and is intended for persons depen-dent on opioids who have already started andare continuing medication therapy.Buprenorphine has great affinity for the :-opioid receptor, inspite of being only apartial agonist, andcan displace otheropioids such as hero-in. This feature givesbuprenorphine theability to precipitateopioid withdrawalwhen administered topatients who haverecently used heroin(Kosten andMcCance-Katz 1995).

An advantage tobuprenorphine is itssafety. Because ofthe partial agonistaction, buprenor-phine has a “ceilingeffect” with regard tooverdose potential(Walsh et al. 1994).That is, unlikemethadone, whichproduces increasingrespiratory suppression with increasing dose,respiratory effects of buprenorphine tend tolevel off due to its partial agonist action.Another advantage of buprenorphine is thatit can be dispensed at a physician’s office,unlike methadone, which can be dispensedonly at designated treatment centers. Thismakes access to this medication for opioiddependence much more convenient for bothpatient and clinician. See TIP 40, ClinicalGuidelines for the Use of Buprenorphine inthe Treatment of Opioid Addiction (CSAT2004a).

71Physical Detoxification Services for Withdrawal From Specific Substances

One advantage of

buprenorphine is

that it can be

dispensed at a

physician’s office,

unlike methadone,

which can be

dispensed only at

designated treat-

ment centers.

Unlike methadone, buprenorphine may beprescribed by physicians who are not con-nected with a certified opioid treatment pro-gram. However, there is a still a specific

training and certifi-cation processphysicians mustundergo in order toprescribe the medi-cation. Informationon the legal aspectsof prescribingbuprenorphine andrules for carryingout detoxification inthe physician’soffice can be foundat www.buprenor-phine.samhsa.gov/.Information givenat the site includesthe following on theDrug AddictionTreatment Act(DATA) of 2000:“[DATA 2000]expands the clinicalcontext of medica-tion-assisted opioid

addiction treatment by allowing qualifiedphysicians to dispense or prescribe specifical-ly approved Schedule III, IV, and V narcoticmedications for the treatment of opioid addic-tion in treatment settings other than the tra-ditional Opioid Treatment Program (i.e.,methadone clinic). In addition, DATA 2000reduces the regulatory burden on physicianswho choose to practice opioid addiction ther-apy by permitting qualified physicians toapply for and receive waivers of the specialregistration requirements defined in theControlled Substances Act” (SAMHSA 2002).

Terminating MethadoneMaintenance TreatmentIndividuals seeking the discontinuation ofmethadone maintenance require a much morelengthy detoxification process than that

described above for heroin. The methadonedose should be tapered gradually by 5 to10mg/week until a daily dose of 30 to 40mg hasbeen attained. At that time, detoxification witheither clonidine or smaller doses of methadonecan be instituted. The use of clonidine has theadvantage of brevity as a complete clonidinedetoxification usually can be conducted within2 to 3 weeks (Gold et al. 1984).

Once the daily dose requirement has beenestablished by using the principles outlinedabove, the patient can be placed on a stand-ing dose of clonidine. The dose required usu-ally is in the range of 0.2mg, three to fourtimes daily, although titration (adjustment ofdosage in light of drug response) is necessarybased on the information gathered during theclinical examination. Additional doses asneeded (sometimes abbreviated “PRN”) of0.2mg clonidine also can be given and bloodpressure parameters must be followed priorto the administration of standing and PRNdoses to avoid orthostatic hypotension. Theinitial standing dose can be reduced to 0.1mg,given three to four times daily, after one weekof detoxification, with PRN doses of 0.1mgavailable. After a period of 1 week on thisreduced dosage, clonidine is given for anadditional week only if needed. Because cloni-dine does not reverse all opioid withdrawalsymptoms, especially insomnia, adjunctivemedications for symptom relief of insomnia,nausea, diarrhea, etc. usually are required.Clonidine detoxification is best conducted onan inpatient basis to ensure appropriate vitalsign monitoring. Inpatient treatment alsoreduces the impulse to relapse, especially ifthe detoxification is difficult.

Methadone detoxification can be continuedonce a daily dose of 30 to 40mg is achieved, asdescribed above. The dose can be reduced to20mg per day by a reduction of 5 to10mg/week. Once the patient is on 20mg/day,methadone can be reduced by 1 to 2mg daily,depending on clinical measures of withdraw-al. As with clonidine detoxification, the final2 to 3 weeks of methadone detoxification isassociated with recidivism (relapsing).

72 Chapter 4

Inpatient

treatment can

provide additional

support, medical

supervision, and

rehabilitative

treatment that

serve as

disincentives to

relapse.

Inpatient treatment, if available, can provideadditional support, medical supervision, andrehabilitative treatment that serve as disin-centives to relapse.

Rapid and UltrarapidDetoxificationAlthough there are few data showing that therapid or ultrarapid methods of opioid detoxifi-cation show a positive correlation with the like-lihood of a patient’s being abstinent a fewmonths later, efforts persist to make the detoxi-fication process shorter and easier. This stemsin part from the desire of the person addictedto opioids for a rapid, painless procedure, andin part from an attempt to coax more such per-sons into treatment (fewer than one in five peo-ple with substance use disorders in the UnitedStates are in treatment at any time) (Office ofNational Drug Control Policy 2002). Anothercontributing factor is the American culture’ssearch for rapidity in most endeavors. Finally,the desire for rapid opioid detoxification is aremnant of the belief system of a century ago,when detoxification often was erroneouslyequated with cure.

Rapid methods of detoxification have at theircore the use of narcotic antagonists; for exam-ple, naloxone, naltrexone, or nalmefene, toprecipitate narcotic withdrawal by displacingexogenous opioids (those not produced by thebody itself) from the receptor sites. The ensu-ing severe symptoms then are managed by avariety of medications and techniques. Thisprocedure was tried in the mid-1970s (Blachlyet al. 1975; Resnick et al. 1977), using naloxonecombined with benzodiazepines or propranololto ameliorate symptoms, but relief was insuffi-cient for the technique to be considered useful.

With the discovery of clonidine as a nonopi-oid that could successfully treat much of thewithdrawal syndrome (Gold et al. 1978), themethod became more successful, but was stillproblematic. Using combinations of clonidine,naltrexone, benzodiazepines, and otheradjunct medications, the method was refined

and shortened during the 1980s (Charney etal. 1982, 1986; Kleber et al. 1987; Riordanand Kleber 1980; Vining et al. 1988) so that ablocking dose of naltrexone—at least 25mg—usually was used by the second or third dayof treatment. The rate-limiting factor of thisrapid clonidine-naltrexone method is itscapacity to adequately relieve the precipitat-ed withdrawal symptoms in the consciouspatient. Golden and Sakhrani (2004) foundthat 25 percent of the 20 patients they studiedwho were undergoing rapid detoxificationusing clonidine and naltrexone developeddelirium and had to discontinue the proce-dure after the first day, and another patientdropped out before completion.

The 1990s witnessed a variety of attempts toovercome this barrier by using general anes-thesia or heavy sedation. Although the ultra-rapid procedure under anesthesia hasreceived wide publicity, controlled studiesthat would make it possible to evaluate therisk/benefit ratio are absent. The procedureis still unproven and controversial. For abrief review of studies done in this area, seeStine and colleagues (2003).

Patient Care and ComfortOpioid detoxification, when properly conduct-ed, usually can be concluded without signifi-cant patient discomfort. Aside from the com-passionate goal of preventing unnecessary suf-fering, appropriate opioid detoxificationstrengthens the therapeutic alliance betweenthe patient and clinician and prevents patientsfrom leaving treatment prematurely.Discomfort also can indicate that too low a doseof the detoxification agent is being adminis-tered. Mere symptomatic treatment is not asubstitute for reversing opioid withdrawal and care should be taken to avoid maskingsymptoms that would better respond to detoxification.

Nevertheless, patients receiving adequatedetoxification doses still may complain ofsymptoms that can be treated with adjunctive

73Physical Detoxification Services for Withdrawal From Specific Substances

medications. Insomnia can be treated withdiphenhydramine (Benadryl) 50 to 100mg,trazodone (Desyrel) 75 to 200mg, or hydrox-yzine (Vistaril) 25 to 50mg at bedtime.Benzodiazepines should be avoided unlessrequired for concomitant alcohol or sedativedetoxification. Headache, muscle aches, andbone pain can be managed with acetamin-ophen (e.g., Tylenol), aspirin, or ibuprofen(e.g., Motrin) as needed. Abdominal crampsare rare when the detoxification dose is suffi-cient but can be ameliorated with dicyclomine(e.g., Bentyl) 10 to 20mg every 6 hours.Mylanta or Maalox can be administered forepigastric complaints and bismuth subcar-bonate (e.g., Pepto-Bismol) 30 cc can be givenevery 2 to 3 hours for diarrhea. Constipation,a frequent complaint during methadone main-tenance, usually can be managed with milk ofmagnesia at 30 cc daily.

Opioid dependence, particularly intravenousheroin dependence, is associated with a num-ber of medical conditions. For this reason, acomplete physical examination, review of sys-tems, and laboratory evaluation (when indi-cated) should be conducted. The patientshould be screened for tuberculosis as well asfor commonly encountered medical complica-tions. These include HIV/AIDS, viral hepati-tis (especially B and C), other sexually trans-mitted diseases, and opportunistic infections.Injection sites should be examined for infec-tion or abscess and patients should bequeried about night sweats, chills, nutritionalintake, diarrhea and gastrointestinal distress,fever, and cough. History or evidence of trau-ma also should be elicited as part of a com-prehensive assessment upon which a fulltreatment plan will be based. In general,patients should be ambulatory and able toparticipate in rehabilitative activities duringdetoxification. However, during the first 24hours they may require bed rest or reducedactivity.

Benzodiazepines and Other Sedative-Hypnotics

Intoxication and WithdrawalSymptoms Associated WithBenzodiazepines and OtherSedative-HypnoticsPatients intoxicated with sedative-hypnoticsappear similar to individuals intoxicated withalcohol. Slurred speech, ataxia, and poor phys-ical coordination are prominent. If benzodi-azepines are used alone, breath and blood alco-hol levels should be zero. It should be remem-bered that benzodiazepines, when ingestedalone, intentionally, or accidentally in over-dose, rarely lead to death by themselves.Unfortunately, most individuals who ingestbenzodiazepines also may be using alcohol,other sedative-hypnotics, or other drugs ofabuse, which in combination with benzodi-azepines could be fatal if not managed appro-priately.

Management of benzodiazepines and othersedative-hypnotics in overdose is in part sup-ported following principles of ACLS with par-ticular attention to ventilation. Additionally,removal of the benzodiazepine from the gas-trointestinal tract using lavage and a cathar-tic is generally carried out, particularly if theoverdose is recent. Flumazenil (Romazicon) isa competitive antagonist that acts at the ben-zodiazepine receptor. It can reverse the seda-tive and overdose effects of benzodiazepinesbut not of alcohol or other sedative-hyp-notics. The medication is administered via IVby slow push (2 to 3 minutes) and dosagevaries, depending on whether one is treatingsedation reversal or overdose coma-reversal.Flumazenil is only effective in benzodiazepineoverdose and is not an effective antidoteagainst other drugs. Clinicians should beaware that in chronic benzodiazepine userswho are physically dependent, flumazenilmay induce seizures, high blood pressure,

74 Chapter 4

and delirium. So patients who are comatosefrom benzodiazepines and are benzodiazepinedependent may move quickly from coma toacute benzodiazepine withdrawal symptomswhen flumazenil is administered.

Assessing the potential or actual severity of abenzodiazepine and other sedative-hypnoticabstinence syndrome is based primarily onclinical information obtained from the patient,significant others, and physical assessment.Confirmation of length of benzodiazepine treat-ment with significant others, local pharmacies,and treating physicians is useful. Specific nameof medication, dose, and duration of therapyare vital. The presence or absence of alcoholuse is also important to know, as with the use ofother sedative-hypnotics, such as medicationsfor sleep. The existence of co-occurring psychi-atric disorders such as panic disorder also areimportant factors and should be investigated.Cigarette smoking tends to induce themetabolism of some benzodiazepines and thiscan be a factor in scheduling a taper. Physicalassessment, with particular attention to mentalstatus, and neurologic exams are important.Determination of vital signs also provides guid-ance. A urine drug screen may confirm thepresence of benzodiazepines but otherwise willnot be particularly helpful. Although sedative-hypnotic withdrawal scales have been used inresearch studies, they are not widely availablefor clinical practice.

Medical complications of withdrawal from ben-zodiazepines include problems similar to thoseseen in alcohol withdrawal. Seizures are partic-ularly worrisome and may occur without beingpreceded by other evidence of withdrawal. Asin alcohol withdrawal, seizures and deliriumrepresent the most extreme pathology seen.Anecdotal reports appearing in the literaturealso have described distortions in taste, smell,and other perceptions. Since many individualswho take benzodiazepines have underlyinganxiety disorders, it often is difficult duringperiods of withdrawal to determine whethersymptomatology is related to withdrawal or theemergence of panic attack symptoms. Elderlypatients who are being withdrawn from benzo-

diazepine are at risk for falls and myocardialinfarctions. Delirium without marked auto-nomic hyperactivity (no elevations of pulse,blood pressure, or temperature) also may beseen in the elderly. The management of benzo-diazepine withdrawal is not recommendedwithout medical supervision. All benzodi-azepines should be tapered rather than stoppedabruptly, regardless of dose or duration ofuse—unless it is amatter of use for onlya few days (Ashton2002).

ManagementofWithdrawalWithMedicationsThere are a limitednumber of controlledtrials that can pro-vide guidance regard-ing the managementof benzodiazepineand other sedative-hypnotic withdrawal.For reviews, seeRickels and col-leagues (1999) andEickelberg and Mayo-Smith (1998). Onestrategy that is appro-priate is to begin witha slow taper of thebenzodiazepine that the patient already is tak-ing. This taper may be conducted over severalweeks or perhaps even months. This may beeffective in cases of long-acting benzodiazepinesbut often is not effective in detoxification fromshort half-life benzodiazepines. Sometimesswitching to another benzodiazepine in apatient who has had serious loss of control andabuse problems with his primary agent is ther-apeutic. Another strategy is to switch thepatient to another benzodiazepine with a longhalf-life. Frequently chlorodiazepoxide and

75Physical Detoxification Services for Withdrawal From Specific Substances

Patients

intoxicated with

sedative-hypnotics

appear similar to

individuals

intoxicated with

alcohol. Slurred

speech, ataxia,

and poor physical

coordination are

prominent.

clonazepam are recommended. Figures 4-5 and4-6 (p. 78) give the equivalent doses of thesemedicines along with numerous other sedative-hypnotics and benzodiazepines.

Another alternative is phenobarbital substitu-tion. For patients who have used high doses ofbenzodiazepines for an extended period oftime, hospitalization is always prudent.Outpatient detoxification should be reservedfor patients whose doses of benzodiazepineswere mainly in therapeutic ranges, who do nothave polysubstance dependence, and who arereliable and have reliable significant others toaid in monitoring and supervising theirprogress. In the outpatient setting, patients andfamilies need to be informed that even withsound withdrawal treatment, seizures anddelirium are possible. The individual should beinstructed not to drive or operate dangerousmachinery during treatment and perhaps forseveral weeks thereafter. Recurring assessmentwill be necessary, particularly around times ofdosage reductions. Pregnant patients will needto be detoxified slowly and in consultation withan obstetrician.

A variety of cognitive and behavioral tech-niques have been proposed to assist in the pres-ence of a medication taper. These techniquesalter negative cognitions regarding medicationcessation, provide patient education, and pro-vide alternative cognitive and behavioral tech-niques for anxiety reduction and sleepenhancement during detoxification (Spiegel1999).

Anticonvulsants such as carbamazepine andvalproate, as well as sedating antidepressantssuch as trazodone and imipramine, have beenadvocated for use in withdrawal (Dickinson etal. 2003). Rickels and colleagues (1999) assertthat these drugs have some beneficial effect inthe management of relatively low-dose benzo-diazepine discontinuation in their ability toreduce patients’ subjective complaints, but

that, in more severe withdrawal syndromes,they do not decrease symptoms. Imipraminecan lower the seizure threshold and thereforeis not recommended. The use of anticonvul-sants is probably best reserved as an adjunc-tive medicine to the long-acting benzodi-azepine or phenobarbital. The use of bus-pirone for benzodiazepine detoxification isineffective and should not be considered. Forpatients with major autonomic symptoms dur-ing withdrawal that cannot be controlled bythe primary treating agent, consideration ofthe use of a low dose of clonidine or propra-nolol may be helpful.

Preparing patients and starting detoxificationduring a period of low external stressors, withpatient commitment to tapering, and a plan tomanage underlying anxiety disorders, also areimportant in detoxification. A flexible detoxi-fication schedule is advised. During periodsof increased withdrawal symptoms, dosageshould be stabilized or even increased for aperiod of days. Frequent in-person or phonecontact with the patient is vital. Patientsbeing detoxified in the outpatient setting mayneed to be seen several times per week, espe-cially at times of dosage reductions.

Stimulants Cocaine and amphetamines (such as metham-phetamine) are the most frequently abused cen-tral nervous system stimulants. These agentsare intensely rewarding and are self-adminis-tered by laboratory animals to the point ofdeath. Individuals dependent on stimulantsexperience profound loss of control over stimu-lant intake, presumably in response to thestimulation and disruption of endogenous (orig-inating internally) reward centers (Dackis andO’Brien 2001). They often use stimulants in abinge pattern that is followed by periods ofwithdrawal. It is not clear whether cravingoccurs predominantly during stimulant with-

76 Chapter 4

77Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-5Benzodiazepines and Their Phenobarbital Withdrawal Equivalents

Generic name Trade name Therapeutic doserange (mg/day)

Dose equal to30mg of pheno-barbital for with-drawal (mg)**

Phenobarbitalconversion constant

Benzodiazepines

alprazolam Xanax 0.75–6 1 30

chlordiazepoxide Librium 15–100 25 1.2

clonazepam Klonopin 0.5–4 2 15

clorazepate Tranxene 15–60 7.5 4

diazepam Valium 4–40 10 3

estazolam ProSom 1–2 1 30

flumazenil Mazicon *** *** ***

flurazepam Dalmane 15–30* 15 2

halazepam Paxipam 60–160 40 0.75

lorazepam Ativan 1–16 2 15

midazolam Versed *** *** ***

oxazepam Serax 10–120 10 3

prazepam Centrax 20–60 10 3

quazepam Doral 15* 15 2

temazepam Restoril 15–30* 15 2

triazolam Halcyon 0.125–0.50* 0.25 120

* Usual hypnotic dose.** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawalequivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dosewithdrawal signs and symptoms.*** Not applicable.

Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.

78 Chapter 4

Figure 4-6Other Sedative-Hypnotics and Their Phenobarbital

Withdrawal Equivalents

Generic name Tradename(s)

Common therapeuticindication

Dose equalto 30mg oftherapeuticdose range(mg/day)

Phenobarbitalfor with-drawal (mg)**

Conversion constants

Barbiturates

amobarbital Amytal sedative 50–150 100 0.33

butabarbital Butisol sedative 45–120 100 0.33

butalbital Fiorinal,Sedapap

sedative/analgesic*

100–300 100 0.33

pentobarbital Nembutal hypnotic 50–100 100 0.33

secobarbital Seconal hypnotic 50–100 100 0.33

Others

buspirone Buspar sedative 15–60 *** ***

chloral hydrate Noctec,Somnos

hypnotic 250–1,000 500 0.06

ethchlorvynol Placidyl hypnotic 500–1,000 500 0.06

glutethimide Doriden hypnotic 250–500 250 0.12

meprobamate Miltown,Equanil,Equagesic

sedative 1,200–1,600 1,200 0.025

methylprylon Noludar hypnotic 200–400 200 0.15

* Butalbital usually is available in combination with opioid or non-opioid analgesics.** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawalequivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high-dosewithdrawal signs and symptoms.*** Not cross-tolerant with barbiturates.

Source: APA 1990; Wesson and Smith 1985.

drawal or after these symptoms have largelydisappeared. While the processes that governaddiction to cocaine and amphetamines arebelieved to be similar, recent animal researchsuggests that there are also subtle differences inthe ways in which these two types of drugs cre-ate sensitization (and perhaps addiction) in reg-ular users (Li et al. 2005).

Stimulant WithdrawalSymptomsStimulants are associated with withdrawalsymptoms that differ markedly from those seenwith opioid, alcohol, and sedative dependence(see Figure 4-7). While most clinicians believethat alcohol and heroin withdrawal should betreated aggressively with detoxification, therehas been little emphasis on treating symptomsof stimulant withdrawal. Consequently, nomedications have been developed for this pur-pose. This situation is understandable becausestimulant withdrawal usually does not involvemedical danger or intense patient discomfort.However, if stimulant withdrawal predicts pooroutcome, it may be a reasonable target for clin-ical interventions.

An often overlooked but potentially lethal“medical danger” during stimulant withdrawalis the risk of a profound dysphoria (depres-sion, negative thoughts and feelings) that mayinclude suicidal ideas or attempts. This maybe, in part, a physiological response to cocaine

or amphetamine withdrawal and, in part, areaction to individuals’ acute realization of thedevastating psychosocial consequences after abinge ends. While both cocaine andamphetamine users may experience depressionduring withdrawal, the period of depressionexperienced by amphetamine users is moreprolonged and may be more intense.Amphetamine users, in particular, should bemonitored closely during detoxification forsigns of suicidality and treated for depression ifappropriate.

Although the literature on cocaine withdrawalis controversial, reasonable consensus supportsthe constellation of symptoms depicted inFigure 4-7 (Coffey et al. 2000; Cottler et al.1993). These symptoms often disappear afterseveral days of stimulant abstinence but canpersist for 3 to 4 weeks (Coffey et al. 2000). Inaddition, since individuals addicted to stimu-lants often fail to achieve abstinence, withdraw-al symptoms can be a persistent component ofactive addiction. In addition, individualsaddicted to stimulants may experience impair-ment in hedonic function (ability to experiencepleasure) that has been ascribed to stimulant-induced disruptions of endogenous reward cen-ters (Dackis and O’Brien 2002). Research onanimals has found that exposure to high dosesof methamphetamine results in changes to boththe dopaminergic and serotonergic systems ofthe brain (Nordahl et al. 2005) and dopamineabnormalities among animals and humans whohad been ingesting cocaine (Schuckit 2000).

79Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-7Stimulant Withdrawal Symptoms

•Depresion

•Hypersomnia (or insomnia)

•Fatigue

•Anxiety

•Irritability

•Poor concentration

•Psychomotor retardation

•Increased appetite

•Paranoia

•Drug craving

Source: Consensus Panelist Robert Malcolm, M.D.

Researchers have also observed abnormalitiesin regions of the brain that govern attentionand memory in animals that were regularlyadministered methamphetamine (Nordahl et al.2005).

Although cocaine withdrawal has traditionallybeen viewed as relatively mild (Satel et al.1991; Weddington et al. 1990), evidence sug-gests that individuals dependent on cocainewith severe stimulant withdrawal are more like-ly to have a poor clinical outcome (Kampmanet al. 2001a). The level of withdrawal symp-toms, therefore, may be clinically significantand should be monitored and recorded forfuture treatment (Kampman et al. 2001b).Kampman reported significantly higherdropout rates in individuals dependent oncocaine who scored high on the CocaineSelective Severity Assessment (CSSA), a reli-able and valid structured interview designed tocapture cocaine withdrawal symptoms(Kampman et al. 1998). Patients with highscores on the CSSA were five times more likelyto leave treatment and four times more likely toresume cocaine use than those with low scores(Mulvaney et al. 1999). The CSSA is an easilyadministered 18-item questionnaire. Each itemis a 7-point rating scale, so that a person canscore a number of points on any given ques-tion. Scores in excess of 22 indicate the pres-ence of significant cocaine withdrawal. Seeappendix C for more information on the CSSA.Given the poor prognosis associated withcocaine withdrawal, it is reasonable that moreclinical attention be directed toward this phe-nomenon.

Medical Complications ofStimulant WithdrawalAs previously noted, stimulant withdrawal isnot usually associated with medical complica-tions. However, patients with recent cocaineuse can experience persistent cardiac complica-tions, including prolonged QTc interval andvulnerability for arrhythmia and myocardialinfarction (Chakko and Myerburg 1995). QT isan interval of time that can be measured on an

electrocardiogram (between the q wave and thet wave), while QTc is the relative (or “correct-ed”) QT interval. Some conditions and manydrugs (LAAM, other opioids, and even antibi-otics) can cause the interval to lengthen andthis can result in cardiac rhythm disturbances.Anterior chest pain or cardiac symptomsshould therefore be fully evaluated in theseindividuals. Seizures also may be a complica-tion of stimulant abuse and can occur duringdetoxification. Persistent headaches could rep-resent a subdural, subarachnoid, or intracere-bral bleed (bleeding in or around the brain)and should be appropriately evaluated. It alsoshould be emphasized that people who abusestimulants usually become addicted to othersubstances, such as alcohol, sedatives, or opi-oids, and therefore can experience any of thecomplications ascribed to detoxification fromthese substances. Covert (secretive) use ofother substances should be suspected andassessed with urine toxicology.

Management of WithdrawalWithout MedicationsThe most effective means of treating stimulantwithdrawal involves establishing a period ofabstinence from these agents. Access to briefhospitalization, a level of care previously avail-able for those who abuse stimulants, has beenlargely eliminated by managed care initiatives.In its place, intensive outpatient treatment canassist the patient to cease use long enough forwithdrawal symptoms to abate entirely.Rehabilitative approaches to achieve stimulantabstinence have been reviewed elsewhere(Dackis and O’Brien 2001). The avoidance ofcue-induced craving is particularly importantin these individuals, especially in light ofresearch that shows limbic activation (activityin a certain part of the brain) in response tocue-induced craving (Childress et al. 1999). Italso is important that individuals dependent onstimulants abstain from other addictive sub-stances.

80 Chapter 4

Management of WithdrawalWith Medications There are no medications with proven efficacyto treat stimulant withdrawal. However,researchers have investigated some medicationsfor cocaine detoxification. Amantadine mayhelp reduce cocaine use in patients with moresevere withdrawal symptoms (Kampman et al.2000). Modafinil, an antinarcolepsy agent withstimulant-like action, is currently under inves-tigation by one research group as a cocainedetoxification agent (Dackis and O’Brien2002). One small study in Thailand found theantidepressant mirtazapine (Remeron) waseffective at reducing a number of the symptomsassociated with amphetamine withdrawal(Kongsakon et al. 2005). None of these medica-tions, however, are approved for use in treatingstimulant withdrawal and further research isneeded. Gorelick and colleagues (2004) reviewthe full range of clinical literature on pharma-cological intervention for cocaine addiction.

Patient Care and Comfort Since stimulant withdrawal is not associatedwith severe physical symptoms, adjunctivemedications are seldom required. Thesepatients often are sleep deprived and might beunable to benefit from therapeutic activitiesduring the first 24 to 36 hours of abstinence.They often are hungry and in need of largemeal portions initially as their food intake mayhave been inadequate during active addiction.Stimulant users also may be irritable and careshould be taken to avoid needless confrontationduring the initial withdrawal phase. Headachesoften are reported and can be treated symp-tomatically. Persistent headaches should beevaluated, as cocaine can produce cerebrovas-cular disease. Similarly, chest pain of possiblecardiac origin should be evaluated medicallywith electrocardiography, cardiac enzymes,and appropriate medical attention. On occa-sion, patients undergoing withdrawal fromcocaine or amphetamines report insomnia andmay benefit from diphenhydramine (Benadryl)50 to 100mg, trazodone (Desyrel) 75 to 200mg,

or hydroxyzine (Vistaril) 25 to 50mg at bed-time. Benzodiazepines should be avoided unlessrequired for concomitant alcohol or sedativedetoxification. As stimulant withdrawal symp-toms wane, patients are best treated with anactive rehabilitative approach that combinesentry into substance abuse treatment with sup-port, education, and changes in lifestyle.

Other Immediate Concerns Central nervous system stimulants exert mostof their toxic effects through vasoconstriction(constriction of the blood vessels).Consequently, a number of medical conditionscan arise fromischemia (lack ofproper blood supply)or infarction (deathof tissue as the resultof lack of blood sup-ply) as a result ofstimulant use.Myocardial (heartmuscle) infarctionand stroke are widelyrecognized complica-tions of stimulant use.However, other prob-lems such as sponta-neous abortion, bowelnecrosis (tissuedeath), and renal(kidney) infarctionalso have beenreported fromcocaine-induced vaso-constriction. Cardiacarrhythmias also are common. Other medicalproblems that are associated with stimulantdependence include dental disease, neuropsy-chiatric abnormalities, and movement distur-bances/disorders.

Antidepressants, such as selective serotoninreuptake inhibitors, can be prescribed for thedepression that often accompanies metham-phetamine or other amphetamine withdrawal.

81Physical Detoxification Services for Withdrawal From Specific Substances

Intensive

outpatient

treatment can

assist the patient

to cease use long

enough for

withdrawal

symptoms to abate

entirely.

Inhalants/Solvents

Withdrawal SymptomsAssociated WithInhalants/SolventsThe term “inhalants” is used to describe alarge and varied group of psychoactive sub-stances that all share the common characteris-tic of being inhaled for their effects. They arecommonly found in household, industrial, andmedical products. These drugs are used pri-marily by adolescents, although some, especial-ly the nitrates, are used by adults as well(NIDA 2000). Figure 4-8 presents some of themore commonly abused inhalants.

Dependence on inhalants and subsequentwithdrawal symptoms are both relativelyuncommon phenomena (Balster 2003). Thereis no specific or characteristic withdrawalsyndrome that would include all drugs in theinhalant class. Intoxication with the solvents,aerosols, and gases often produces a syn-drome most like that of alcohol intoxicationbut lasting only 15 to 45 minutes (Miller andGold 1990). Rarely, symptoms similar tosedative withdrawal have been described,including “fine tremors, irritability, anxiety,insomnia, tingling sensations, seizures andmuscle cramps” (Miller and Gold 1990, p.87). Toluene withdrawal has been reported tocause delirium tremens (Miller and Gold1990). Longtime users also may exhibit weak-ness, weight loss, inattentive behavior, anddepression (NIDA 2005). It has been reportedthat withdrawal symptoms can occur with aslittle as 3 months of regular usage (Ron 1986).When present, the withdrawal typically lasts2 to 5 days (Evans and Raistrick 1987).

In addition to their short-term intoxicatingaffects, nitrates are used to enhance sexualpleasure by vasodilation (dilation of bloodvessels) that produces a rush and sensation ofwarmth. There is no withdrawal syndromethat has been associated with nitrate abuse.

There are no specific assessment instrumentsavailable to measure inhalant withdrawalsymptoms. A patient who presents with a his-tory of inhalant use and symptoms of seda-tive-like withdrawal should alert the clinicianto the possibility of inhalant withdrawal.These patients require a complete history andphysical exam. Additionally, a blood alcohollevel and urine drug screen are helpful in thecases of suspected polydrug abuse.

Medical Complications ofWithdrawal FromInhalants/SolventsThere are a large number of medical complica-tions associated with inhalant abuse and intoxi-cation. Many of these complications are not theresult of withdrawal but may still be seen whenthe patient presents to the clinician. Mostinhalants produce some neurotoxicity with cog-nitive, motor, and sensory involvement.Additionally, damage to internal organs includ-ing the heart, lungs, kidneys, liver, pancreas,and bone marrow has been reported.

Management of WithdrawalWithout MedicationsIt is crucial to provide the patient with an envi-ronment of safety that removes him from accessto inhalants. This can pose a challenge due tothe almost universal availability of these drugsin society. Many of the medical consequences ofinhalant usage will remit once the patientachieves abstinence (Balster 2003). The patientshould be monitored for withdrawal symptomsand changes in mental status.

Most patients presenting for treatment ofinhalant dependence will be adolescents.Ideally, they should be entered into an age-appropriate treatment program that meetstheir medical and psychosocial needs.Supportive care, including helping them to getenough sleep and a well-balanced diet, usuallywill be sufficient to get patients safely throughwithdrawal (Frances and Miller 1998).

82 Chapter 4

Management of WithdrawalWith MedicationsPatients presenting with only inhalant with-drawal are unusual. Clinicians should prompt-ly ascertain if the patient has been abusing anyother substances and proceed with appropriatedetoxification as clinically indicated. When apatient presents with (1) a history of extensiveinhalant usage, (2) a sedative-like withdrawalsyndrome, and (3) no significant history or lab-oratory data that supports other substances,then the clinician can assume that the patient isin inhalant withdrawal.

As noted before, withdrawal from inhalants issimilar to withdrawal from sedative-hyp-notics. No systematic detoxification protocol

has been established, although some clinicianshave found phenobarbital useful (CSAT1995d). The usefulness of benzodiazepines isunknown but would seem a reasonable alter-native given our current understanding ofinhalant withdrawal (Brouette and Anton2001). No other medications have been rou-tinely used for inhalant withdrawal.

Patient Care and ComfortFor patients who have only been abusinginhalants, treatment of insomnia during with-drawal is not usually necessary. Sedative sub-stitution during the period of detoxificationmay allow the patient to sleep. However, aperiod of postdetoxification insomnia shouldbe expected and usually can be treated by the

83Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-8Commonly Abused Inhalants/Solvents

Type Example Chemicals in Inhalant/Solvent

Adhesives Airplane glue Toluene, ethyl acetate

Other glues Hexane, toluene, methyl chloride, acetone, methyl ethylketone, methyl butyl ketone

Special cements Trichloroethylene, tetrachloroethylene

Aerosols Spray paint Butane, propane (U.S.), fluorocarbons, toluene, hydro-carbons, “Texas shoe shine” (a spray containing toluene)

Hair spray Butane, propane (U.S.), chlorofluorocarbons (CFCs)

Deodorant; air freshener Butane, propane (U.S.), CFCs

Analgesic spray CFCs

Asthma spray CFCs

Fabric spray Butane, trichloroethane

PC cleaner Dimethyl ether, hydrofluorocarbons

Anesthetics Gaseous Nitrous oxide

Liquid Halothane, enflurane

Local Ethyl chloride

Cleaning agents Dry cleaning Tetrachloroethylene, trichloroethane

Spot remover Xylene, petroleum distillates, chlorohydrocarbons

Degreaser Tetrachloroethylene, trichloroethane, trichloroethylene

recommendation of good sleep hygiene prac-tices such as avoiding caffeine, daytime nap-ping, and overstimulation in the evening.

If the patient is able to refrain from inhalant(and other substance) use and has no seriouspsychiatric or medical consequences, thenoutpatient treatment should be the firstoption. Inpatient or residential treatmentshould be used for those patients who cannotachieve abstinence or have serious co-occur-ring medical or psychiatric disorders.Hospitalized patients will need a thoroughhistory and physical exam. Therapy toaddress denial, addiction, and pertinent psy-chosocial issues should be initiated as soon aspossible during the hospitalization.Supportive care and abstinence will resolvemost medical problems associated with chron-ic inhalant usage (Balster 2003).

NicotineIn 2004, approximately 44.5 million adultswere cigarette smokers (23.4 percent weremen and 18.5 percent were women) (CDC2005a). Nicotine addiction in the form ofcigarette smoking accounts for more deathseach year than AIDS, alcohol, cocaine, hero-in, homicide, suicide, motor vehicle crashes,and fires combined (U.S. Department ofHealth and Human Services [U.S. DHHS]2000b). Between 1995 and 1999, there were490,000 smoking-related premature deathsannually, and smoking cost the country atleast $157 billion yearly in health-related eco-nomic losses. This amounts to approximately$7.18 per pack of cigarettes (Fellows et al.2002), a truly staggering figure.

Smokers are at increased risk for severalmedical problems, including myocardialinfarction, coronary artery disease, hyperten-sion, stroke, peripheral vascular disease,

84 Chapter 4

Figure 4-8 (continued)Commonly Abused Inhalants/Solvents

Solvents and gases Nail polish remover Acetone, ethyl acetate

Paint remover Toluene, methylene chloride, methanol acetone, ethylacetate

Paint thinner Petroleum distillates, esters, acetone

Correction fluid and thinner Trichloroethylene, trichloroethane

Fuel gas Butane, isopropane

Lighter Butane, isopropane

Fire extinguisher Bromochlorodifluoromethane

Food products Whipped cream Nitrous oxide

Whippets Nitrous oxide

“Room odorizers” Locker Room, Rush,Poppers

Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal),cyclohexyl

Source: Balster 2003.

chronic obstructive lung disease, chronicbronchitis, and several types of cancer (lung,stomach, head and neck, and bladder). Otherproblems associated with nicotine addictioninclude gastro-esophageal reflux disease andgastric ulcerations, cataracts, and prematurewrinkling of the skin. There also appears tobe an antiestrogen effect (suppression of animportant hormone) that may lead to earlydevelopment of osteoporosis in women(Okuyemi et al. 2000).

In 1988, the U.S. Surgeon General’s Reportconcluded that nicotine is the principal addic-tive agent in tobacco. Nicotine binds to nico-tinic acetylcholine receptors in the brain andhas the direct ability to stimulate the releaseof dopamine in the nucleus accumbens area.The nucleus accumbens has long been consid-ered the “reward center” in the brain. Thisincrease in dopamine is similar to what occurswhen patients use stimulants and is felt to bean essential element in the reward process ofaddiction (Glover and Glover 2001).

As many as 90 percent of patients enteringtreatment for substance abuse are currentnicotine users (Perine and Schare 1999).There has long been controversy in the fieldof addiction medicine as to how best to handlethe problem of nicotine dependence inpatients seeking treatment for other types ofsubstance abuse. Traditionally, it has beenargued that patients would find that trying tostop smoking while also contending with other(more pressing) addiction problems would betoo difficult and distracting in early absti-nence. However, others argue that nicotinedependence is a lethal disease and that physi-cians have the responsibility to intervene inthis addiction with the same aggressivenessthey show toward other addictive substances.This pro-intervention position has receivedincreasing attention from clinicians, inasmuchas it is now understood that alcohol consump-tion is associated with increased nicotineusage (Henningfield et al. 1984). Gulliver andcolleagues (1995) have demonstrated that theurge to smoke is correlated with the urge to

drink, and others have shown that continuednicotine dependence may be a relapse triggerfor resumption of drinking (Stuyt 1997). Theconcern that smoking cessation may precipi-tate relapse to other substances of abuse hasnot been supported in the literature (Hughes1995).

Treatment programs that have attempted totreat nicotine dependence in conjunction withother drugs of addiction have met with limit-ed success (Bobo and Davis 1993; Burling etal. 1991; Hurt et al. 1994) and have generat-ed increased interest in smoking cessation asa part of a patient’s overall substance abusetreatment (Sees and Clark 1993). One studyreported that forcing unmotivated patients(or patients who did not consider smoking aproblem) to quit was countertherapeutic(Trudeau et al. 1995).

Moreover, it has traditionally been acceptedthat nicotine detoxification concurrent withdetoxification from other substances makesthe undertaking more difficult. Several fac-tors are involved including the following: (1)patient ambivalence and/or lack of interest insmoking cessation; (2) physician ambivalenceabout the importance of smoking cessationearly in treatment; (3) staff’s use of nicotine;(4) staff’s ambivalence about the importanceof nicotine cessation early in treatment; (5)easy availability of cigarettes from peers,family, visitors, staff, and at 12-Step meet-ings; (6) lack of sufficient training and exper-tise on the part of physicians and staff inmanaging nicotine withdrawal; and (7) staffresistance to patient smoking cessationbecause withdrawal symptoms include irri-tability, anxiety, and depression, all of whichcan make patients more difficult to manage.

Withdrawal SymptomsAssociated With Nicotine The Diagnostic and Statistical Manual ofMental Disorders, 4th edition, text revision(DSM-IV-TR) (APA 2000) notes that typically,a person in nicotine withdrawal will have four

85Physical Detoxification Services for Withdrawal From Specific Substances

or more of the signs presented in Figure 4-9,though some clinicians believe that three ormore is sufficient to make the diagnosis ofnicotine withdrawal. Furthermore, it shouldbe noted that symptoms vary in duration andintensity, with decreased heart rate and light-headedness resolving in 48 hours, whileincreased appetite may remain present forweeks to months (Glover and Glover 2001).Smokers who have severe craving duringwithdrawal are less likely to be successful intheir attempt at quitting (Hughes andHatsukami 1992). Depression during with-drawal also has been linked to relapse tosmoking (Covey et al. 1993).

Assessing SeveritySince 1978, the standard instrument used tomeasure physical dependence on nicotine hasbeen the eight-item Fagerstrom ToleranceQuestionnaire (FTQ) (Fagerstrom 1978). Alater revision known as the Fagerstrom Testfor Nicotine Dependence (FTND) (see Figure

4-10) has been reduced to six questions(Giovino et al. 1995; Heatherton et al. 1991).Scores greater than seven are consistent withnicotine dependence.

While both the FTQ and FTND are very use-ful for estimating a patient’s physical depen-dence on nicotine, there is still a need toassess more accurately the degree to whichsmoking behavior plays a role in maintainingaddiction. The Glover-Nilsson SmokingBehavioral Questionnaire (GN-SBQ) is an 11-question, self-administered test that evaluatesthe impact of behaviors and rituals associatedwith smoking (see Figure 4-11, p. 88). It wasdesigned to assist clinicians in identifying andquantifying behavioral aspects of smokingthat play a role in maintaining nicotinedependence, which can then help the cliniciandevelop a cessation strategy that takes intoaccount both physical dependence and behav-ioral dependence (Glover et al. 2002).

86 Chapter 4

Figure 4-9 DSM-IV-TR 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 24hours 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 anothermental disorder.

Source: APA 2000, pp. 244–245.

To better understand a patient’s level of nico-tine dependence, providers can assess bio-chemical markers including nicotine, coti-nine, and carbon monoxide. Nicotine and itsmetabolite cotinine can be measured in urine,blood, or saliva. Cotinine continues to be pre-sent in bodily fluids for up to 7 days after ces-sation. Clinicians should use caution wheninterpreting the meaning of nicotine and coti-nine assays, as they are not specific to tobac-co-derived nicotine and may indicate thepatient’s compliance with nicotine replace-ment therapy rather than smoking.

Carbon monoxide is easily measured inexpired breath and can show whether thepatient has been smoking within a few hoursprior to the test. It can be used to monitorsmoking cessation for patients receiving nico-

tine replacement therapy and patients oftenfind it a helpful motivator in their attempt tomaintain abstinence (Benowitz 1983).

Medical Complications ofWithdrawal From NicotineThere are no major medical complications pre-cipitated by nicotine withdrawal itself.However, patients frequently experienceuncomfortable withdrawal symptoms startingwithin a few hours of cessation. In addition tothe symptoms previously noted, patients maycomplain of increased coughing, a desire forsweets, and difficulty concentrating (Hughesand Hatsukami 1992). Clinicians should beaware that withdrawal symptoms can masquer-

87Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-10Items and Scoring for the Fagerstrom Test for Nicotine Dependence

Questions Answers Points

1. How soon after you wake up do you smoke yourfirst cigarette?

2. Do you find it difficult to refrain from smoking inplaces where it is forbidden (e.g., in church, at thelibrary, in the cinema, etc.)?

3. Which cigarette would you hate most to give up?

4. How many cigarettes/day do you smoke?

5. Do you smoke more frequently during the firsthours of waking than during the rest of the day?

6. Do you smoke if you are so ill that you are in bedmost of the day?

Within 5 minutes6–30 minutes31–60 minutesAfter 60 minutes

YesNo

The first thing in the morningAll others

10 or less11–2021–3031 or more

YesNo

YesNo

3210

10

10

0123

12

10

Source: APA 1996.

88 Chapter 4

Figure 4-11The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ)

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.

2. I handle and manipulate my cigarette as part of the ritual of smoking.

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?

4. Do you reward yourself with a cigarette after accomplishing a task?

5. If you find yourself without cigarettes, will you have difficulties in concentratingbefore attempting a task?

6. If you are not allowed to smoke in certain places, do you then play with yourcigarette pack or a cigarette?

7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa,room, car, or drinking alcohol)?

8. Do you find yourself lighting up a cigarette routinely (without craving)?

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 orfrustration, etc.?

10. Does part of your enjoyment of smoking come from the steps (ritual) you takewhen lighting up?

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?

TOTAL_______Scoring for Behavioral Dependence

<12 Mild12–22 Moderate23–33 Strong

>33 Very Strong

Source: Glover et al. 2002

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

ade as other psychiatric conditions, especiallyanxiety and depression (see Figure 4-12).

Smoking cessation also may affect themetabolism of other drugs primarily throughthe Cytochrome P 450 (CYP450) system. Thissystem is one of many hepatic liver enzyme sys-tems that is responsible for the metabolicbreakdown of various drugs into inactive com-pound products. Different drugs and com-pounds have varying affinities for the CYP450system. The higher the affinity, the faster thebreakdown of the drug or compound in thebody. Some compounds can slow themetabolism or breakdown of other drugs with alower affinity, leading to a buildup of that drugor compound in the body.

During detoxification from nicotine, somemedications will have their metabolismaltered, including theophylline, caffeine,tacrine, imipramine, haloperidol, penta-zocine, propranolol, flecainide, and estradiol;in general, these effects are short-lived andseldom drastic. Nicotine also reduces betablockers’ ability to lower blood pressure andheart rate and decreases the amount of seda-tion from benzodiazepines as well as de-creases the amount of pain relief provided bysome opioids, most likely because of its stimu-lant effects (Zevin and Benowitz 1999). Acomplete discussion of nicotine’s effects onmedications is beyond the scope of this TIPand physicians are encouraged to consult thePhysicians’ Desk Reference (2004) or equiva-

lent pharmaceutical guide. Figure 4-13 (p. 90) shows the effects of abstinencefrom smoking on blood levels of a number ofmedications.

Management of WithdrawalWithout MedicationsAbout one third of current smokers attemptto quit smoking each year and more than 90percent of these try to do so without any for-mal nicotine cessation treatment. Most smok-ers will make several attempts on their own toquit and ultimately, only about 50 percent aresuccessful over a lifetime (U.S. DHHS 2000b).While some smokers are able to quit on theirown, others may require intervention in theform of behavioral treatment and/or pharma-cotherapy.

There are insufficient data available to deter-mine who will benefit most from a particulartype of treatment. Some patients may preferto stop smoking without the use of medica-tion. An elevated score on the GN-SBQ wouldindicate a strong behavioral component tosmoking that might guide the clinician in rec-ommending behavioral treatment as a prima-ry intervention. Patients who also have ele-vated FTQ scores may benefit by a combina-tion of behavioral and pharmaceutical inter-vention.

89Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-12Some Examples of Nicotine Withdrawal Symptoms That Can Be

Confused With Other Psychiatric Conditions

AnxietyDepressionIncreased REM (rapid eye movement) sleepInsomniaIrritabilityRestlessnessWeight gain

Source: APA 1996.

The U.S. Public Health Service’s TreatingTobacco Use and Dependence: ClinicalPractice Guideline is a comprehensive reviewof the smoking cessation literature (Fiore etal. 2000a). It discusses a range of nonphar-macological interventions for the managementof withdrawal from nicotine; these can be sep-arated into two basic categories: self-helpinterventions and behavioral interventions(Anderson and Wetter 1997).

Self-help interventionsMany tobacco users prefer to attempt to quitwithout any assistance from professionals. Anumber of self-help products are availablethat can assist them in their cessationattempts. These include a wide array of pam-phlets, manuals, video- and audiotapes (e.g.,from the American Lung Association and theNational Cancer Institute), 12-Step self-helpsupport groups, and telephone helplines. TheU.S. Public Health Service’s Guideline, whichanalyzed all types of self-help interventionstogether, found that the self-help approach tocessation yielded results only slightly betterthan no intervention at all. To date, self-help

interventions alone have not been very suc-cessful at helping people achieve abstinencefrom tobacco. The Guideline suggests, howev-er, that self-help can be a useful adjunct toother forms of treatment (Fiore et al. 2000a).

One type of self-help intervention that showssome promise is the use of computer-generat-ed personalized written feedback for patients.The computer makes recommendations basedon an individual’s response to standardizedquestions about her smoking (Etter andPerneger 2001; Shiffman et al. 2000).

Behavioral interventionsThe U.S. Public Health Service study notedthat when physicians took as little as 3 min-utes to advise their patients to stop smoking,long-term quit rates were modestly improvedfrom 7.9 percent to 10.2 percent (Fiore et al.2000a). Westmaas and colleagues note that“simple, clear advice from a physician can beconsidered an easy, cost-effective interventionthat not only moves smokers closer to thedecision to quit, but also may motivate somesmokers to make an actual attempt”

90 Chapter 4

Figure 4-13Effects of Abstinence From Smoking on Blood Levels of

Psychiatric Medications

Abstinence Increases BloodLevels

Abstinence Does Not IncreaseBlood Levels

Effect of Abstinence on BloodLevels Is Unclear

Clomipramine ClozapineDesipramineDesmethyldiazepamDoxepinFluphenazineHaloperidolImipramineOxazepamNortriptylinePropranolol

AmitriptylineChlordiazepoxideEthanolLorazepamMidazolamTriazolam

AlprazolamChlorpromazineDiazepam

Source: APA 1996.

(Westmaas et al. 2000, p. 58). The greater theamount of time in face-to-face interventions,the higher the success rate for patients, butinterventions as short as 3 minutes have beenfound to be effective (Fiore et al. 2000a). Acounseling session of longer than 10 minutesproduced a cessation rate of 20.1 percentcompared to a rate of 10.9 percent for notreatment. The guideline also indicated that ifcessation information is given by multipletypes of providers (e.g., physician, psycholo-gist, dentist, nurse, and pharmacist) it canhave a dramatic effect on cessation rates,increasing the rate to 23 percent compared to10.8 percent for patients who had noprovider contact.

A review of behavioral intervention studiesconcluded that both supportive care by aclinician and the ability of patients to developproblemsolving and coping skills improvedsuccess rates for smoking cessation (Andersonand Wetter 1997). Other components such ascigarette fading (gradually decreasing thenumber of cigarettes smoked over a period oftime), establishing a quit date, enhanced envi-ronmental support, improved diet andincreased exercise, relaxation training, andcontingency contracting were not associatedwith improved outcome. Aversive condition-ing, such as rapid smoking techniques, is

effective but not routinely recommended(Fiore et al. 2000a).

Management of WithdrawalWith MedicationsA U.S. Public Health Service panel recom-mends that all primary care physicians pro-vide a five-step intervention, known as the “5A’s,” to all tobacco users. The panel recom-mends that all smokers who want to quitshould be offered active medication that hasbeen approved for assisting in smoking cessa-tion unless there is a medical contraindication(Fiore et al. 2000a). Figure 4-14 provides asummary of the “5 A’s” for brief intervention.

Nicotine ReplacementTherapy (NRT)Nicotine polacrilex gum was approved by theFDA in 1984. In the 1990s other NRTs receivedFDA approval, including the nicotine transder-mal patch, the nicotine nasal spray, and thenicotine inhaler. Nicotine gum and nicotinetransdermal patch are now available over thecounter. After the acute withdrawal period,patients are then weaned off the medicationuntil they become nicotine free. All NRTs are

91Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-14 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 thistime?

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.

effective, with 1-year quit rates between 11 and34 percent (Okuyemi et al. 2000).

There has been some concern about theaddictive potential of NRTs, and it has beenreported that 5 to 20 percent of patients usingnicotine polacrilex gum continue to use it formore than 1 year (Hughes 1989). There wasalso initial concern that the nicotine nasalspray, with its rapid onset of action and highplasma concentrations, might become a drugof abuse. This has not been reported in the

literature, and itcould be speculatedthat this is becauseof the nasal spray’srelatively uncom-fortable side effectsthat cause manypatients to dislikethe product (Schuhet al. 1997). In gen-eral, withdrawalsymptoms fromNRTs are mild com-pared to those thatoccur in smokingcessation, and con-tinued use of theseproducts may be theresult of patients’fear of returning toactive smoking(APA 1996). Forthose patients whocontinue to useNRTs, providers

should balance the patient’s continued depen-dence on nicotine with the considerablehealth benefit of decreasing active tobaccousage. It is clear that constituents of tobaccoother than nicotine are responsible for caus-ing cancer. No ill effects have been attributedto long-term use of nicotine replacement ther-apy (Benowitz and Gourlay 1997).

Bupropion SRBupropion SR (Sustained Release) was initiallymanufactured under the name Wellbutrin as atreatment for major depressive disorder. In1997, the FDA approved bupropion SR forsmoking cessation, and it has been marketedunder the name Zyban. Bupropion is a novelantidepressant that is involved primarily withdopamine but also affects adrenergic mecha-nisms in the central nervous system. Its exactmechanism of action is unknown, but it is not anicotine substitute or replacement like theNRTs. The recommended dose is 150mg dailyfor 3 days and then 150mg twice daily for 7 to12 weeks. Typically patients set their quit date1 to 2 weeks from the time they start the medi-cation in order to get the drug to therapeuticlevels. This is an ideal time for the patient tofocus on making behavioral changes and enlist-ing social support to augment his quit attempt.Bupropion SR has proven useful in smokingcessation with a 12-month abstinence rate of35.5 percent compared to a placebo at 15.6percent and the nicotine patch at 16.4 percent(Westmaas et al. 2000). The most commonlyreported side effects include dry mouth andinsomnia. Bupropion SR should not be used inpatients with a history of seizures, heavy alco-hol use, head trauma, or with anorexia orbulimia.

Other nonnicotine pharmacotherapyCovey and colleagues examined nonnicotinepharmaceutical products that have been evalu-ated in controlled trials of smoking cessation(Covey et al. 2000). These drugs include thefollowing:•The alpha-2 agonist antihypertensive,

clonidine

•The tricyclic antidepressant, nortriptyline

•The monoamine oxidase inhibitor (MAOI)antidepressant, moclobemide

•The serotonin 5-HT1A agonist anxiolytic,buspirone

92 Chapter 4

Patients should be

encouraged to use

combined NRT

treatments if they

are unable to quit

using a single type

of first line

pharmacotherapy.

•The antihypertensive CNS nicotinic receptorblocker, mecamylamine

•Oral dextrose tablets

Although none of these agents has beenapproved by the FDA for smoking cessation,clonidine, nortriptyline, and moclobemide haveall been found to be effective treatments (Coveyet al. 2000). Clonidine may be a helpfuladjunct to nicotine replacement during acutenicotine withdrawal. Doses of 0.05mg to 0.1mgthree times a day can be tried as tolerated(sedation and low blood pressure are con-cerns), and the medication needs to be taperedwhen discontinued to avoid rebound hyperten-sion.

The Public Health Service’s TreatingTobacco Use and Dependence: ClinicalPractice Guideline (Fiore et al. 2000a) hasclassified nortriptyline and clonidine as sec-ond-line treatments. Clonidine is an antihy-pertensive and may be appropriate forpatients addicted to certain types of drugs butnot appropriate for others. The antidepres-sant selective serotonin reuptake inhibitor(SSRI) fluoxetine has been tested in a numberof multisite trials (Cook et al. 2004; Hitsmanet al. 1999; Niaura et al. 2002) and found tohave a small benefit at best, although forpatients who experience mild depressivestates it may be a worthwhile adjunctivetreatment. The usefulness of other SSRIs forsmoking cessation is unknown, but studieshave generally been unfavorable. More infor-mation on smoking cessation for people withco-occurring substance use and other mentaldisorders can be found in appendix D of TIP42, Substance Abuse Treatment for PersonsWith Co-Occurring Disorders (CSAT 2005c).

Combination drug therapyCombining NRT productsNRT products typically provide less than halfthe nicotine plasma levels that cigarette usersachieve through smoking (Benowitz et al. 1997;Dale et al. 1995; Gupta et al. 1995; Lawson etal. 1998). To attempt to increase nicotine lev-

els, several clinical trials have evaluated theeffectiveness of combining available products.The simultaneous use of nicotine gum and thenicotine patch has been evaluated in severalstudies. Short-term gains in cessation were seenwith the combination compared to either medi-cation alone, but no long-term benefits in absti-nence were demonstrated (Anderson andWetter 1997). Blondal and colleagues (1999)compared the combination of nicotine nasalspray and the nicotine patch to the patch aloneand found that at 3 months 37 percent of thepatients were smoke free (compared to 25 per-cent for the patch alone). An open-label studyof the combined use of nicotine inhaler and thenicotine patch found a 12-week cessation rateof 30 percent and good tolerability for the com-bination (Westman et al. 2000).

So-called “combination NRT” involves com-bining different types of nicotine replacementproducts, such as the patch and gum, on thepremise that doing so will boost nicotineblood levels. Further rationale for this prac-tice is that a “passive” nicotine delivery sys-tem (i.e., patch) produces relatively steadylevels of nicotine in the body that prevent theuser from going below a threshold minimumwhile “active” NRTs (i.e., gum, inhaler,spray, sublingual tablet, etc.) permit the userto respond to situational cravings with ad libi-tum dosing on an acute basis. Several clinicaltrials have evaluated the effectiveness of com-bining available NRT products (for a reviewsee Silagy et al. 2000). After reviewing avail-able data, the Guideline panel (Fiore et al.2000a) felt that there was moderately strongevidence to conclude that “Combining thenicotine patch with a self-administered formof nicotine replacement therapy (either thenicotine gum or nicotine nasal spray) is moreefficacious than a single form of nicotinereplacement, and patients should be encour-aged to use such combined treatments if theyare unable to quit using a single type of first-line pharmacotherapy” (Fiore et al. 2000a, p.77).

93Physical Detoxification Services for Withdrawal From Specific Substances

NRT using high-dose nicotinepatch therapyThe highest dose of nicotine available by patchis 22mg. Several studies have evaluatedwhether higher doses of nicotine (up to 44mg)improve abstinence rates. The effect of thisstrategy has been small and the routine use ofhigher dose patches is not recommended(Hughes et al. 1999; Killen et al. 1999).

Combining nicotine patchand bupropion SRIn a double-blind, placebo-controlled study,the combination of bupropion SR and the nico-tine transdermal patch showed higher absti-nence rates at 12 months (35.5 percent) com-pared to bupropion SR alone (30.3 percent),nicotine patch alone (16.4 percent), or placebopatch and pill group (15.6 percent) (Jorenby etal. 1999). This combination was well tolerated.Clinicians who use this combination shouldfirst start the patient on bupropion SR 150mgfor 3 days and then increase the dosage to150mg twice daily for 1 to 2 weeks prior to theday of smoking cessation. On the “quit day,”nicotine patch therapy should be initiated andthe combination treatment continued for 3 to 6months (Okuyemi et al. 2000).

Patient Care and ComfortMost smokers attempt cessation on an outpa-tient basis and without any assistance fromprofessionals. However, if a patient decidesthat she or he wants help with smoking cessa-tion, it is important for the clinician to presenta supportive and nonjudgmental attitude anddevelop a therapeutic alliance with the patient.It must be emphasized that nicotine depen-dence is a chronic relapsing disorder and thatpatients often make several attempts at quittingbefore succeeding.

Most smokers who want treatment will seekhelp from their primary care physician. Thephysician has the responsibility of providingpharmaceutical treatment, education aboutcommon problems associated with cessation,

and emotional support to patients attemptingto quit. Discussing nicotine withdrawal symp-toms can often help allay patient concerns.

Fear of weight gain is a barrier for many whowant to quit smoking (French et al. 1995).This is an especially important issue forwomen and may deter their attempts to stopsmoking (Gritz et al. 1989). Though thehealth gains of stopping smoking clearly out-weigh the health risks of weight gain, thisargument does little to assuage patients’fears. Dieting during smoking cessation is notrecommended in general and has been shownto increase the likelihood of smoking relapse(Hall et al. 1992). Physicians should, howev-er, recommend both exercise and propernutrition for patients attempting to stopsmoking. Patients should be informed thatalcohol use also is considered a risk factor forrelapse to smoking by most clinicians(Shiffman 1982), and patients who canabstain from drinking during the withdrawalperiod should do so.

Patients generally will find a smoke-free envi-ronment helpful during quit attempts. If thepatient lives in a household where otherssmoke, household members and friends canhelp by not smoking in front of the patientand limiting the number of smoking cues intheir residence.

Patients with more severe nicotine depen-dence may benefit from enrollment in a spe-cialized smoking cessation program. Theymight also benefit from more intensive medi-cal management using several drugs (NRT +anticraving), medication for longer periods oftime, closer followup, and longer enrollmentin treatment. There are a number of cessationprograms available from organizations suchas the American Lung Association (www.lungusa.org) and the American CancerSociety (www.cancer.org). Some communityand local organizations also sponsor smokingcessation programs. For the most severelydependent smokers, there are a limited num-ber of residential facilities that treat nicotinedependence on an inpatient basis (Hurt et al.1992). Providers of detoxification services

94 Chapter 4

should be familiar with the programs avail-able in their communities in order to makereferrals.

Marijuana and OtherDrugs Containing THCMarijuana and hashish are the two sub-stances containing THC (delta-9-tetrahydro-cannabinol) commonly used today. The fieldof addiction medicine has given considerableattention to the question of whether there is aspecific withdrawal syndrome associated withcessation from prolonged THC use. In thepast, many have stated that there is no acuteabstinence syndrome that develops in peoplewho abruptly discontinue THC (CSAT1995d). More recently this has been calledinto question and most experts now believethat a THC-specific withdrawal syndromedoes occur in some patients who are heavyusers (Budney et al. 2001), though cannabiswithdrawal is not yet included in the APA’sDiagnostic and Statistical Manual of MentalDisorders.

The THC abstinence syndrome usually startswithin 24 hours of cessation. The amount ofTHC that one needs to ingest in order toexperience withdrawal is unknown. It can beassumed, however, that heavier consumptionis more likely to be associated with withdraw-al symptoms. The most frequently seen symp-toms of THC withdrawal are anxiety, restless-ness and irritability, sleep disturbance, andchange in appetite (usually anorexia). Othersymptoms of withdrawal are less frequentlyseen and appear to include tremor, diaphore-sis (sweating), tachycardia (elevated heartrate), and GI disturbances, including nausea,vomiting, and diarrhea. Cognitive difficultiesincluding depression also have been reportedand may persist but usually improve withtime. There are no medical complications ofwithdrawal from THC, and medication is gen-erally not required to manage withdrawal.

Clinicians may see a variety of the symptomsmentioned above, but these generally require

no immediate medication during the detoxifi-cation period and usually are self-limiting.However, the clinician should be aware of thepotential for more persistent problems.Screening the patient for suicidal ideation orother mental healthproblems is warrant-ed. Some reviewshave advocated theuse of buspirone asan alternative tobenzodiazepines forthe management ofpersistent general-ized anxiety (Gatchand Lal 1998). Othercommon problemsencountered duringwithdrawal can bemanaged with nonad-dictive, supportivemedications. Forpatients with morepersistent difficultysleeping, clinicalexperience suggeststhat Trazodone maybe useful. Trazodonecan lead to low bloodpressure upon stand-ing, dizziness, andmay increase falls,particularly in indi-viduals over age 60.Benzodiazepines andother addictive medi-cations should beavoided.

The patient should be encouraged to maintainabstinence from THC as well as other addic-tive substances. Some patients will require asubstance-free, supportive environment toachieve and maintain abstinence. Cliniciansshould educate all patients about the effectsof withdrawal, validate their complaints, andreassure them that their symptoms will likelyimprove with time. Symptomatic relief may beprovided in order to increase the patient’scomfort.

95Physical Detoxification Services for Withdrawal From Specific Substances

Most experts now

believe that a

THC-specific with-

drawal syndrome

does occur in some

patients who are

heavy users,

though cannabis

withdrawal is not

yet included in the

APA’s Diagnostic

and Statistical

Manual of

Mental Disorders.

There are no clinical assessment instrumentsavailable that measure THC withdrawal.Both animal and human studies indicate thata withdrawal syndrome starts within 24 hoursof cessation and may last for up to a week.

Anabolic SteroidsAnabolic steroids, as differentiated from cor-ticosteroids and female gonadotropic hor-mones, are androgens (male hormones) andsubject to abuse as a means of increasing

muscle mass. Theseagents also can pro-duce aggressive,manic-like behaviorthat may includedelusions (Lukas1998). Malesinvolved in profes-sional sports,weight lifting, bodybuilding, or otherpursuits that valuemuscular mass aremore likely to usethese substancesthan are women,although use inwomen has beenreported.Adolescents useanabolic steroids toimprove theirappearance andmay have increasedaccess to these com-pounds (Yesalis etal. 1993). The largenumbers of anabol-ic steroid prepara-tions that havemedical and veteri-nary uses are pri-

marily obtained illegally through diversion.High doses of anabolic steroids can be medi-cally dangerous but side effects, usuallyinvolving endocrine, liver, central nervoussystem, and cardiac function, tend to bereversible upon cessation of anabolic steroid

use. However, neither cessation nor disclo-sure of anabolic steroid use can be assumedwhen treating these individuals.

Withdrawal SymptomsAssociated With SteroidsAnabolic steroids can be associated with with-drawal symptoms emerging after their abruptdiscontinuation. Withdrawal symptomsinclude (in descending order of prevalence)craving for more steroids, fatigue, depres-sion, restlessness, anorexia (loss of appetite),insomnia, reduced libido (sex drive),headaches, and nausea (Lukas 1998). It is notknown how commonly this syndrome occurs,but steroid withdrawal appears more likely inheavy users. The clinician’s index of suspi-cion should be raised when evaluating indi-viduals who are predisposed to steroid misuseand who exhibit these symptoms. Also indica-tive of possible steroid abuse are certainphysiological signs of androgen exposure,including hair loss, acne, dysuria (difficult orpainful urination), small testicles, edema ofthe extremities, and rapid weight gain.Females can develop decreased breast size,acne, virilism (clitoral enlargement, excessiveand abnormal bodily hair growth, male pat-tern baldness) and amenorrhea (suppressionof menstruation). Males who abuse steroidshave been reported to possess a distortedbody image and may inaccurately view them-selves as small and weak (Pope et al. 1993).

Medical Complications ofSteroid WithdrawalDue to anabolic steroids’ long duration ofaction, side effects that might emerge cannotbe quickly reversed by the discontinuation ofthese substances. Therefore, related sideeffects might require medical managementbeyond the simple recommendation thatsteroids immediately be discontinued.Persistent side effects include urinary tractinfections, bladder irritability, skin blistering(at the injection site), erythema (abnormalskin redness) when given as a skin patch, and

96 Chapter 4

Interventions

directed toward

cessation should

involve patient

education regarding

the dangers and

medical complica-

tions of anabolic

steroids, their

behavioral effects,

and a thorough

evaluation of the

patient’s rationale

for misuse.

priapism (prolonged erections lasting hours).The latter condition involves a painful penileerection and constitutes an emergency thatrequires specialized medical attention. Edema(swelling) of the hands or feet, commonly seenwith anabolic steroids, can be treated withdiuretics (medications that increase urineflow). Elevated liver function tests and jaun-dice usually resolve with cessation of anabolicsteroid administration, although hepatic car-cinoma (cancer of the liver) has been report-ed. Other side effects such as headache, nau-sea, vomiting, acne, insomnia, and lethargyare time-limited and resolve after steroid ces-sation. Behavioral disturbances, such as psy-chosis or severe aggressiveness, should betreated symptomatically with appropriatepsychopharmacological interventions. Inextreme cases of psychotic or manic presenta-tions, emergency psychiatric hospitalizationmight be necessary to address dangerousnessto self or others.

Management of SteroidWithdrawalThere is no recommended detoxification pro-tocol for anabolic steroids. The key medicalgoal is that of persuading the patient to ceasesteroid misuse. This intervention should befollowed by evaluating and treating any sideeffects (discussed above) that might be pre-sent. Interventions directed toward cessationshould involve patient education regardingthe dangers and medical complications ofanabolic steroids, their behavioral effects,and a thorough evaluation of the patient’srationale for misuse. A family meeting often ishelpful if agreed upon by the patient.Unfortunately, education alone often is insuf-ficient. Patients with distorted body imagesmight be especially difficult to dissuade fromsteroid misuse, and referral to psychotherapyby a qualified clinician trained in the treat-ment of body image disorder should be con-sidered. Similarly, patients who derive signifi-cant muscle gain from anabolic steroids mightbe resistant to cessation and may conceal con-tinued steroid use.

Patient Care and Comfort Patient comfort during steroid withdrawal canbe achieved by addressing side effects, if pre-sent, that are discussed above. Counseling alsois a useful intervention and specialized psychi-atric interventions may be necessary. If theindividual also is using other substances ofabuse, referral to drug or alcohol rehabilitativetreatment should be made.

Club DrugsClub drugs represent diverse classes of drugsthat include sedative-hypnotic type agents aswell as stimulant/hallucinogens. Club drugs areillicit drugs used in the setting of nightclubs,dance clubs, parties, and “raves.” Raves areovernight dance parties, usually with severalhundred people in attendance.

Abuse of these drugs by adolescents andyoung adults has risen greatly in recent years.All healthcare professionals need familiaritywith their short- and long-term effects.Although withdrawal syndromes have beenreported with some of these drugs, this is notthe most common clinical problem.Intoxication and severe intoxication withoverdose are more frequent problems. Withsome of these compounds, there appears to bethe potential for neurotoxicity (destructiveeffects on the nervous system) and persistentpsychiatric and neurologic syndromes. At thepresent time, much of the available informa-tion regarding club drugs comes from surveysand anecdotal case reports. Human laborato-ry studies and rigorously controlled clinicaltrials are not common.

One difficulty in assessing the effects of intox-ication, overdose, withdrawal, and long-termhealth consequences of club drugs is that ingeneral, there are no baseline evaluations ofindividuals before they used club drugs. Also,these individuals abuse more than one sub-stance. Some of these patients may have hadmoderate to severe psychopathology (includ-ing psychosis) prior to their introduction toclub drugs. In the past, some club drugs were

97Physical Detoxification Services for Withdrawal From Specific Substances

referred to as “designer drugs” because oftheir production in a laboratory rather thanbeing processed from plant products.

HallucinogensHallucinogens are a broad group of sub-stances that can produce sensory abnormali-ties and hallucinations. Most hallucinogenshave some adrenergic effects as well.Hallucinogens also are referred to aspsychedelics and psychomimetics. The moretraditional hallucinogens such as lysergic aciddiethylamide (LSD) are considered primarilyserotonergic-acting agents. Some of the othercompounds include phenylethylamines whichhave hallucinogenic properties but act likeamphetamines as well. These drugs includemescaline and MDMA (3,4-methylenedioxy-N-methylamphetamine). Other drugs includeMDA (3,4-methylenedioxyamphetamine) andDOM (dimethyloxymethylamphetamine). (Seesection on ecstasy below.) Other hallucinogensare acetylcholine antagonists. These includebelladonna, drugs such as benzotrophineused to treat parkinsonian symptoms, andmany common over-the-counter antihis-tamines.

Hallucinogen intoxication often begins withautonomic effects, sometimes nausea andvomiting, and mild increases of heart rate,body temperature, and slight elevations ofsystolic blood pressure. Dizziness and dilatedpupils may occur. The prominent effects dur-ing intoxication are sensory distortions withillusions and hallucinations. Visual distor-tions are more common than auditory or tac-tile ones. So-called “bad trips” may involveanxiety including panic attacks, paranoidreactions, anger, violence, and impulsivity.Either due to delusions or misperceptions,individuals may feel they can fly or have spe-cial powers, and thus injure themselves infalls or other accidents. Suicide attempts alsocan occur during “bad trips” and possiblesuicidal ideation should be carefully evaluat-ed, even though it may be quite transient.

Withdrawal syndromes have not been report-ed with hallucinogens; however, considerableattention has been paid to residual effectssuch as delayed perceptual illusions with anx-iety, “flashbacks,” residual psychotic symp-toms, and long-term cognitive impairment.Controversies around these issues are notimportant in the clinical setting. The impor-tant thing is to determine whether residualsymptoms are present and provide an appro-priate environment and appropriate care forthe individual who has them. Generally, staffof emergency rooms, clinics that treat peoplewho abuse substances, and social detoxifica-tion centers have individuals who are veryfamiliar with “talking down” individuals withbad hallucinogenic trips.

Acute intoxication and bad trips usually canbe managed with placement of the individualin a quiet, nonstimulating environment withimmediate and direct supervision so that thepatient does not cause harm to herself or toothers. Occasionally, a low dose of a short- orintermediate-acting benzodiazepine may beuseful to control anxiety and promote seda-tion. Individuals with chronic depressive-likereactions may require antidepressant thera-py. Individuals with residual psychotic symp-toms are likely to require antipsychotic medi-cations. On rare occasions, the use of a lowdose, high-potency antipsychotic medicationmay be required orally or parenterally (anymethod other than the digestive tract, e.g.,intravenously, subcutaneously, or intramus-cularly). Assessment of residual psychiatricand cognitive symptoms should be made priorto treatment referral.

Gamma-hydroxybutyrate(GHB)GHB use has increasingly been reported innight clubs and at raves by adolescents andyoung adult populations. GHB is a compoundthat is produced in the central nervous sys-tem, and it acts as an inhibiting neurotrans-mitter similar to GABA (Shannon and Quang2000). In pharmacologic (medication-propor-

98 Chapter 4

tioned) doses, GHB serves as a sedative-hyp-notic medication. GHB intoxication may looklike alcohol or sedative-hypnotic intoxication.

Although GHB is illegal, psychotropic com-pounds similar to GHB such as gamma-hydroxy lactone (GBL) and 1,4-butanediol(1,4-BD) are widely available chemical com-pounds and may be obtained through catalogsand the Internet. These compounds produceeffects similar to those of GHB. At the pre-sent, overdose syndromes are more likely tobe seen than withdrawal syndromes.Overdose syndromes may require airway andrespiratory management. GHB has been stud-ied in Europe (Addolorato et al. 1999a) in arandomized, single-blind study comparing itto diazepam as a treatment for alcohol with-drawal. GHB was as effective as diazepam insuppressing alcohol withdrawal symptomsand was said to be quicker in reducing anxi-ety and agitation with less sedation thandiazepam. Because of its history of abuse inthe United States, it is unlikely to be viewedas a therapeutic agent any time in the nearfuture.

Miotto and Roth (2001) describe a GHB with-drawal syndrome, noting that it shares fea-tures of both alcohol and benzodiazepinewithdrawal. They have found this syndromemost pronounced in patients who have takenGHB around-the-clock, at 2- to 4-hour inter-vals. The GHB withdrawal syndrome has theprolonged duration of symptoms found inbenzodiazepine withdrawal and featuresdelirium tremens that appear early (oftenwithin an hour) with peak manifestationsoccurring within 24 hours; the delirium maylast up to 14 days. Confusion, psychosis, anddelirium are the most prominent features ofGHB withdrawal, and the autonomic effects(i.e., tremor, diaphoresis [sweating], hyper-tension, and temperature changes) are lesssevere than found in alcohol withdrawal.They note that brief periods of significanttachycardia (rapid heart rate) begin early inGHB withdrawal. Garvey and Fitzmaurice(2004) also report seizure activity in a case ofGHB withdrawal in a male who had been

using the substance regularly over a 2-yearperiod, and Rosenberg and colleagues (2003)note that in severe cases GHB withdrawalmay be life-threatening.

Milder cases of GHB withdrawal syndromemay be managed with benzodiazepines suchas lorazepam and supportive care. However,in more severe cases high doses of intra-venous benzodi-azepines (e.g.,lorazepam) or barbi-turates (e.g., pheno-barbital, pentobar-bital) may berequired (Miottoand Roth 2001;Rosenberg et al.2003). Patientsexperiencing GHBwithdrawal are like-ly to have a high tol-erance for the seda-tive effects of benzo-diazepines andrequire large andfrequent doses tomanage the with-drawal (Miotto andRoth 2001); in caseswhere high doses oflorazepam proveineffective, pento-barbital may beeffective (Sivilotti etal. 2001). Clonidinemay be used to treatepisodes of tachy-cardia (rapid heartrate) (Miotto andRoth 2001).

EcstasyMDMA (3, 4-methylenedioxy-metham-phetamine) commonly known as ecstasy, wassynthesized around the turn of the century andpatented by Merck Pharmaceuticals in 1914(Christophersen 2000; Parrot et al. 2000).These drugs are phenel-ethylene stimulants

99Physical Detoxification Services for Withdrawal From Specific Substances

Withdrawal

syndromes have not

been reported with

hallucinogens;

however, consider-

able attention has

been paid to

residual effects such

as delayed

perceptual illusions

with anxiety,

“flashbacks,”

residual psychotic

symptoms, and

long-term cognitive

impairment.

with various substitution groups off the ben-zene ring that give the medications hallucino-genic properties. There are a number of relat-ed compounds that are designated by their ini-tials (MDMA, MDA, MDEA, DOM, 2-CB, andDOT). Clinicians are likely to have to managethe complications of intoxication and overdosebut not withdrawal.

Patients using MDMA or related compoundsfrequently are hyperactive and hyperverbal,reporting heightened tactile and visual sensa-tions. They frequently will use camphor onthe skin in facial masks, gloves, and otherclothing to heighten their tactile sensations.Sometimes light sticks are used to heightenvisual experiences at raves. Hyperthermia,dehydration, water intoxication with low sodi-um, rhabdomyolysis (severe muscular injuryand breakdown of muscle fibers), renal fail-ure, cardiac arrhythmia, and coma have beenreported.

MDMA has been proven to be toxic to sero-tonergic neurons in several animal studies.Heavy ecstasy users can have paranoid think-ing, psychotic symptoms, obsessional think-ing, and anxiety (Parrott et al. 2000).Impaired cognitive performance in heavyecstasy users also has been identified(Gouzoulis-Mayfrank et al. 2000). Ecstasyusers performed more poorly than controlgroups in complex attention, memory, andlearning tasks. The duration or permanenceof such effects has not yet been well studied.

Ketamine and PCP(Phencyclidine)Ketamine and PCP (phencyclidine) were bothdeveloped in the 1950s as anesthetic agents forhumans. Phencyclidine was briefly marketedfor human anesthetic use but taken off themarket because of an unusual high incidence ofpsychotic symptoms. PCP remains in legitimateuse for veterinarian anesthesia for large ani-mals as does ketamine for small animals.Although both drugs were originally developedfor intravenous use, they are now manufac-

tured illicitly as oral drugs of abuse. PCP fre-quently is sold as LSD.

Some studies have found that ketamine andPCP act specifically at the MDMA/glutamatereceptor as noncompetitive MDMA receptorantagonists. Research in animals indicatesthat both drugs are reinforcing, in that ani-mals will press a bar to obtain doses of eitherdrug. Furthermore, in these same animalmodels, abstinence syndromes have beenobserved. Withdrawal symptoms in humanshave included depression, drug craving,increased appetite, and hypersomnolence(excessive sleep).

In the clinical setting, syndromes of acuteintoxication with hallucinations, delusions,agitation, and violence are the most pressingproblems. A human laboratory study (Lahtiet al. 2001) conducted a comparison ofketamine and placebo in normal volunteersnever exposed to ketamine and to people withschizophrenia with a previous history ofketamine use. In both groups, ketamine pro-duced a dose-related, but brief, increase inpsychotic symptoms. The magnitude ofketamine-induced positive psychotic symp-toms was similar for both groups, althoughthe schizophrenia group had higher baselinescores.

Although originally MDMA receptor antago-nists were felt to have neuroprotective effects(preventing damage to brain cells) and havebeen explored as post-stroke medications,there is some evidence now that ketamine andPCP may in fact have some neurotoxiceffects. Studies (e.g., Curran and Monaghan2001) have found greater memory impairmentamong chronic ketamine users than infre-quent ketamine users. Acute human laborato-ry studies by this group indicate persistentmemory impairment with ketamine exposure.This same study did not find persistent psy-chotic features beyond acute use.

In the clinical setting, ketamine and PCP userequire management for the agitation andpsychotic features produced during acute use.Occasionally, patients will have such large

100 Chapter 4

overdoses, intentionally or accidentally, thatthey will require airway management andventilatory support for some hours. Thebehavioral management of the agitation andviolence that may be seen is best managed ina controlled environment with limited stimuliand very close supervision. Occasionally, oralor parenteral uses of sedating medicationssuch as benzodiazepines will be required. Inextreme cases, restraints may be required forprotection of the patient and staff.

Following acute management, assessment ofpersistent mood and cognitive effects must bemade prior to any treatment attempts. Thepersistence of psychotic symptoms may repre-sent an underlying psychiatric disorder thatmay require medication treatment. There areno studies to guide the treatment of ketamineor PCP detoxification. The need to managewithdrawal symptoms from these drugs isunlikely, but if it should arise, benzodi-azepines should be administered.

OtherRohypnol is a benzodiazepine that is soldunder trade names in Europe and Mexico as asedative-hypnotic. Rohypnol is occasionallyused as a club drug and at dance clubs. In thelast decade it began to be smuggled into theUnited States and was commonly used amonghomeless youth involved in the sex industry.Rohypnol has a reputation as a “date rape”drug because it can produce powerful amnesticand hypnotic effects, as well as coma. For fur-ther details on benzodiazepines, see the benzo-diazepine section regarding intoxication andpotential withdrawal reactions.

Management ofPolydrug Abuse: AnIntegrated ApproachOne of the most significant changes in detoxi-fication services in recent years has been theincrease in the number of patients requiringdetoxification from more than one substance.

In an evaluation of admissions to publiclyfunded detoxification programs inMassachusetts between 1984 and 1996,McCarty and colleagues (2000) found a steadyincrease in the number of patients using bothalcohol and other substances in the monthprior to admission. In 1988, 26 percent ofadmissions reported using two or more sub-stances in the previous month; by 1996 thatnumber had nearlydoubled to 50 per-cent (McCarty et al.2000). There is noreason to believe thatthis trend has notappeared elsewherein this country. AsMiller and colleagues(1990a) note, “Forthe contemporarydrug addict, multipledrug use and addic-tion that includesalcohol is the rule”(p. 597).

In the Massachusettsevaluation, whichdid not include mari-juana or nonopioidprescription medica-tion use, the mostcommonly seen com-bination of sub-stances was alcoholand cocaine. Thirtypercent of patientsadmitted for detoxifi-cation in 1996 reported using this combina-tion; 12 percent used alcohol, cocaine, andheroin together; 10 percent combined alcoholand cocaine; and 7 percent combined heroinand cocaine (McCarty et al. 2000). Otherstudies, evaluating patient populations atinpatient treatment centers, found thatbetween 70 and 90 percent of patients whoreported cocaine abuse also abused alcohol.Rates of alcohol dependence amongmethadone patients and patients dependenton heroin were between 50 and 75 percent,

101Physical Detoxification Services for Withdrawal From Specific Substances

One of the most

significant changes

in detoxification

services in recent

years has been the

increase in the

number of

patients requiring

detoxification

from more than

one substance.

and 80 to 90 percent who were being treatedfor cannabis abuse also reported alcoholabuse (Miller et al. 1990a).

Clinicians need to be constantly aware that apatient may be abusing multiple substances.Even if a patient admits the abuse of one sub-stance he may not admit to using others.Patients may not see that other substancesare a problem, they may be worried about thelegal consequences of use, or they sometimesmay not even be aware of what substancesthey have been using. For these reasons, clin-icians should not rely on patients’ self-reportsto determine which substances are beingused. Interviews with family, friends, or oth-ers who know the patient may be helpful, butthese also are insufficient. The consensuspanel strongly recommends that all patientsreceive an immediate urine drug screeningupon admission to a detoxification program todetermine the types of substances beingabused. It is not necessarily true that the per-son is drug free simply because a drug is notdetected on a drug screen. It is possible thatthe toxicology is not able to detect the class ortype of drug. Staff should be aware of whatthe program/detoxification center/hospitaltests for, what is not tested for, what cannotbe tested for or found, and the limitations of“dip” tests.

Prioritizing Substances ofAbuseWhile substances of abuse may have complexinteractions, it is not always possible to deter-mine how those interactions will affect with-drawal. Therefore, it is generally best practiceto prioritize the substances an individual hasbeen dependent on and treat them sequentiallyaccording to the severity of the withdrawal pro-duced by the substance. The substances withthe most serious withdrawal syndromes, thosewhere the withdrawal syndrome can be fatal,are alcohol and the sedative-hypnotics. Whendetoxifying a patient who has been dependentupon multiple substances, the sedative-hyp-notics must be addressed first.

Oral methadone, LAAM, or buprenorphineshould be used to stabilize withdrawal fromopioids while tapering the dose of the seda-tive-hypnotic or anxiolytic (anti-anxiety medi-cation) by 10 percent each day. After thepatient has been tapered off of the sedative-hypnotic or anxiolytic, withdrawal from thesubstitute opioid can begin (Wilkins et al.1998). Some patients can successfully bedetoxified from both sedative-hypnotics andopioids simultaneously, but this requires agreat deal of medical and nursing attention.Most patients will benefit from opioid mainte-

102 Chapter 4

An Example of Potential Problems: Detoxification for Polydrug Abuse

Mr. L is a 43-year-old male with a 25-year heroin dependence. He is well known to the detoxification center,having been through the program there (which consisted primarily of support and hydration) on manyoccasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time hearrived, 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 askedhim several times if he had used anything else and each time he denied it. His drug of choice was alwaysheroin—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 hewas observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand malseizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates,opioids, and trace amounts of benzodiazepines

nance for an extended period of time follow-ing the completion of sedative withdrawal.

If the patient has been abusing multiple seda-tive-hypnotic substances or a sedative-hypnoticand alcohol, withdrawal should be handled inthe same way as withdrawal from one such sub-stance. The patient should be administered aregularly decreasing dosage of sedative-hypnot-ic, usually a benzodiazepine that the clinician iscomfortable with and accustomed to using. Thedosage should be decreased according to thepatient’s physiologic response. Providers alsomay administer an anticonvulsant such as car-bamazepine (Tegretol XR), even in the absenceof epilepsy or withdrawal seizures, to helpensure patient safety (Wilkins et al. 1998).Phenobarbital also may be used for detoxifyingpatients who have been abusing both alcoholand benzodiazepines. When the dose of alcoholand sedative-hypnotics that a patient is takingis not known, tolerance testing as previouslydescribed can be helpful in determining thedose of phenobarbital.

When treating patients detoxifying from sub-stances other than sedative-hypnotics, manage-ment of opioid detoxification should be the nextpriority. Generally, other substances of abuse,including stimulants, marijuana, hallucinogen-ics (LSD and similar drugs), and inhalants, willnot require specific treatment in patients whoare being detoxified from sedative-hypnoticsand/or opioids.

Patients may abuse a wide range of substancesin various combinations, and the clinician mustbe vigilant in assessing and treating withdrawalfrom multiple substances. The case study aboveillustrates some of the serious problems theclinician faces in evaluating and treatingpatients withdrawing from multiple substances.

In the private sector, where money for toxico-logical screening is readily available, the firstquestion many would ask concerning the caseof Mr. L. is, “Why wasn’t the drug screen donesooner?” However, those working in publicfacilities will recognize that such screeningsoften are unavailable or available only after anextended turnaround time. Toxicological

screening, even a hand-held screening, can bean expensive item for what often is a very limit-ed budget. Besides, in this case, the patient wasbelieved to be a known quantity—someone whoonly used heroin.

This scenario is not uncommon. It is likely thatthe patient himself was unaware of what was inhis body. One of the more frightening facts con-cerning the purchase of illicit drugs is the lackof knowledge of what is in them. To make buy-ers believe that they are buying a higher-quali-ty product than they are, drugs often are cutwith adulterants (inferior ingredients) that canproduce effects similar to the drug they thinkthey are buying. In this case, Mr. L may havebeen buying barbiturates and benzodiazepinesin his heroin for some time without knowing it,a fact that could have had deadly conse-quences. Both are sedating and could havegiven him some of the comfortable sedation andeuphoria he was seeking from his drug ofchoice. Unfortunately, however, where opioidwithdrawal is not life-threatening, withdrawalfrom barbiturates can be. Furthermore, hecould have gotten PCP in the marijuana heoccasionally used, again without knowing it.

AlternativeApproaches Alternative methods that have been studied sci-entifically do not claim to be stand-alone with-drawal methods, nor stand-alone treatmentmodalities. Alternative approaches aredesigned to be used in a comprehensive, inte-grated substance abuse treatment system thatpromotes health and well-being, provides pal-liative symptom relief, and improves treatmentretention. Therefore, because isolation of anyof these approaches as an independent variablein rigorous controlled studies is difficult, if notimpossible, there are no conclusive data on theeffectiveness of alternative methods(Trachtenberg 2000).

Auricular (ear) acupuncture has been usedthroughout the world, beginning in Hong Kong,as an adjunctive treatment during opioid

103Physical Detoxification Services for Withdrawal From Specific Substances

detoxification for about 30 years. Its use in theUnited States originated in California(Seymour and Smith 1987) and New York(Mitchell 1995) but has not been subjected torigorous controlled research. One report(Washburn et al. 1993) noted that patientsdependent on heroin with mild habits appearedto benefit more than those with severe with-drawal symptoms, which acupuncture did notalleviate. The 1997 National Institute of HealthConsensus Statement on acupuncture statedthat acupuncture treatment for addiction couldbe part of a comprehensive management pro-gram. The National AcupunctureDetoxification Association has developedacupuncture protocols involving ear acupunc-ture in group settings that originated at LincolnHospital in the Bronx and are used by over 400drug treatment programs and 40 percent ofdrug courts. SAMHSA’s National Survey ofSubstance Abuse Treatment Services (NSSATS)found that 5.4 percent of the 13,720 facilitiespolled in 2001 offered acupuncture as a service(Office of Applied Studies 2002b).

Acupuncture is one of the more widely usedalternative therapies within the context ofaddictions treatment. It has been used as anadjunct to conventional treatment because itseems to reduce the craving for a variety ofsubstances of abuse and appears to con-tribute to improved treatment retention rates.In particular, acupuncture has been viewedas an effective adjunct to treatment for alco-hol and cocaine disorders, and it also hasplayed an important role in opioid treatment(i.e., methadone maintenance). It is used asan adjunct during maintenance, such as whentapering methadone doses. The ritualisticaspect of the practice of acupuncture as partof a comprehensive treatment program pro-vides a stable, comfortable, and consistentenvironment in which the client can activelyparticipate. As a result, acupunctureenhances the client’s sense of engagement inthe treatment process. This may, in part,account for reported improvements in treat-ment retention (Boucher et al. 2003). A 1999CSAT-funded study showed that patients

choosing outpatient programs with acupunc-ture were less likely to relapse in the 6months following discharge than were patientswho had chosen residential programs(Shwartz et al. 1999).

Ear acupuncture detoxification, which wasoriginally developed as an alternative treat-ment for opioid agonist pharmacotherapy, isnow augmenting pharmacotherapy treatmentfor patients with coexisting cocaine problems(Avants et al. 2000). The advocates ofacupuncture have joined with the advocatesof opioid agonist pharmacotherapy to create aholistic synthesis. Each has contributed to thesuccess of the other, both clinically and inpublic perception.

Care must be taken to ensure sterile acupunc-ture needles in the heroin-dependent popula-tion, given the high incidence of HIV infec-tion, viral hepatitis, and other infections.Acupuncture is not recommended as a stand-alone treatment for opioid withdrawal.

Other alternative management approachesthat are not supported by controlled studiesinclude neuroelectric therapy (the adminis-tration of electric current through the skin)and herbal therapy. In fact, the former hasbeen shown to be no better than placebo in acontrolled study (Gariti et al. 1992). The useof herbs for healing purposes dates back tothe dawn of civilization, while the use ofherbs in the treatment of substance abuse hasbeen documented since 1981 in methadoneprograms, free clinics, therapeutic communi-ties, outpatient programs, and hospitals(Nebelkopf 1981). Herbal remedies are usedin substance abuse detoxification and treat-ment in a number of cultures around theworld. However, in no scientific studies haveherbs been isolated as a discrete variable totest their efficacy. Much research is currentlybeing conducted on the effectiveness of herbalmedicine on a wide variety of physical conditions.

104 Chapter 4

Considerations forSpecific Populations All individuals undergoing detoxification areespecially vulnerable. Patients who experiencenegative attitudes from staff may experiencefurther loss of self-esteem, may leave detoxifi-cation prematurely, or may experience otherpsychologically damaging feelings. Negativeexperiences can undermine the recovery pro-cess. It is important to recognize that individu-als do not fit into just one population category.A person will be a member of several popula-tions (e.g., a Latina woman who is pregnant,bisexual, and has psychiatric diagnoses of post-traumatic stress disorder and major depres-sion) and may benefit from a number of theconsiderations discussed below. It also shouldbe noted that the information in the specificpopulations sections should not be used to cate-gorize individuals or leave the reader with theimpression that the information below will fitall individuals who are members of a group.

Pregnant WomenWhile in detoxification, pregnant womenshould receive comprehensive medical care,especially since this may be the first time theyhave sought any type of care or treatment.Ideally, programs detoxifying pregnant womenfrom alcohol and illicit drugs should includethe following services: •Detoxification on demand

•Woman-centered medical services

•Transportation services to and from detoxifi-cation (as well as to substance abuse treat-ment afterward)

•Childcare services

•Counseling and case management services

•Access to drug-free, safe, affordable housing

•Help with legal, nutritional, and other socialservice needs

While it is recognized that provision of all ofthese services is an ideal to be striven for, at aminimum detoxification programs must have

strong linkages to agencies that provide theabove-mentioned services and should set upsystems to ensure that pregnant women canaccess the additional services they need.

Pregnant women who present for detoxificationwill benefit from a comprehensive medicalexamination that includes a careful obstetricalcomponent. Since it is estimated that approxi-mately 44 to 70 percent of women who abusesubstances have a his-tory of physical, emo-tional, and sexualabuse (Moylan et al.2001; Stevens et al.1997), care should begiven to the comfortof the patients duringthe examination. Oneof the major internalbarriers that preventspregnant women fromseeking treatment isthe shame and stigmaattached to substanceuse, especially duringpregnancy. Any nega-tive experienceencountered duringdetoxification canlead these women toleave treatment andnot return.

Detoxification duringpregnancy poses aspecial risk in thatcare should be takento ensure the health and safety of both themother and fetus. From a clinical standpoint,before giving any medications to pregnantwomen it is of vital importance that theyunderstand the risks and benefits of takingthese medications and sign informed consentforms verifying that they have received andunderstand the information provided to them.Since pregnant women often present to treat-ment in mid- to late-second trimester and poly-drug use is the norm rather than the exception(Jones et al. 1999), it is important first to

105Physical Detoxification Services for Withdrawal From Specific Substances

Pregnant women

who present for

detoxification will

benefit from a

comprehensive

medical examina-

tion that includes

a careful

obstetrical

component.

screen these women for dependence on the twoclasses of substances that can produce a life-threatening withdrawal: alcohol and sedative-hypnotics. Pregnant women should be madeaware of all wraparound services that willassist them in dealing with newborn issues,including food, shelter, medical clinics for inoc-ulations, as well as programs that will help withdevelopmental or physical issues that theneonate (newborn baby) may experience as a

result of substanceexposure.

AlcoholWhen pregnantwomen are detoxi-fied from alcohol,benzodiazepinetapers appear to bethe current practiceof choice. The cur-rent state of knowl-edge suggests thatbenzodiazepinetherapy in generaldoes not have asmuch of a terato-genic (producing adeformed baby) riskas do other anticon-vulsants as long asthey are given overa short time period.It appears thatshort-acting benzo-diazepines, like theones described totreat alcohol with-drawal above, can

be used in low doses for acute uses such asdetoxification, even in the first trimester(Robert et al. 2001). Long-acting benzodi-azepines should be avoided—their use duringthe third trimester or near delivery can resultin a withdrawal syndrome in the baby (Garbisand McElhatton 2001).

Although no teratogenic effects have beenobserved, little is known about the effects of

naltrexone, naloxone, or nalmefene adminis-tration during pregnancy. Although propra-nolol (Inderal), labetalol (Trandate), andmetoprolol (Lopressor) are the beta blockersof choice for treating hypertension (highblood pressure) during pregnancy(McElhatton 2001), the impact of using themfor alcohol detoxification during pregnancy isunclear. The use of SSRIs, a class of antide-pressant medication, is safer for the motherand fetus than are tricyclic antidepressants(Garbis and McElhatton 2001). Fluoxetine(Prozac) is the most studied SSRI in pregnan-cy and no increased incidence in malforma-tions was noted, nor were there neurodevel-opmental effects observed in preschool-agechildren (Garbis and McElhatton 2001).However, possible neonatal withdrawal signshave been observed. Given that the greatestamount of data are available for fluoxetine,this is the recommended SSRI for use duringpregnancy (Garbis and McElhatton 2001).

The use of anticonvulsants, such as valproicacid, is associated with several disfiguringmalformations. If this type of medicationmust be used during pregnancy, the womanmust be told that there is substantial risk ofmalformations (Robert et al. 2001).Barbiturate use during pregnancy has beenstudied to some extent, and phenobarbital isused therapeutically during pregnancy, butthe risk of any anticonvulsive medicationshould be discussed with the patient (Robertet al. 2001). There also are reports of a with-drawal syndrome in the neonate followingprenatal exposure to phenobarbital (Kuhnz etal. 1988).

OpioidsWhile it is not recommended that pregnantwomen who are maintained on methadoneundergo detoxification, if these womenrequire detoxification, the safest time todetoxify them is during the second trimester.For further information, consult the forth-coming TIP Substance Abuse Treatment:Addressing the Specific Needs of Women(CSAT in development e) and TIP 43

106 Chapter 4

A National

Institutes of

Health consensus

panel

recommended

methadone

maintenance as

the standard of

care for pregnant

women with

opioid

dependence.

Medication-Assisted Treatment for OpioidAddiction in Opioid Treatment Programs(CSAT 2005d). In contrast, it is possible todetoxify women dependent on heroin who areabusing illicit opioids by using a methadonetaper.

Before starting a detoxification, womenshould weigh the risks and benefits of detoxi-fication, since many women eventuallyrelapse to drug use and thus place themselvesand their fetuses at risk for adverse conse-quences (Jones et al. 2001b). During pregnan-cy, the protein binding of many drugs, includ-ing methadone and diazepam (a benzodi-azepine), is decreased (e.g., Adams andWacher 1968; Dean et al. 1980; Ganrot 1972)with the greatest decrease noted during thethird trimester (Perucca and Crema 1982).This decreased binding may be due to thedecreased levels of albumin reported duringpregnancy (Yoshikawa et al. 1984). From aclinical standpoint, it may be that pregnantwomen could be at risk for developing greatertoxicity and side effects, yet at the same timean increase in metabolism of the drug mayresult (such as found with methadone). Thismay result in reduced therapeutic effect fromthe drug, since many women require anincrease in their dose of methadone duringthe last trimester (Pond et al. 1985).

Other medications used to treat the withdraw-al signs and symptoms include clonidine.Clonidine is used as a second-line drug totreat hypertension (high blood pressure) dur-ing pregnancy and appears to lack teratogeniceffects (McElhatton 2001). It has reportedlybeen abused by pregnant women. Some preg-nant women take clonidine with theirmethadone because it is hard to detect inurine and it increases the high they get frommethadone. However, little is known about itseffects on the baby following therapeuticdoses given in a detoxification context ordoses taken in higher than therapeuticamounts (Anderson et al. 1997a).Buprenorphine has been examined in preg-nancy and appears to lack teratogenic effects

but may be associated with a withdrawal syn-drome in the neonate (Jones and Johnson2001).

A National Institutes of Health consensuspanel recommended methadone maintenanceas the standard of care for pregnant womenwith opioid dependence. Methadone currentlyis the only medication recommended for med-ication-assisted treatment for pregnantwomen. Clinical trials are being conducted todetermine the efficacy and safety ofbuprenorphine with pregnant women but ithas not yet been approved for use with thispopulation. Two early studies on treatment ofpregnant women with opioid dependence withbuprenorphine showed promising results(Fischer et al. 2000; Johnson et al. 2001).Comer and Annitto (2004) conclude, fromtheir review of the research literature, thatbuprenorphine should be used more aggres-sively to detoxify pregnant women who wantto be opioid-free at delivery.

Because of the potential for premature laborand delivery and risks of morbidity and mor-tality to the fetus related to withdrawal fromopioids, it is recommended that a pregnantwoman who is dependent on opioids be main-tained during pregnancy (Kaltenbach et al.1998). Other reasons to stabilize a pregnantwoman on methadone rather than attemptwithdrawal are the risks of relapse, conse-quences associated with HIV and use of multi-ple needles, and the potential lack of prenatalcare.

The Federal government mandates that pre-natal care be available for pregnant womenon methadone. It is the responsibility of treat-ment providers to arrange this care. Morethan ever, there is need for collaborationinvolving obstetric, pediatric, and substanceabuse treatment caregivers. Comprehensivecare for the pregnant woman who is opioiddependent must include a combination ofmethadone maintenance, prenatal care, andsubstance abuse treatment.

107Physical Detoxification Services for Withdrawal From Specific Substances

Pregnant women should be maintained on anadequate (i.e., therapeutic) methadone dose.An effective dose prevents the onset of with-drawal for 24 hours, reduces or eliminatesdrug craving, and blocks the euphoric effectsof other narcotics. An effective dose usually isin the range of 50–150mg (Drozdick et al.2002). Dosage must be individually deter-mined, and some pregnant women may beable to be successfully maintained on lessthan 50mg while others may require muchhigher doses than 150mg. The dose oftenneeds to be increased as a woman progressesthrough gestation, due to increases in bloodvolume and metabolic changes specific topregnancy (Drozdick et al. 2002; Finneganand Wapner 1988).

Generally, dosing of methadone is for a 24-hour period. However, because of metabolicchanges during pregnancy it might not be pos-sible to adequately manage a pregnant womanduring a 24-hour period on a single dose.Split dosing, particularly during the thirdtrimester of pregnancy, may stabilize thewoman’s blood methadone levels and effec-tively treat withdrawal symptoms and crav-ing.

Breastfeeding is not contraindicated forwomen who are on methadone. Very littlemethadone comes through breast milk; theAmerican Academy of Pediatrics (AAP)Committee on Drugs lists methadone as a“maternal medication usually compatible withbreastfeeding” (AAP 2001, pp. 780–781).

BenzodiazepinesThe principles of detoxification from benzodi-azepines are the same for pregnant and non-pregnant patients. It is important to taper thedose of benzodiazepine slowly in order not toinduce fetal withdrawal or other adverse con-sequences in the fetus or mother.Detoxification is most likely safest during thesecond trimester in order to avoid sponta-neous abortion or premature labor. For moreinformation, see the forthcoming TIPSubstance Abuse Treatment: Addressing the

Specific Needs of Women (CSAT in develop-ment e). There is a documented withdrawalsyndrome in neonates who have been prena-tally exposed to benzodiazepines (Sutton andHinderliter 1990), and this syndrome may bedelayed in onset more than that associatedwith other drugs.

StimulantsThe principles of detoxification from stimulantssuch as cocaine are the same for pregnant andnonpregnant women. Since there is no currentpharmacotherapy to use in tapering individualsfrom stimulant use, the use of any medicationsto treat medical complications that might arisefrom the withdrawal should only be done afterdiscussion with the patient of the risks and ben-efits of each medication.

SolventsThe principles of detoxification from solventsare the same for pregnant and nonpregnantwomen. It should be noted that based on areview of case reports, there is a complexarray of characteristics that appear to be sim-ilar to fetal alcohol effects. Fetal AlcoholSyndrome (FAS) is characterized by growthdeficiency (born small for gestational age;failure to grow at a normal rate), particularfacial features (e.g., eyes are too close togeth-er, ears are set low on the head), and CNSdysfunctions (mental retardation, microen-cephaly [small brain size]) and brain malfor-mations (Costa et al. 2002). Thus fetal devel-opment in pregnant women who have a histo-ry of solvent abuse should be evaluated andcarefully monitored (Jones and Balster 1998).

NicotineThere is extensive documentation that smokingduring pregnancy causes numerous adversefetal consequences (see Schaefer 2001).Cigarette smoking during pregnancy is thelargest modifiable risk for pregnancy-relatedmorbidity and mortality in the United States(Dempsey and Benowitz 2001). While women

108 Chapter 4

are undergoing detoxification, they should beoffered education about the risk of cigarettesmoking during pregnancy and, ideally, pre-vented from smoking. This is especially impor-tant since cigarette smoking is strongly associat-ed with decreased birth weight, which is a pre-dictor of developmental problems in newborns(Ernst et al. 2002). If women are unable to stopsmoking using behavioral interventions, nico-tine replacement products may be used; how-ever, the woman should fully understand thepossible risks and benefits of these pharma-cotherapies (Jones and Johnson 2001).

It also is important to point out to patientsthat there are data to suggest that women mayderive less benefit from NRT than do menand that they may derive greater benefit fromsome non-NRT medications (e.g., bupropion),thus producing quit rates in women compara-ble with those in men (Perkins 2001).However, the data regarding the use ofbupropion during pregnancy are limited.

Examinations of the acute effects of NRT inpregnant women reveal that nicotine has min-imal impact on the maternal and fetal cardio-vascular systems. NRT may well be viewed asthe lesser of two evils, inasmuch as smokingcigarettes delivers, in addition to nicotine,thousands of chemicals. Among these aremany that also are viewed as developmentaltoxins (e.g., carbon monoxide and lead). It isdoubtful that the reproductive toxicity ofcigarette smoking is primarily related to nico-tine. Thus, if NRT is to be used during preg-nancy, the dose of nicotine in NRT should besimilar to the dose of nicotine that the preg-nant woman received from her ad lib (when-ever desired) smoking. Although intermittent-use formulations of NRT (e.g., chewing gum)have been recommended over continuous-useformulations (e.g., transdermal patch) due toreductions in the total dose of nicotine deliv-ered to the fetus (Dempsey and Benowitz2001), it is unknown what the impact of inter-mittent acute doses followed by withdrawal ofnicotine has on the fetus.

Marijuana, anabolic steroids,and club drugsThe principles of detoxification from thesedrugs is the same for pregnant and nonpreg-nant women. The use of anabolic steroids dur-ing pregnancy is rare; however, these can becatastrophic to a pregnancy, and if use isfound, a detailed ultrasound examination isrecommended to determine the morphological(physical or structural) development of thefetus (Scialli 2001).

Although the class ofclub drugs is rela-tively new there havebeen a few reports(McElhatton et al.1999) suggesting thatthere is an increasedrisk of congenitalmalformation inneonates prenatallyexposed to ecstasy.Other club drugssuch as fluni-trazepam (Rohypnol)may have effects sim-ilar to those of somebenzodiazepines;however, this is spec-ulative. For compre-hensive informationon the treatment ofthis specific popula-tion, see the forth-coming TIPSubstance AbuseTreatment:Addressing the Specific Needs of Women(CSAT in development e).

Older AdultsIt has been recommended that, when treatingolder adults, there should be a policy of usingage-specific group treatment that is both sup-portive and nonconfrontational (Royer et al.2000; West and Graham 1999). Older adultsmay be dealing with depression, loneliness,

109Physical Detoxification Services for Withdrawal From Specific Substances

While women are

undergoing

detoxification,

they should be

offered education

about the risk of

cigarette smoking

during pregnancy

and, ideally,

prevented from

smoking.

and loss of career or a loved one. Thus, as astandard policy, older adults should bescreened for depression and grief or loss-related issues. Similar to the situation withother specific populations, the detoxificationsetting should ideally have in place a policythat mandates, at a minimum, well-estab-lished linkage with general medical servicesand specialized services for the aging, becauseof their increased vulnerability to physicalailments. Establishing policies that create anenvironment that is positive and does not tol-erate “ageism”—a general tendency to reactnegatively toward elderly adults—is impor-tant for the optimal treatment of older indi-viduals.

Alcohol and other drug-related disorders inelderly individuals often are more severe thanthose of younger individuals and they are atincreased risk for co-occurring medical disor-ders. It is the medical complications ratherthan age itself for which detoxification in amedical setting is needed. The elderly mayhave slower metabolism of medications mak-ing dosage adjustments necessary in somecases. The elderly also may be at greater riskfor drug interactions, since they may bereceiving medications to treat other problems.A complete and careful assessment with ongo-ing monitoring should be done to examine theexistence of diseases such as, but not limitedto, heart disease, respiratory disease, dia-betes, and dementia. Potential for falls alsoshould be evaluated in the context of pre-scribed medications. The previously present-ed protocols for detoxification from alcohol,opioids, benzodiazepines, stimulants, sol-vents, nicotine, marijuana, anabolic steroids,and club drugs (anabolic steroids and clubdrug abuse are rare in this population)appear to be applicable to the elderly popula-tion as long as sensitivity to the withdrawalmedication is considered. TIP 26, SubstanceAbuse Among Older Adults (CSAT 1998f),provides comprehensive information on thetreatment of this population.

People With Disabilities or Co-Occurring ConditionsIn any patient population, the clinicianshould expect to encounter persons with dis-abilities including co-occurring medical ormental disorders. These patients often willrequire special assistance to overcome bothphysical and psychological barriers in under-going detoxification and treatment, includingtheir own psychological barriers that must beovercome, as well as those attitudinal andcommunication barriers that often preventcomplete and clear understanding betweenpatient and clinician or clinician and institu-tion. Effective communication is essential foreffective services. Accommodations must takeinto consideration the expressed preference ofthe individual with a disability. Substanceabuse treatment programs need to be in com-pliance with two Federal laws regarding thismatter: the 1992 Amendments to theRehabilitation Act of 1973 and the Americanswith Disabilities Act [ADA] of 1990.According to the ADA, programs mustremove or compensate for physical or archi-tectural barriers to existing facilities whenaccommodation is readily achievable, mean-ing “easily accomplishable and able to be car-ried out without much difficulty or expense”(P.L. 101-336 § 301). Providers should exam-ine their programs and modify them to elimi-nate four fundamental groups of barriers totreatment for people with disabilities and/orco-occurring disorders: (1) attitudinal barri-ers; (2) discriminatory policies, practices, andprocedures; (3) communications barriers; and(4) architectural barriers. Federal, State, andother sources of assistance might be availableto fund ADA-related improvements. See TIP29, Substance Use Disorder Treatment forPeople With Physical and CognitiveDisabilities (CSAT 1998g) for further infor-mation.

The following passage clarifies terms andaddresses the basic issues presented bypatients with disabilities and/or co-occurringdisorders. Diseases, disorders, and injuries,

110 Chapter 4

whether congenital or acquired, can havediverse effects on organs and body systems.Conditions (and diseases) such as multiplesclerosis, traumatic brain injury, spinal cordinjury, diabetes, and cerebral palsy can leadto impairments, such as impaired cognitiveability, paralysis, blindness, or muscular dys-function. These impairments in turn causedisabilities, which limit an individual’s abilityto function in various areas of life, such aslearning, reading, and mobility. While dis-eases, impairments, and disabilities are dis-tinct categories, they often are used inter-changeably. These essential terms are definedin Figure 4-15.

The field of disability services has developedits own terminology to discuss physical, senso-ry, and cognitive disabilities (see definitionsbelow), and many treatment providers of peo-ple with substance use disorders will not befamiliar with these terms as the professiondefines them. WHO has devised a method forthe classification of impairments and disabili-

ties (WHO 1980). This complex system hasbeen simplified here into four main cate-gories:

1. Physical impairments are caused by con-genital or acquired diseases and disordersor by injury or trauma. For example,spinal cord injury is a disorder that cancause paralysis, an impairment.

2. Sensory impairments include blindnessand deafness, which may be caused bycongenital disorders, diseases such asencephalopathy or meningitis, or traumato the sensory organs or the brain.

3. Cognitive impairments are disruptions ofthinking skills, such as inattention, memo-ry problems, perceptual problems, disrup-tions in communication, spatial disorienta-tion, problems with sequencing (the abilityto follow a set of steps in order to accom-plish a task), misperception of time, andperseveration (constant repetition ofmeaningless or inappropriate words orphrases).

111Physical Detoxification Services for Withdrawal From Specific Substances

Figure 4-15Some 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 inthe manner or within the range considered normal for a human being. A disability is always perceivedin the context of certain societal expectations, and it is only within that context that the disadvantagesresulting 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 certainsocial 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 onthe part of the individual in meeting life activities and reflect the interaction between the person and theenvironment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure4-16, p112.)

Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.

4. Affective impairments are disruptions inthe way emotions are processed andexpressed. For the purposes of this discus-sion, affective impairments are consideredto include problems caused by both affec-tive and mood disorders, such as majordepression and mania. These impairmentsinclude the symptoms of mental disorders,such as disorganized speech and behavior,markedly depressed mood, and anhedonia(joylessness).

One of the most important practices thatshould be in place as a standard in any detox-ification setting is routine screening for dis-

abilities and co-occurring medical and/or psy-chiatric conditions. The failure to recognizethese problems in patients can result in pooroutcomes (Cook et al. 1992). Additionally,intoxicated individuals with co-occurringdepressive disorders are at high risk for sui-cide attempts. Of course, an individualpatient may present with two or more disabil-ities and/or co-occurring disorders. Clinicianstreating people with co-occurring substanceuse and mental disorders should consult TIP42, Substance Abuse Treatment for PersonsWith Co-Occurring Disorders (CSAT 2005b).

112 Chapter 4

Figure 4-16Impairment and Disability Chart

Impairment Category Common Disabilities

Physical Spina bifidaSpinal cord injuryAmputationDiabetesChronic fatigue syndromeCarpal tunnelArthritis

Sensory BlindnessHearing impairmentDeafnessDeaf-blindness Visual impairment

Cognitive Learning disabilitiesTraumatic brain injuryMental retardation Attention deficit disorder

Affective DepressionBipolar disorderSchizophreniaEating disorderAnxiety disorderPosttraumatic stress disorder

Source: CSAT 1998e.

All programs should make a good faith effortto provide equal access in as comprehensive amanner as possible for all patients. Individualunique needs should be taken into accountwhen providing services. For example,patients with physical, sensory, or cognitivedisabilities may need help with self-care (e.g.,eating, grooming), moving (e.g., using stairs,walking), communication (e.g., reading,speaking), learning, social skills, and execu-tive functions (e.g., planning and organiza-tion, decisionmaking). Unresponsiveness toinstructions, lack of participation in discus-sions and activities, forgetfulness, or confu-sion by an individual with cognitive disabili-ties should not be viewed as a lack of motiva-tion, resistance, or denial. Programs mayneed to develop the expertise or engage anexpert on cognitive disabilities to determinethe limitations resulting from the substanceabuse and those resulting from the disability.Both require patience in the response.Information presented to the person with acognitive disability should include differentand complementary media; for example, visu-al and tactile materials can reinforce theusual verbal interaction.

Programs also may need to alter their policiesregarding the use of drugs prescribed for paincontrol, since most medications of this classare drugs with a high abuse potential. A num-ber of patients with substance use disordersalso live with chronic pain. Living in a drug-free state may not be desirable if it is associ-ated with unrelieved pain, which can be quitedisabling. The clinician should explore withpatients what pain management options havebeen tried in the past, and which managementmedications are being used currently.Patients should be encouraged to discusstheir feelings about pain and how it affectstheir daily life, and especially to what extentit curtails or prevents their participation inthe activities of daily living.

There are a number of alternative treatmentsfor chronic pain. Acupuncture is already inuse in some treatment programs for detoxifi-cation to help relieve symptoms of withdraw-

al. Physical therapy and exercise, chiroprac-tic care, biofeedback, hypnotism, and thera-peutic heat or cold are some other approach-es to caring for persons with physical prob-lems. Most of these alternative treatmentshave limited or no research support of theirefficacy; yet some clinicians believe theywork. Thus, consultation with experts ontheir use is necessary before starting a personwith chronic pain on these remedies.

An alternative model supports the idea thatpatients should be treated simultaneously insubstance abuse treatment, mental/physicalhealth, and detoxification settings, yet treat-ments may occur in separate facilities and beconducted by separate staff. The consequenttask for all is to be supportive and knowl-edgeable about each other’s interventions.The severity of the addiction andmedical/psychiatric problems at the time ofdetoxification entry should determine whichacute services the patient receives first.Naturally, a person’s medical and psychiatricdisabilities must be accounted for in thepreparation of any treatment plan. In somecases, substance abuse treatment cannotbegin until issues relating to medical and psy-chiatric disabilities are settled.

There are a number of resources for clini-cians to employ, including experts in the fieldof disability services. Figure 4-17 (p. 114) dis-cusses ways of locating expert help for treat-ing patients with disabilities and/or co-occur-ring disorders.

Finally, integrated treatment combines sub-stance abuse treatment, treatment for co-occurring disorders, and detoxification servicesinto one program. For more complete informa-tion on the treatment of many of these disor-ders, see chapter 5.

African Americans For African Americans, entrance into detoxifi-cation has been associated with enrolling in fur-ther treatment, reductions in HIV/AIDS riskbehaviors, and linkages with social and health-

113Physical Detoxification Services for Withdrawal From Specific Substances

care services (Lundgren et al. 1999). AfricanAmericans are at greater risk than other popu-lations for the co-occurrence of diabetes andhypertension (high blood pressure) that canpredispose them to a risk of stroke. Thisshould be taken into account when placing andmonitoring them on withdrawal medications.

In treating African-American patients, treat-ment efficacy and therapist efficacy may beassociated with the therapist’s understandingof how race plays a role in recovery(Luborsky et al. 1988; Pena et al. 2000). Inaddition, when working with counselors fromother cultures, African Americans may dis-play mistrust and a reluctance to show anyweakness. To overcome this mistrust and tobuild rapport, especially when the clinician isdiscussing the detoxification process, it is par-ticularly important for the clinician to keep in

mind the standard of respecting the client asan equal partner in treatment. For furtherinformation on this subject (as well as infor-mation on working with members of othercultural/ethnic groups), see the forthcomingTIP Improving Cultural Competence inSubstance Abuse Treatment (CSAT in devel-opment a).

The previously discussed protocols for detoxi-fication from all substance of abuse appearadequate for the detoxification of AfricanAmericans. However, there are a few furtheraspects to consider:•If treating African Americans with beta

blockers, propranolol is less effective intreating African Americans than Caucasians(Pi and Gray 1999).

•African Americans are more likely (15 to 25percent) to have less of the enzyme activity

114 Chapter 4

Figure 4-17Locating Expert Assistance

“Experts” in disability services can be located in several ways, depending upon the nature of the patient’sdisability 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 suchcases, immediate family members or close friends may be important sources of information and guidance.The treatment team also should consider contacting other sources: •A disability-specific 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, theAssociation for Retarded Citizens)

•Social workers

•Case managers

•Rehabilitation specialists

•Psychologists

•Nurses or physicians associated with a social service agency providing disability services for the individualpatient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard ofhearing, the Department of Veterans Affairs’ physical rehabilitation unit, community case managementservices)

•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 consumercoalitions for persons with disabilities)

Source: CSAT 1998e.

needed to eliminate diazepam than others, soit may have a longer half-life in AfricanAmericans than it does in other ethnic groups(Pi and Gray 1999).

•Since co-occurring disorders such as depres-sion frequently are seen in people with sub-stance use disorders, it is important to knowthat African Americans may require lowerdoses and may be at greater risk of develop-ing toxic side effects when prescribed antide-pressants, since they are likely to metabolizetricyclic antidepressants and SSRIs less effi-ciently than Caucasians (Pi and Gray 1999).

•Although the clearance of nicotine is similarfor African Americans and Caucasians, theclearance of cotinine, a metabolite of nico-tine, is slower in African Americans, whichmay cause different smoking patterns thanfound in Caucasians (Ahijevych 1998).

Asians and Pacific Islanders This group is the most diverse in nations oforigin and has widely differing languages,beliefs, practices, dress, and values. Oftenthe only common thread among these peopleis their geographic origin (Chang 2000).Although this group appears to have lowerrates of alcohol and illicit drug use, theseproblems should not be overlooked; membersof this group may not seek treatment until theproblems are quite severe. Successful treat-ment involves the family and important val-ues include balance, harmony, wisdom, andmodesty. Thus, it may be important to talk tothe family about the process of detoxificationand dispel their fears and concerns as well asthe patient’s.

Asians and Pacific Islanders tend to be con-cerned about the clinician’s credibility andtrustworthiness. Generally speaking, male-ness, mature age, the projection of self-confi-dence, possession of sound cultural compe-tence skills, good educational background,and level of experience are of importance. Inaddition, a concrete logical approach to theproblem at hand is valued (Brems 1998). Thepreviously discussed protocols for detoxifica-tion from all substances of abuse appear ade-

quate for the detoxification of Asians andPacific Islanders. During the detoxificationprocess, there are a number of issues to con-sider:•If possible and appropriate, incorporate tra-

ditional healing methods (e.g., meditationand religious exercises). These can helpreduce stress and anxiety and promote recov-ery (Chang 2000). While there is a largeimmigrant population among many Asian-American groups, it is erroneous to assumethat all are foreign born. Variation in prac-tice of traditional healing methods is consid-erable and consistent with generational dif-ferences. When considering detoxification,recognize the importance of bicultural prac-tices, values, and beliefs that might influenceresponsiveness to treatment.

•When discussing detoxification medications,discuss with patients their feelings about tak-ing “Western” medications for detoxification.In some Southeast Asian cultures, Westernmedications are believed to be too strong forthe Asian person. It is important to assess aperson’s feelings about these since the patientmay not wish to disagree with the clinicianyet may be noncompliant in taking the medi-cations. Compliance with detoxification medi-cation may be better achieved if doses arereduced or regimens shortened, yet thisshould only be attempted if it is in the bestinterest of the patient.

•Racial differences in alcohol sensitivityamong Asians and Caucasians have long beenrecognized, with more than 80 percent ofsome Asians compared to 10 percent ofCaucasians being sensitive to alcohol (i.e.,having a flushing reaction) (Wolff 1972,1973). This is the result of genetic differencesin alcohol metabolizing enzymes.Approximately 50 percent of Asians lack theenzyme ALDH2, found in the liver, that helpsthe body get rid of alcohol (Hsu et al. 1985;Yoshida et al. 1985). One reason for lowerdrinking rates among Asians may be theflushing reaction in the face and body follow-ing alcohol ingestion and an increase in skintemperature. Other uncomfortable signs andsymptoms associated with the negative reac-

115Physical Detoxification Services for Withdrawal From Specific Substances

tion to alcohol ingestion can include nausea,dizziness, headache, fast heartbeat, and anx-iety (Caetano et al. 1998).

•Five studies have shown that the metabolismof codeine is slower in Chinese people thanin Caucasians. Chinese patients seem torequire lower doses of codeine, since theslower metabolism leads to a higher concen-tration of codeine in the blood (Smith andLin 1996).

•If treated with beta blockers, Asians requiremuch lower doses than Caucasians, sincethey are very sensitive to this medication’sblood pressure and heart rate effects (Piand Gray 1999).

•Asians as a group have a higher number ofindividuals than other ethnic groups whoare poor metabolizers of diazepam. Thismay result in the need for lower doses,since they report greater sedative effectswith a typical dose (Lesser et al. 1997). Italso may be that a lower body fat, which istypical of Asian-American individuals, canlead to differences in the pharmacokineticsof lipophilic drugs (Lesser et al. 1997).

•In treatment for co-occurring depressionand a substance use disorder, Asiansappear to metabolize clomipramine moreslowly than Caucasians (Pi and Gray 1999).In contrast, Asians may metabolizephenelzine faster, resulting in the need for ahigher dose relative to that which would beappropriate for Caucasians (Pi and Gray1999).

•Chinese Americans tend to metabolize nico-tine 35 percent more slowly thanHispanics/Latinos and Caucasians. Thus,they may need to smoke less frequently andtake in less nicotine to achieve the samenicotine levels as do Hispanics/Latinos andCaucasians. This may have implications forthe dosing of NRTs (Benowitz et al. 2002).

•Smoking rates among male AsianAmericans, especially immigrant males, areexceedingly high and masked by the lowerrates among Asian-American females.

American Indians There are currently more than 500 federallyrecognized American-Indian tribes, and thereis among them great variability in appear-ance, dress, values, religious beliefs, prac-tices, and traditions. More than 200 differentlanguages are spoken by American-Indiantribes. Alcohol use varies widely among tribes(Mancall 1995). Of all ethnic and racialgroups, American Indians have the greatestrates of alcohol and illicit drug use (Office ofApplied Studies 2002a).

An early study of treatment utilization byAmerican Indians found that there was a sig-nificant association between involvement insociety and treatment outcomes. Thoseinvolved in either the traditional Indian soci-ety or both the traditional Indian society andCaucasian society had more than a 70 percentsuccess rate, whereas those involved in nei-ther society had a 23 percent success rate(Ferguson 1976). At a 10-year followup, thosewho had reported greater Indian culture affil-iation and more severe liver dysfunction atbaseline had better alcohol treatment out-comes (Westermeyer and Neider 1984).

When engaging an American Indian in theprocess of detoxification, moving through theprocess too quickly or abruptly can be per-ceived as showing a lack of caring and is con-sidered contrary to trust building (Brems1998). The pace of conversation is important;a slower pace is more agreeable than a rapidconversation. Moreover, a confrontationalapproach also is not advised with this popula-tion (Abbott 1998). American Indians maywant a close and involved relationship withtheir therapists and often want the clinicianto be a friend or relative (Brems 1998). Thetrust often is built by idle small talk to a levelof shared understanding. Use of fables andillustrative stories to express ideas can beextremely helpful. According to the forthcom-ing TIP Improving Cultural Competence inSubstance Abuse Treatment (CSAT in devel-opment a), avoidance of eye contact also istraditional. The Talking Circle is a native tra-

116 Chapter 4

dition that can be helpful in the treatmentprocess (Canino et al. 1987; Coyhis 2000).The previously discussed protocols for detoxi-fication from all substances of abuse appearadequate for the detoxification of AmericanIndians. The following are some issues to con-sider during detoxification.•Fetal Alcohol Syndrome is 33 times higher in

this population than the national average(CSAT in development a). This may beimportant for pregnant women coming todetoxification and also may be important ifthe adult has FAS.

•Indian women who drink have a six-foldincrease in cirrhosis of the liver relative toCaucasian women (Heath 1989).

•Although some American Indians havereported a flushing response to alcohol, itappears that the flushing reaction inAmerican Indians is milder and less adversethan that experienced by Asians (Gill et al.1999).

•If Alcoholics Anonymous or other 12-Stepprograms are to be introduced, framing thesteps in terms of a circle rather than a laddermay be better received, since the circle isimportant concept in Indian culture (CSATin development a).

•If possible and appropriate, other traditionalmethods that can help recovery are sweatlodges, vision quests, smudging ceremonies,sacred dances, and four circles (Abbott1998).

•Overall, detoxification for this population isthe same as for other populations, butAmerican Indians are likely to seek treatmentlater and have more medical complicationsand poorer nutrition (Abbott 1998).

Hispanics/LatinosHispanics/Latinos are now the largest ethnicminority group in America. Assessment of thepatient’s level of acculturation can be helpfulin understanding substance abuse patterns.Language is one of the most difficult barriersto treatment entry and success forHispanics/Latinos. However, simply knowing

Spanish or Portuguese does not guaranteecultural sensitivity or competence. Forinstance, it is important that the treatmentstaff understand the role of the family. Thefunctional family can be extended and shouldtake into account people who have day-to-daycontact with and a role in the family(Markarian and Franklin 1998).Hispanics/Latinos are likely to view drugdependency as moral failing or personalweakness. Traditional healing such as folkremedies and folkhealers may providebenefit. The previ-ously discussed pro-tocols for detoxifica-tion from alcohol,opioids, benzodi-azepines, stimulants,solvents, nicotine,marijuana, anabolicsteroids, and clubdrugs appear ade-quate for the detoxi-fication ofHispanics/Latinos.

Gays andLesbiansApproximately 5 to33 percent of all les-bian and gay individ-uals are estimated tohave a substanceabuse problem(Cochran and Mays2000; Hughes andWilsnack 1997). Acontributing factor may be the stress andanxiety associated with the social stigmaattached to homosexuality. Further, alcoholand drugs may serve as an escape and easesocial interactions at social settings such asbars. More information on this subject will beavailable in the forthcoming TIP ImprovingCultural Competence in Substance AbuseTreatment (CSAT in development a). Thepreviously discussed protocols for detoxifica-

117Physical Detoxification Services for Withdrawal From Specific Substances

Hispanics/Latinos

are now the

largest ethnic

minority group in

America.

Assessment of the

patient’s level of

acculturation can

be helpful in

understanding

substance abuse

patterns.

tion appear adequate for gay and lesbianpatients. Since numerous misconceptions andstereotypes exist concerning gay and lesbianindividuals, it is important for the clinician toassess his beliefs and take care not to imposethem on the patient.

There are a number of principles of care fortreating gay and lesbian individuals, whichare outlined in A Provider’s Introduction toSubstance Abuse Treatment for Lesbian,Gay, Bisexual, and Transgender Individuals(CSAT 2001). These principles include: (1)counselors’ being able to monitor their ownfeelings about working with this population ofpatients in order to provide professional, eth-ical, and competent care; (2) helping patientsheal from the negative experiences of homo-phobia and heterosexism; (3) helping patientsunderstand their reactions to discriminationand prejudice; and (4) helping patients acceptpersonal power over their own lives by help-ing them improve their self-images and buildsupport networks.

Adolescents The previously discussed protocols for detoxifi-cation from all substances of abuse appear ade-quate for the detoxification of adolescents;however, there are several additional aspects toconsider:•Physical dependence generally is not as

severe, and response to detoxification is morerapid than in adults.

•Retention is a major problem in adolescenttreatment (Thurman et al. 1995).

•Peer relationships play a large role in treat-ment. Among adolescents who do not usedrugs, few of their friends reported use. Inone study, among those who reported specificdrug use, over 90 percent of their friendsreported using the same drug (Dinges andOetting 1993).

•It is estimated that 75 percent of thosereporting steroid use are high school stu-dents, and most of them are male. Detoxifica-tion from steroids does not typically requirespecific pharmacological intervention unless

there is liver toxicity or suicidal intent(Giannini et al. 1991). The use of club drugsis higher in this population than in others.

TIP 31, Screening and Assessing Adolescentsfor Substance Use Disorders (CSAT 1999d),and TIP 32, Treatment of Adolescents WithSubstance Use Disorders (CSAT 1999f), pro-vide comprehensive information on the treat-ment of adolescents.

Incarcerated/Detained Persons Substance use disorders are common amonginmate populations. At the time of arrest anddetention, it has been estimated that 70 to 80percent of all inmates in local jails and Stateand Federal prisons had regular drug use orhad committed a drug offense, and 34 to 52percent of these inmates were intoxicated atthe time of their arresting offense (FederalBureau of Prisons 2000; Mumola 1999).Although women comprise a small proportionof the incarcerated population (12.3 percentin jails and 7.4 percent in State and Federalprisons) than men (Harrison et al. 2004),females have a greater prevalence of illicitdrug use (i.e., 40 percent compared to 32 per-cent were under the influence of drugs at thetime the crime was committed) than do males(Greenfeld and Snell 1999).

Persons who are incarcerated or detained inholding cells or other locked areas should bescreened for physical dependence on alcohol,opioids, and benzodiazepines and providedwith needed detoxification and treatment.Screening should occur over time, since theonset and intensity of withdrawal is depen-dent on the type of drug taken, when the per-son last took the drug, and how long the druglasts in the person’s body. The duration ofdetention will affect what detoxification ser-vices can be provided, and many facilities willnot be able to provide detoxification or con-tinuing care services. There are some specialconsiderations for the detoxification of thispopulation:•Abrupt withdrawal from alcohol can be life-

threatening.

118 Chapter 4

•Abrupt withdrawal from opioids or benzo-diazepines is not life-threatening but cancause severe withdrawal signs and symp-toms and great distress.

•It should be determined whether depen-dence on either opioids or benzodiazepinesis the result of illicit use and not the resultof taking medications that have been pre-scribed to treat pain or anxiety disorders.

•If medically supervised withdrawal is indi-cated, the substitution of a long-acting drugfrom the same class of substances thepatient is using (e.g., giving methadone totreat heroin dependence) and the gradualtapering of that substance (no faster than10 to 20 percent per day) should be con-ducted under closely monitored settings.

•There are cases when individuals main-tained on opioid agonist medications aredetained or incarcerated. If the incarcera-tion is 30 days or less, the individual shouldbe maintained on her usual dosage. If theincarceration is longer, the individual maybe 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 overdoseupon relapse to opioid use.

•Many correctional facilities have restric-tions on the use of methadone or LAAM andspecial provisions for maintaining or taper-ing the individual may need to be made.

•If medications are provided to medicallydetoxify inmates, the Federal Bureau ofPrisons’ Clinical Practice Guidelines forDetoxification of Chemically DependentInmates (2000) suggest retaining strict con-trol over access to these medications to pre-vent diversion or misuse (e.g., eating cloni-dine patches to obtain a state of euphoria).

TIP 44, Substance Abuse Treatment forAdults in the Criminal Justice System (CSAT2005b), and TIP 30, Continuity of OffenderTreatment for Substance Use Disorders FromInstitution to Community (CSAT 1998b), pro-vide more detailed information about thetreatment of this population. TIP 21,Combining Alcohol and Other Drug AbuseTreatment With Diversion for Juveniles inthe Justice System (CSAT 1995b), also pro-vides information about incarcerated youth.

119Physical Detoxification Services for Withdrawal From Specific Substances

5 Co-Occurring Medicaland PsychiatricConditions

In ThisChapter…General Principles

of Care forPatients With Co-Occurring Medical

Conditions

Treatment of Co-OccurringPsychiatricConditions

Standard of Carefor Co-Occurring

PsychiatricConditions

Patients undergoing detoxification frequently present with medicaland psychological conditions that can greatly affect their overall well-being and the process of detoxification. These may simply be pre-existing medical conditions not related to substance use or the directoutcome of the substance abuse. In either case, the detoxification pro-cess can negatively affect the co-occurring disorder or vice versa.Furthermore, people who abuse substances often present with medicalconditions in advanced stages or in a medical crisis. Co-occurringmental disorders also are likely to be exacerbated by substance abuse.For more on treating patients with co-occurring psychiatric disorders,the reader should refer to TIP 42, Substance Abuse Treatment forPersons With Co-Occurring Disorders (Center for Substance AbuseTreatment [CSAT] 2005c).

This chapter is intended primarily for medical personnel treatingpatients in detoxification settings, though nonmedical staff may find itinformative as well. This chapter is not meant to take the place ofauthoritative sources from internal medicine. Rather, it presents acursory overview of special conditions, modifications in protocols, andthe use of detoxification medications in patients with co-occurringconditions or disorders. Overall treatment of specific conditions is notaddressed unless modification of such treatment is needed.

121

General Principles ofCare for Patients WithCo-Occurring MedicalConditionsPatients who use substances can present withany of the conditions or combinations of con-ditions that can be found in the general popu-lation. In most cases, the management of themedical condition in the patient with a sub-stance use disorder diagnosis does not differfrom that of any other patient. However, themedication used for detoxification and theactual detoxification protocol may need to bemodified to minimize potentially harmfuleffects relevant to the co-occurring condition.

Detoxification staff providing support shouldbe familiar with the signs and symptoms ofcommon co-occurring medical disorders.Likewise, personnel at medical facilities (i.e.,emergency rooms, physicians’ offices) shouldbe aware of the signs of withdrawal and howit affects the treatment of the presenting med-ical conditions.

The setting in which detoxification is carriedout should be appropriate for the medicalconditions present and should be adequate toprovide the degree of monitoring needed toensure safety (e.g., oximetry [a measurementof the amount of oxygen present in theblood], greater frequency of taking vitalsigns, etc.). Acute, life-threatening conditionsneed to be addressed concurrently with thewithdrawal process and intensive care unitmonitoring may be indicated.

Clinicians should keep in mind that consulta-tion with specialists in infectious diseases,cardiology, pulmonary medicine, hematology,neurology, and surgery may be warranted.Whenever possible, consent should be soughtto involve the patient’s primary healthcareprovider in the coordination of care.Attending medical staff should be aware thatco-occurring medical conditions present anopportunity to engage patients. By focusingon the adverse effects of the substance abuse

on the overall health of patients, staff mem-bers are in a position to help patients see theimportance of engaging in treatment for theirsubstance use disorders. Patients should haveappointments for followup care made prior todetoxification discharge for all chronic medi-cal conditions, conditions needing furtherevaluation, and substance abuse treatment.

This section highlights the conditions mostfrequently seen in individuals who abuse sub-stances, though it is not inclusive. Disordersof the following systems will be covered: gas-trointestinal (including the gastrointestinal[GI] tract, liver, and pancreas), cardiovascu-lar system, hematologic (blood) abnormali-ties, pulmonary (lung) diseases, diseases ofthe central and peripheral nervous system,infectious diseases, and special miscellaneousdisorders. Where special considerations areneeded for a patient presenting with a givendisorder in a detoxification setting they arelisted following the heading “SpecialConsiderations.”

Gastrointestinal DisordersFrequently, the use of substances can presenta range of gastrointestinal problems. Cocaineuse, for example, can result in various gas-trointestinal complications, including gastriculcerations, retroperitoneal fibrosis, visceralinfarction, intestinal ischemia, and gastroin-testinal tract perforations (Linder et al.2000). Gastrointestinal disorders may affectmany different organs and organ systems(e.g., liver, pancreas), making diagnosis diffi-cult. Since symptoms can be vague andpatients are not always able to articulate thespecific problem, diagnosis can be difficult.For a simple rule of thumb, urgent attentionis needed if the patient is diagnosed with anyof the following:

•Appendicitis

•Abdominal aortic aneurysm

•Perforated peptic ulcer

•Boerhaave’s Syndrome (spontaneousesophageal rupture)

•Obstructed or strangulated bowel

122 Chapter 5

•Ischemic bowel disease (a condition thatresults from inadequate blood supply to theintestines)

•Abcess of the pancreas or liver

•Ruptured spleen or other trauma to theabdominal area

Other possible diagnoses of abdominal paininclude:

•Hepatitis

•Peptic ulcer (nonperforating)

•Peritonitis

•Acute pancreatitis

•Pelvic inflammatory disease

•Endometriosis

•Nephrolithiasis (kidney stones)

•Inflammatory bowel disease

•Ovarian cysts

Clinicians should also be aware of some decep-tive causes of abdominal pain:

•Myocardial infarction

•Pulmonary emboli

•Herpes zoster (shingles)

•Acute pylonephritis (kidney infection)

Specific co-occurring gastrointestinal disordersrequiring special attention in patients undergo-ing detoxification are discussed below.

Reflux esophagitisReflux esophagitis can be a result of alcohol’seffect on the lower esophageal sphincter (i.e.,relaxation) and a decrease in peristalsis of thedistal esophagus, allowing gastric contents tocome into contact with the lower esophagus.Typical symptoms include burning in the epi-gastric or retrosternal area (commonly called“heartburn” or “indigestion”). Esophagealbleeding can result from reflux esophagitis andesophageal varices (resulting from portalhypertension).

Special considerationsSeveral drugs used in typical protocols, such asbeta blockers and calcium channel blockers,

may decrease lower esophageal sphincter pres-sure and aggravate reflux (Dell’Italia 1994).

Mallory–Weiss SyndromeMallory–Weiss Syndrome is caused by tornmucosa of the esophagus at the gastro-esophageal junction due to protracted or vio-lent vomiting. Mallory–Weiss Syndrome is theetiology of 5 to 15 percent of all upper GIbleeds (Schuylze-Delrieu and Summers 1994).

Boerhaave’ssyndromeBoerhaave’s syn-drome is manifestedby rupture of theesophagus. Patientspresenting with thiscondition complain ofacute epigastric pain(83 percent ofpatients), vomiting(79 percent), andshortness of breath(39 percent) as thepredominant, nonspe-cific symptoms. Thislack of specificity candelay making the cor-rect diagnosis (Braueret al. 1997).Tachycardia,cyanosis, and subcu-taneous emphysemaalso can be seen. Ifthis condition is leftuntreated, the prognosis is severe.

GastritisGastritis is described as the disruption of thegastric mucus lining that allows gastric acid tocontact the mucosa with resultant inflammationand possible bleeding. The patient presentswith nausea, vomiting, and abdominal pain(Ivey 1981). Alcohol increases gastric acidsecretion and reduces the mucosal cell barrier,

123Co-Occurring Medical and Psychiatric Conditions

Co-occurring

medical conditions

present an

opportunity to

engage patients in

treatment for

their substance

use disorders.

allowing back-diffusion of the gastric acid intothe mucosa. This frequently causes an occur-rence of erosive gastritis in the individual withan alcohol use disorder (Fenster 1982).

Special considerationsAspirin and nonsteroidal medications should beavoided in the withdrawal protocols.

PancreatitisPancreatitis can becaused by many fac-tors, although stud-ies suggest that alco-hol may be a factorin anywhere from 5to 90 percent of allcases (Apte et al.1997), with someexperts suggestingabout 60 percent ofall cases result fromexcessive alcoholconsumption(Yakshe 2004). Theacute condition pre-sents with abdomi-nal pain, which isdescribed as sharp,burning, and con-stant and is locatedin the epigastricarea of the

abdomen with radiation to the back.Presenting symptoms and signs can includeabdominal tenderness, decreased bowelsounds, low-grade fever, tachycardia, nausea,and vomiting. Pancreatitis can proceed to achronic condition where pancreatic calcifica-tion, diabetes mellitus, malabsorption, andchronic abdominal pain occur.

Special considerationsThere may be a need to forbid oral intake offood and medications, necessitating a changeof route of administration of both food andmedications to intravenous forms. In alcoholwithdrawal protocols, Ativan might be consid-

ered as an appropriate agent, as it can beadministered intravenously or intramuscular-ly. Opioids may have to be used to controlpain.

Liver disordersLiver disease can range from fairly benignfatty liver, which presents usually as anasymptomatic enlargement of the liver associ-ated with mild elevation of the serum liverenzymes, to a broad spectrum of viral infec-tions and the toxic consequences of alcoholand other drug use. The end point of liverdisease is liver necrosis or failure. Midway inthe progression of liver disease is acute alco-holic hepatitis. The presentation is one ofliver tenderness, jaundice, fever, ascites, andan enlarged liver. The patient is quite sickand frequently has nausea and vomiting.

Special considerationsAlcoholic hepatitis usually needs acute medi-cal treatment to prevent electrolyte imbalanceand dehydration. Protocols may have to beadapted if the patient cannot take oralagents.

Portal hypertensionPortal hypertension is a frequent conse-quence of liver disease. If elevation of theportal pressure goes untreated, esophagealvarices develop and hemorrhage can ensue.Treatment of acute hemorrhage includesendoscopic sclerotherapy or ligation. Initialtherapy should include prompt and adequateintravascular volume replacement, correctionof severe anemia and coagulopathies, andadequate airway management.

Special considerationsPropranolol or isosorbide therapy is effectivein the prophylaxis of variceal bleeding(Trevillyan and Carroll 1997), though betablockers can interfere with measuring thetrue heart rate that determines the content ofmany detoxification protocols. If bleeding is

124 Chapter 5

Detoxification

staff providing

support should be

familiar with the

signs and

symptoms of com-

mon co-occurring

medical conditions.

present, changeover to intravenous medica-tion protocols is recommended, as the patientwill not be able to take oral medications.

CirrhosisCirrhosis, or the formation of fibrous tissuein the liver, leads to a state of increased resis-tance in the hepatic venous circulation. Theinability of blood to flow freely gives rise toportal hypertension with ensuing esophagealvarices, splenomegaly, ascites, dilatation ofsuperficial veins, peripheral edema, and hem-orrhoids.

Liver necrosis can be seen in patients who useinhalants, particularly chronic use of benzeneand carbon tetrachloride. African Americansand Hispanics/Latinos have higher mortalityrates from cirrhosis of the liver resulting fromalcohol abuse than do Caucasians and Asiansand Pacific Islanders (Sutocky et al. 1993).Liver function test abnormality and jaundicecan occur in individuals who use anabolicsteroids, but this usually resolves on cessationof the drugs. Studies in the elderly show that1-year mortality was 50 percent amongpatients over age 60 with cirrhosis, versus 7percent for those under age 60 (Potter andJames 1987). Great care needs to be usedwhen giving diuretics to elderly patients withcirrhosis, since their total body water mayalready be decreased, making them more sus-ceptible to fluid and electrolyte depletion(Scott 1989).

Alcohol-related hepatic injury is seen in ahigher proportion of women due to a possiblepotentiation (strengthening) of this effect byestrogen (Brady and Randall 1999).

Special considerationsFor the treatment of alcohol withdrawal,lorazepam (Ativan) is well tolerated inpatients with severe liver disease (D’Onofrioet al. 1999) as is oxazepam (Serax), with itsshort half-life of 6 to 8 hours and simplemetabolism with no metabolites.

Cardiovascular DisordersThe presentation of chest pain or discomfortremains one of the most difficult differentialdiagnoses to sort through, as disorders of sev-eral systems can cause this single complaint.Inability to correctly diagnose this symptomcan be brought about by the patient’s inabili-ty to be interviewed and give succinct symp-toms (the intoxicated or severely withdrawingpatient), a sociocultural or educational levelthat does not allow for the verbal nuancesnecessary to making a diagnosis, or fabrica-tion of symptoms by a patient seeking toobtain pain medications or other drugs.

A normal resting electrocardiogram does notrule out the presence of organic heart diseaseand the presence of nonspecific changes doesnot necessarily mean that heart disease is pre-sent. Final diagnoses can range from reflux tomyocardial infarction brought about byunderlying ischemic heart disease or the useof cocaine. Frequently, lung diseases can haveas their presenting symptom chest discomfort.The consensus panel believes that this condi-tion should never be overlooked or minimizedand it is imperative that an especially promptdiagnosis be made and treatment be under-taken to ensure patient safety.

Underlying cardiac illness could be worsenedby the presence of autonomic arousal (elevat-ed blood pressure, increased pulse and sweat-ing) as seen in alcohol, sedative, and opioidwithdrawal. Thus prompt attention to thesefindings and aggressive withdrawal treatmentis indicated. Special considerations for thetreatment of specific cardiac conditions areoutlined below.

HypertensionHypertension frequently is seen in the detoxi-fication patient. Evaluation should include acomplete history to determine if the elevatedblood pressure predated the present with-drawal status. Consideration should be givento include serum electrolytes, urinalysis,BUN/creatinine, and an EKG in the detoxifi-

125Co-Occurring Medical and Psychiatric Conditions

cation unit’s initial workup. More elaborateworkup can be carried out after completionof detoxification.

Propranolol (Inderal), labetalol (Trandate)and metoprolol (Lopressor) are the betablockers of choice for treating hypertensionduring pregnancy (McElhatton 2001), howev-er, the impact of using them for alcoholdetoxification during pregnancy is unclear. Iftreating African Americans with beta block-ers, clinicians should be aware that propra-nolol is less effective in this population than itis in Caucasians (Pi and Gray 1999). Asiansrequire much lower doses of beta blockersthan Caucasians, inasmuch as they tend to bevery sensitive to the blood pressure and heartrate effects (Pi and Gray 1999).

Special considerationsThe presence of a hypertensive history andpoorly controlled blood pressures may havean effect on the proper evaluation of with-drawal as the examiner would have difficultydetermining whether the elevated blood pres-sure was due to withdrawal or to the underly-ing hypertensive history. Thus modificationsof the usual parameters and scheduling ofdetoxification medications should be consid-ered. In any event, severe elevation of bloodpressure should be treated concurrently with,at minimum, salt restriction and rest. If theblood pressure is still elevated in several daysdespite a reduction in other withdrawalparameters and symptoms, then medication iswarranted.

Beta blockers and clonidine have been usedin the treatment of alcohol withdrawal andclonidine also has been used in opioid proto-cols. These medications can help controlblood pressure and also work well in the pro-tocol. Calcium channel antagonists have alsobeen used to ameliorate some of the symptomsof alcohol withdrawal and can be used con-currently for blood pressure control.

Ischemic heart diseaseIschemic heart disease presents as chest painor pressure, palpitations, dizziness, and/orshortness of breath and requires immediateattention, which will dictate what setting isappropriate for the detoxification.

Cocaine use is associated with various cardio-vascular complications including angina pec-toris, myocardial infarction, and suddendeath. It is estimated that over half of the64,000 patients evaluated annually forcocaine-associated chest pain will be admittedto hospitals for evaluation of myocardialischemia. Only about 6 percent of patientswill demonstrate biochemical evidence ofmyocardial infarction (Hoffman andHollander 1997). The typical patient withcocaine-related myocardial infarction is amale in his mid-30s with a history of chronictobacco and repetitive cocaine use (Hollander1995). This effect of cocaine appears to beincreased because the drug causes an increasein myocardial oxygen demand and thus adecrease in oxygen supply. These two factors,which are caused by vasospasm and vasocon-striction of the coronary arteries, may lead tocardiovascular disorders.

Patients with recent cocaine use can experi-ence persistent cardiac complications such asprolonged QT interval and vulnerability forarrhythmia and myocardial infarction(Chakko and Myerburg 1995). (QT is the Q toT interval measured on EKGs. If the intervalis prolonged, it can lead to cardiac rhythmdisturbances.) Amphetamines are rarelyreported as the cause of myocardial infarc-tion, though a case report shows that apatient subsequently experienced a non–Q-wave anterior wall infarction associated withamphetamine use (Waksman et al. 2001).Cocaine use and HIV infection have beenassociated with an increased incidence of car-diac dysfunction, but concomitant exposuremay cause a synergistic effect (Soodini andMorgan 2001).

126 Chapter 5

Special considerationsBeta-adrenergic blocking agents may exacer-bate cocaine-induced coronary arterial vaso-constriction and thereby increase the myocar-dial ischemia. Nitroglycerin and verapamilreverse cocaine-induced hypertension andcoronary arterial vasoconstriction and arethe medications of choice in the patient whouses cocaine and presents with chest pain(Pitts et al. 1999). Cocaine may cause plateletactivation leading to acute coronary events—thus more aggressive antiplatelet therapy maybe indicated (Callahan et al. 2001).

CardiomyopathyCardiomyopathy is caused by degenerativechanges of the cardiac muscle with enlarge-ment of the heart (cardiomegaly) and left ven-tricular failure. Alcoholic cardiomyopathypresents with a similar picture as cardiac fail-ure from other etiologies, with shortness ofbreath on exertion, shortness of breath whenthe patient is lying flat, and edema of thelower extremities.

Besides alcohol as the etiology, a dilated car-diomyopathy can be seen with use of theinhalant trichlorethylene. Cardiomyopathy inthe elderly patient with an already underlyingischemic or atherosclerotic heart disease canbe quite debilitating. Women have shownalcohol metabolism different from that of menand distinct pathophysiologic mechanisms,which frequently lead to a higher sensitivityto alcohol-induced heart damage. The preva-lence of cardiomyopathy in women is equal tothat in men, despite cases in which womenhave consumed far less ethanol (Fernandez-Sola and Nicolas-Arfelis 2002).

Special considerationsAlcoholic cardiomyopathy may respond poor-ly to digitalis with increased likelihood of digi-talis toxicity (Zakhari 1991).

ArrhythmiasArrhythmias (irregular heartbeats) can beseen in the presence of ischemia and car-diomyopathy. Two specific cases of arrhyth-mogenic disorders are “holiday heart,” wherethe patient who has ingested alcohol presentswith supraventricular arrhythmia(Greenspon and Schaal 1983), and the indi-vidual who uses cocaine with the stimulantleading to significant atrial and ventriculararrhythmias. Consumption of anabolicsteroids also hasbeen associated withhypertension,ischemic heart dis-ease, cardiomyopa-thy, and arrhythmia(Sullivan et al.1999).

Special consider-ations Treatment of arrhyth-mia in the person whoabuses substances issimilar to that for thepatient who does notabuse substances,though the setting ofdetoxification mayhave to be altered toallow for cardiacmonitoring (teleme-try).

HematologicDisordersHematologic (blood) disorders can be seen dueto several factors, such as a direct toxic effectof the drug on the bone marrow, as seen inalcohol and benzene use, or as a result of mal-absorption of essential nutrients (B12, folate),or as a general poor state of nutrition.

127Co-Occurring Medical and Psychiatric Conditions

Cocaine use is

associated with

various

cardiovascular

complications

including angina

pectoris,

myocardial

infarction, and

sudden death.

AnemiaAnemia can be seen due to folate deficiency,iron deficiency, B12 deficiency, acute bloodloss, or more frequently as a combination offactors. Folate deficiency can cause a mega-loblastic anemia, which is diagnosed bymacroovalocytes and hypersegmented neu-trophils seen on a peripheral blood smear.Iron deficiency anemia results from blood lossand thus subsequent iron loss. This can be

seen in low-levelgastrointestinalbleeding, afterchildbirth, and as aresult of menstrualblood loss. The pre-sentation of anemiausually is nonde-script with general-ized fatigue andweakness. Withsevere anemia,shortness of breathon exertion and anelevated heart ratecan be seen.Specific to themegaloblastic ane-mias (B12 andfolate deficiency)one can see neuro-logic complicationssuch as peripheralneuropathy.

White blood cell disordersWhite blood cell disorders can occur due tomalnutrition and liver disease. Lymphopeniamay be present in the patient with HIV disease.

Platelet disordersPlatelet disorders frequently are attributableto the direct effect on the bone marrow by thesubstance being abused or, as seen in alcohol-related thrombocytopenia, are due to bonemarrow suppression. Splenomegaly caused byportal hypertension also can cause a low

platelet count (thrombocytopenia), which isdue to enlargement of the spleen and abnor-mally high platelet storage. Thrombocyto-penia also can be seen in cases of vitamin B12and folate deficiency.

The African-American patient with sickle celldisease or trait can be severely affected (inas-much as the patient already has an impairedoxygen delivery system) if other harm threat-ens the bone marrow.

Special considerationsElevated heart rates can hinder the use of theheart rate as a parameter in various detoxifica-tion protocols.

Pulmonary Disorders (OtherThan Infectious)Pulmonary disorders are common in peoplewho abuse substances, in part because of thehigh rate of nicotine use in this population(Graham et al. 2003).

Aspiration pneumoniaAlcohol or other drug ingestion may reduce apatient’s gag reflex, leading to the blockage ofthe airways. Aspiration pneumonia occurswhen oro-pharyngeal secretions and/or gastriccontents enter into the lower airways. This seri-ous condition may require prolonged hospital-ization.

AsthmaAsthma, a chronic condition characterized byexacerbations of bronchial spasm manifestedby wheezing, should be differentiated frombronchospasm, which is related to inhaleddrugs and usually is self-limited. Treatment issimilar to that provided to patients who donot use substances, with the addition of cessa-tion of the substance use.

The patient with underlying chronic asthmacan be severely compromised if the use of asmokeable drug causes exacerbation of analready impaired system.

128 Chapter 5

Traumatic brain

injury (TBI)

should always be

considered in

patients with

neurological

impairment.

Special considerationsAsthma medications can cause a significantincrease in heart rate, which can affect theevaluation of withdrawal protocols that useheart rate as one of the parameters.

Chronic ObstructivePulmonary DiseaseChronic obstructive pulmonary disease(COPD) (emphysema, chronic bronchitis) fre-quently is due to cigarette use and the result-ing alterations of the pulmonary immune sys-tem, inflammation, and destruction of lungparenchyma. Presentation includes shortnessof breath on exertion, a cough producingmucous, and wheezing.

African Americans who smoke cigarettes takein more nicotine, and therefore more tobaccosmoke toxins per cigarette, than Caucasians(Perez-Stable et al. 1998).

Daily marijuana smoking has been shown tohave adverse effects on lung function includ-ing a productive cough, wheezing, and exces-sive sputum production. However, the habitu-al marijuana-only smoker, in the absence ofalpha-1-antitrypsin deficiency, would have tosmoke four to five marijuana cigarettes perday for a span of at least 30 years to developovert manifestations of COPD (Van Hoozenand Cross 1997).

Special considerations During nicotine withdrawal and cessationtreatment, different levels of nicotine absorp-tion, as seen in some groups, will affect dosingfor nicotine replacement therapies (Perez-Stable et al. 1998). The patient with COPD,especially if elderly, would be sensitive to thesedating effects of many of the detoxificationprotocol medications, especially the benzodi-azepines, which may have to be reduced indosage to avoid respiratory depression andworsening hypoxemia and hypercarbia(decrease in oxygen and increase in carbondioxide). For smokers, always consider theuse of the nicotine replacement agents, partic-

ularly in hospitalized patients. Evaluation forinfections and the use of oxygen, steroids,and inhalers is dictated by the clinical pic-ture. During detoxification, if nicotine use isnot allowed, there can be significant effectson drug levels (see chapter 4).

Neurologic SystemThe neurologic system of patients with sub-stance use disorders is affected directly in thetoxic effects on cell membranes, effects onneurotransmitters, associated metabolicchanges from other underlying disorders, andchanges in blood flow. Researchers havefound that the majority of those with an alco-hol use disorder (75 percent) have somedegree of cognitive impairment (Goldstein1987). Specific disorders found in patientswith substance use disorders can affect thecentral nervous system and the peripheralsystem. For example, a broad array of neu-ropathologic changes are seen in the brains ofpeople who use heroin. The main findings aredue to infections as a result of endocarditis orHIV infection. Other complications includehypoxic-ischemic changes with cerebraledema, ischemic neuronal damage thought tobe due to heroin-induced respiratory depres-sion, stroke due to thromboembolism, vas-culitis, septic emboli, and hypotension.Myelopathy occurs as a result of possible iso-lated vascular accident in the spinal cord,and a distinct condition, leukoencephalopa-thy, has been described after the inhalation ofpre-heated heroin (Buttner et al. 2000).

As a final note, traumatic brain injury (TBI)should always be considered in patients pre-senting with neurological impairment. Peoplewho abuse substances are at high risk of falls,motor vehicle accidents, gang violence,domestic violence, etc., which may result inhead injury (Graham et al. 2003).Unrecognized TBI can affect the treatmentoutcome.

129Co-Occurring Medical and Psychiatric Conditions

Wernicke-Korsakoff’sSyndromeWernicke-Korsakoff’s Syndrome is composedof Wernicke’s encephalopathy andKorsakoff’s psychosis. Wernicke’sencephalopathy is an acute neurological dis-order with a triad of

•Oculomotor dysfunction (bilateral abducensnerve palsy—eye muscle paralysis)

•Ataxia (loss of muscle coordination)

•Confusion

Weakness and nystagmus are also seen in thissyndrome on examination of the eyes.Wernicke’s encephalopathy is clearly related tothiamine deficiency.

Korsakoff’s psychosis is a chronic neurologi-cal condition resulting from thiamine defi-ciency that includes retrograde and antegradeamnesia (profound deficit in new learning andremote memory) with confabulation (patientsmake up stories to cover memory gaps).

Special considerations Thiamine initially is given parenterally andthen oral administration is the treatment ofchoice. Always give thiamine prior to glucoseadministration.

Alcohol and sedative withdrawal seizuresAlcohol and sedative withdrawal seizures rep-resent a significant medical challenge (Ahmedet al. 2000), since no large clinical studieshave been conducted to firmly establish thebest treatment practices. Up to 90 percent ofalcohol withdrawal seizures occur in the first48 hours and usually are single and nonfocal.Repeated episodes of drinking and withdraw-al are thought to predispose people toseizures due to a kindling phenomenon (Postet al. 1987). Patients with a history of with-drawal seizures are at greatest risk andshould receive prophylactic doses of a long-acting benzodiazepine (e.g., chlordiazepoxide

50mg every 6 hours for 24 hours) when detox-ifying from alcohol.

Individuals with an alcohol use disorder showan increase in seizures due to withdrawal,metabolic insults such as hypoglycemia orelectrolyte imbalance, or head trauma. In onestudy, researchers found that of 195 cases ofseizures in those with an alcohol use disorder,59 percent were due to alcohol withdrawal, 20percent to head trauma, and 5 percent to vas-cular disorders (Earnest et al. 1988).

Special considerationsEvaluation of a first seizure should include aneurological evaluation and evaluation forhead trauma. Metabolic etiologies, such as lowmagnesium levels, should be considered.

Mayo-Smith (1997) has shown that benzodi-azepines confer protection against alcoholwithdrawal seizures and thus patients withprevious seizures should be treated early withthis class of medications. The consensus panelsuggests that anti-epileptic drug therapyshould be considered in alcohol withdrawalpatients with multiple past seizures (of anycause), a history of recent head injury, pastmeningitis, encephalitis, or a family history ofseizures.

Clinicians should be aware that treatment ofthe first seizure with benzodiazepines doesnot prevent the likelihood of a second seizure(D’Onofrio et al. 1999). Slower medicationtapers should be considered when this condi-tion co-occurs with detoxification.Lorazepam, which can be used in patientswith liver disease, has been suggested asappropriate, but it and other short-actingbenzodiazepines may not prevent late-occur-ring withdrawal seizures (Shaw 1995).Dosages of anticonvulsant medications shouldbe stabilized before sedative-hypnotic with-drawal begins. Adequate treatment with along-acting benzodiazepine is effective in pre-venting withdrawal seizures (Mayo-Smith andBernard 1995). D’Onofrio and colleagues(1999) found that a one-time dose of the rela-

130 Chapter 5

tively shorter acting agent lorazepam alsoreduced the risk of a subsequent seizure com-pared to placebo. However, in D’Onofrio’sstudy doses were small and the results werelimited somewhat by use in an emergencyroom setting.

Older, first-generation anticonvulsants havelimitations in that they have only been stud-ied in mild to moderate withdrawal, on rareoccasions they can cause serious hepatic andbone marrow toxicities, and they can interactwith other classes of medication. Newerdrugs, such as gabapentin (Neurontin) andoxcarbazepine (Trileptal), do not appear tohave these liabilities, but sufficient studies toshow this have not yet been done. There is lit-tle evidence that long-term use of phenytoin ishelpful in the patient who does not have anunderlying seizure disorder (Kasser et al.2000). Medications that may lower the seizurethreshold, including phenothiazines, such asprochlorperazine (Compazine), and severalantidepressants, such as bupropion, shouldbe used with great caution in the patient witha seizure history.

The use of anticonvulsants, such as valproicacid and barbiturates, has been studied inpregnant women. Valproic acid is associatedwith several malformations in the fetus. Theuse of any anticonvulsant medication shouldbe discussed with the pregnant patient andrisks and benefits explained (Robert et al.2001).

Cerebrovascular accidentsCerebrovascular accident (stroke) can be seenin alcohol and cocaine use, coagulation impair-ment, and severe uncontrolled hypertension.

Patients with recent cocaine/amphetamine usemay present with headaches, which couldrepresent subarachnoid and/or intracerebralbleed, and therefore should be appropriatelyevaluated (Buxton and McConachie 2000).Heavy alcohol consumption increases the riskfor all major types of stroke by a variety ofmechanisms (Hillbom and Numminen 1998).

There is a higher than normal incidence ofhemorrhagic stroke and other intracranialbleeding among patients with heavy alcoholuse, and a particular association of strokeswithin 24 hours of a drinking binge (Altura1986).

Special considerationsNifedipine and verapamil have been shown toprevent alcohol-induced vasospasm, which sug-gests a possible therapeutic approach to hyper-tension and stroke in the patient with heavyalcohol use (Altura 1986).

Polyneu-ropathyPolyneuropathy fre-quently is seen innutritional deficien-cies that occur in thepatient with chronicalcohol use.Presenting signs andsymptoms includelower extremitypain, distal motorloss, numbness ortingling, and loss ofreflexes.Polyneuropathy canbe seen in theinhalation of h-hex-ane, methyl-n-butylketone, and toluene(Geller 1998).

Hepatic encephalopathyHepatic encephalopathy is a toxic brain syn-drome that results from the accumulation ofunmetabolized nitrogenous waste products ina patient with severe liver dysfunction.Presenting signs and symptoms include analteration in consciousness and behavior,fluctuating neurologic signs such as a flappingtremor (asterixis), and an elevated serumammonia level. Clinicians should evaluate

131Co-Occurring Medical and Psychiatric Conditions

Treatment of the

first seizure with

benzodiazepines

does not prevent

the likelihood of a

second seizure.

patients for precipitating causes, whichinclude the following:

•GI hemorrhage

•Electrolyte imbalance (metabolic alkalosis)

•Infections

•Excessive diuresis (dehydration)

•Use of sedatives

•Increase of dietary protein intake

Those patients who are infected withHelicobacter pylori may be more prone tohepatic encephalopathy (Duseja et al. 2003).

Special considerationsClinicians should avoid the use of diuretics,identify and treat factors that may have pre-

cipitated theencephalopathy,decrease dietaryprotein intake, anduse Lactulose todecrease nitroge-nous waste prod-ucts via the GItract. Protocolsthat use the benzo-diazepines shouldbe adjusted to usethose specific medi-cations that arehepatically metabo-lized minimally ornot at all.

Infectious DiseasesThe viral causes of hepatitis are multiple,though the hepatitis B and C viruses are thepredominant causative agents. Hepatitis Cvirus infection appears to be the most com-mon form of infectious hepatitis in patientswith substance use disorders. At least 76 per-cent of patients who have used injection drugsfor less than 7 years are positive for hepatitisC, while 25 percent of patients with alcoholuse disorders and those who do not injectdrugs show serologic evidence of infection(Fingerhood et al. 1993; National Institute on

Drug Abuse 2000). Hepatitis B infections arelikely to present more often as a chronicinfection than as an acute-stage phenomenon.Testing for chronic hepatitis B and C infec-tion is appropriate during the detoxificationperiod.

Special considerationsFollowup for hepatitis B and C should bearranged for after discharge from the detoxi-fication setting. Vaccination is recommendedfor hepatitis A and B in the patient with hep-atitis C. The vaccination schedule is over a 6-month period, so it needs to be done after thedetoxification program. If significant liverdisease is present, use of shorter-acting medi-cation with less liver metabolism should beconsidered. For more on infectious diseaseand substance abuse, see TIP 6, Screeningfor Infectious Diseases Among SubstanceAbusers (CSAT 1993c).

EndocarditisEndocarditis is caused by the introduction ofvarious bacterial species into the vascularsystem when the protective defense mecha-nisms of the skin are bypassed through injec-tion. The patient frequently will present withfever, cardiac murmur, anemia, enlargementof the spleen, petechiae, and peripheralembolic disease. The course can be subtle andindolent to fulminant, and if untreated canlead to a poor prognosis. In the patient whouses drugs intravenously, the tricuspid valveis affected in 70 percent of cases, followed byeffects on the aortic valve and the mitralvalve. Seventy-five percent of all cases arecaused by Staphylococcus aureus and up to15 percent are caused by gram negative aero-bic bacilli (Aragon and Sande 1994).

Endocarditis always should be suspected inthe febrile patient who uses intravenousdrugs. Patients who use drugs intravenouslyare 300 times more likely to die suddenlyfrom infectious endocarditis than patientswho use drugs nonintravenously (Burke et al.1997). Patients who use cocaine intravenously

132 Chapter 5

Immuno-

compromised

patients may not

react to the

tuberculin skin

tests.

may have a higher rate of endocarditis as aresult of more frequent injections and thereduced need to solubilize cocaine solutionswith heat (Chambers et al. 1987).

Bacterial pneumoniaBacterial pneumonia can result from immunesystem dysfunction, interference with normalrespiratory defense mechanisms (from alcoholor smoked drugs), direct toxicity, or aspiration.

The treating physician should be aware thatthe usual pathogens found in community-acquired pneumonia (i.e., Streptococcuspneumoniae) may not be the causative agentin pneumonias seen in patients dependent onalcohol. Haemophilis influenzae, Klebsiellapneumoniae, and other gram-negativemicroorganisms must be suspected and treat-ment given until definitive culture results arereported. Among patients who use parenteraldrugs, pneumonia is the most common reasonfor admission to the hospital, accounting for38 percent of all hospitalizations in this popu-lation (Marantz et al. 1987).

Special considerationsCareful use of respiratory depressants is rec-ommended. Indications for hospitalization ofthe patient with pneumonia (Neu 1994) includethe following:

•Old age

•Dehydration

•Vomiting and inability to take in oral fluidsand medications

•Multilobar disease

•Low white blood cell count

•Respiratory acidosis

•pO2 less than 55 mm Hg

•Significant concomitant diseases

•HIV

TuberculosisTuberculosis (TB) is caused by acid-fast rod(Mycobacterium tuberculosis). Transmissionis by droplets spread through the air. The

infected patient presents with complaints ofcough (most common finding), bloody spu-tum, chest pain, fever, and weight loss.Recent immigrants from countries where TBis prevalent, socioeconomically disadvantagedpopulations, homeless persons, people whouse illicit drugs, incarcerated people, andpeople who live in areas where infection withHIV is prevalent, are at increased risk forthis disease and should be tested. Further-more, new strains of multidrug-resistant TBare appearing, especially among the homelesspopulation (Borgdorff et al. 2000; Moss et al.2000).

TB is endemic in many areas of the world(Asia, Africa, and South and CentralAmerica) (Gupta et al. 2004). As a publichealth concern, testing all patients is of theutmost importance, even more so for patientsfrom regions where TB is endemic. It isimportant to remember that immunocompro-mised patients may not react to the skin tests(anergy). Diagnosis is made with tuberculinskin testing, sputum smears and cultures, andradiographic findings. For more informationon dealing with tuberculosis in detoxificationand treatment settings see TIP 18, TheTuberculosis Epidemic: Legal and EthicalIssues for Alcohol and Other Drug AbuseTreatment Providers (CSAT 1995i).

Skin infectionsSkin infections frequently are seen as a resultof the intravenous administration of drugs.Staphylococcus aureus and Streptococcuspyogenes are frequently the infectious agents.The patient presents with tenderness,swelling, pain, erythema, and warmth in theinjection area. The type and route of antibi-otic is determined by the infecting organismand the extent and severity of the infection.Clinicians should remember that injectionsites can be found virtually any place on thebody where there is access to the venous sys-tem.

Patients who use drugs intravenously,patients with peripheral vascular disease, and

133Co-Occurring Medical and Psychiatric Conditions

patients with diabetes (particularly withinfections of the feet) should all be evaluatedcarefully for skin disease.

Sexually transmitted diseasesSexually transmitted diseases can be seen in theform of urethritis, vaginitis, cervicitis, and gen-ital lesions. These disorders are caused by avariety of microorganisms, and a complete his-tory and physical that includes examination ofthe genitalia is indicated in all patients. Theclinical picture and cultures frequently canguide the treatment protocols. Patients who usedrugs intravenously occasionally display afalse-positive serologic test for syphilis, possiblydue to a nonspecific reaction to repeated expo-sure of injected antigens (Hook 1992).

HIV/AIDSHIV/AIDS is a serious and prevalent medicalcondition among persons with substance usedisorders, especially those who inject drugsand may share needles with other users.Patients with AIDS can present with a spec-trum of complaints and illnesses ranging froman asymptomatic history to complaints offever, enlargement of the lymph nodes, diffi-culty swallowing, diarrhea, weight loss, skinlesions, shortness of breath (due toPneumocystis carinii pneumonia), headaches(due to Toxoplasma gondii), seizures, anddementia. As a rule of thumb, no complaintin the patient infected with HIV should bedismissed as irrelevant.

Gay men and patients who use drugs intra-venously may be at higher risk for HIV/AIDSthan other groups; thus, testing or referralfor testing should be done and appropriatecounseling offered. All such patients shouldbe tested for HIV/AIDS or referred for test-ing. Some States, such as Colorado, requirethat a risk assessment be administered to allclients and that clients be advised of theirrisk and referred for testing if they are at riskfor HIV/AIDS. Patients who decline HIV test-

ing still should be educated about the riskand prevention.

Due to increased virulence of syphilis inpatients who are HIV positive, as well asincreased resistance to the treatments indicat-ed in the usual treatment protocols, all suchpatients should be tested for syphilis and allpatients who test positive for syphilis shouldbe sent for HIV testing (McNeil et al. 2004).

Special considerationsIf methadone is being used in withdrawal pro-tocols, or maintenance is being continued, theclinician should be aware that certain HIVmedications can cause an increased metabolismof methadone:

•Efavirenz (Sustiva)

•Nevirapine (Viramune)

•Lopinavir/ritonavir (Kaletra)

•Rifampin (a drug to prevent mycobacteriumavium complex, a serious bacterial infection,in HIV-positive clients)

•Amprenavir (Agenerase)

•Abacavir

•Ritonavir

TIP 37, Substance Abuse Treatment forPersons With HIV/AIDS (CSAT 2000e) pro-vides further information about substanceabuse treatment for patients with HIV/AIDS.

Other Conditions

CancerCancer occurrence is increased in people withsubstance use disorders due to the carcino-genicity of the drugs used. Cigarette smokingis linked to lung, larynx, oral cavity, esopha-gus, stomach, bladder, and pancreatic can-cer. Heavy alcohol consumption is associatedwith an increased incidence of oral, pharyn-geal, esophageal, laryngeal, respiratory tract,and breast cancer (Polednak 2005).Synergism is seen with alcohol and smokingbeing associated with even higher risks ofcancer (Fagerstrom 2002). A history of weight

134 Chapter 5

loss could suggest many chronic diseases,though cancer should be considered in thedifferential. There may be an increase inhead and neck cancers in persons with heavycannabis use (Donald 1991). Liver cancermay be seen in patients with hepatitis C andthose using anabolic steroids (Socas et al.2005). There is a particular interrelationshipamong alcohol intake, hepatitis C, and hepa-tocellular carcinoma (Yoshihara et al. 1998).

DiabetesPatients who use drugs intravenously mayexperience infections that affect diabetic con-trol, though any infection in any detoxificationpatient needs to be addressed both from aninfectious disease and diabetic viewpoint.

Special considerationsSeveral medications can lead to impaired glu-cose tolerance and an elevated serum glucose(Garber 1994). Some examples include

•Thiazide diuretics

•Clonidine

•Glucocorticoids

•Haloperidol

•Lithium carbonate

•Phenothiazines

•Tricyclic antidepressants

•Indomethacin

•Olanzapine

•Risperdol

Antidiabetic agents in concert with alcohol mayproduce hypoglycemia and lactic acidosis.Diabetes mellitus also is seen in patients whopresent with new-onset hyperglycemia (elevatedglucose) or with a history of diabetes and poorcontrol.

Acute trauma/fracturesAcute trauma/fractures can be seen in anypatient with a substance use disorder due to analtered level of consciousness or impaired gaitwhen intoxicated. Patients with substance use

disorders appear to be particularly prone toaccidents of all kinds, with a spectrum of com-plications from head trauma to falls with frac-tures. Chronic pain frequently is seen inpatients as a result of trauma (treated oruntreated), poor health maintenance, or aninability to deal with pain without drug use.Chronic pain treatment and the issues of opioiduse have to be considered for each patient onan individual basis.

The surgeon shouldconsider drug with-drawal in the differ-ential diagnosis ofany physical or neu-rologic symptoms orsigns that emergeduring the perioper-ative period. Thereis a two- to threefoldincrease in postoper-ative morbidity inpatients with alcoholuse disorders, themost frequent com-plications beinginfections, bleeding,cardiopulmonaryinsufficiency, andwithdrawal compli-cations (Tonnesen and Kehlet 1999).

Special considerationsOpioids may be used to control pain in the ini-tial period of trauma. Detoxification protocolsshould be started prior to anticipated surgeryand continued throughout the perioperativeperiod. Pain that causes an increased heartrate, as well as postoperative temperature ele-vation, may impact the detoxification parame-ters.

Due to tolerance to opioids, the dailymethadone dose in a methadone-maintainedindividual will not serve as an analgesic forpain relief from surgical or other illnesses.Full therapeutic doses of analgesic drugsshould be given to methadone-maintained

135Co-Occurring Medical and Psychiatric Conditions

Certain HIV

medications can

cause an increased

metabolism of

methadone.

patients who have co-occurring painful condi-tions (CSAT 2005d; Ho and Dole 1979).

Since most medications for pain managementare drugs with a high abuse potential, pro-grams may need to alter their policies regard-ing the use of such drugs. Pain patients donot require detoxification from prescribedmedications unless they meet the criteria foropioid abuse or dependence described in theAmerican Psychiatric Association’sDiagnostic and Statistical Manual of MentalDisorders, Fourth Edition. Treatments forpain include physical therapy, transcutaneouselectrical nerve stimulation, and therapeutic

heat and cold.Trials of nons-teroidal anti-inflam-matory agents ornerve block shouldbe considered priorto the use of highlyaddictive and abus-able medications.

The use ofacetaminophen inthe patient with analcohol use disorderalways has beenquestioned, espe-cially if there is evi-dence of liver dis-ease. However, areview article of themedical literatureshowed that repeat-

ed ingestion of a therapeutic dose ofacetaminophen over 48 hours by patients withsevere alcoholism did not produce an increasein hepatic aminotransferase enzyme levels orany clinical manifestations as compared to aplacebo group (Dart et al. 2000).

Treatment of Co-OccurringPsychiatric ConditionsPharmacological agents can be used as indi-cated for co-occurring psychiatric conditionsin patients with substance use disorders.Incidence of the co-occurrence of psychiatricconditions and substance use disorders ishigh; moreover, there is a higher rate of psy-chiatric conditions in patients dependent onalcohol than that found in the general popula-tion (Kessler et al. 2003; Modesto-Lowe andKranzler 1999).

Comorbidity of substance use and co-occur-ring mental disorders serves to complicatediagnosis and treatment for patients (Salloumand Thase 2000). It is difficult to accuratelyaccess underlying psychopathology in a per-son undergoing detoxification. The effects ofdrug toxicity and withdrawal often can mimicpsychiatric disorders. For this reason, it maybe best to conduct psychiatric evaluationsafter several weeks of abstinence; however,this should be weighed against the time anindividual has been in detoxification andwhat treatment plan is set up for him. Somepatients also present to detoxification whiletaking medications to treat underlying psychi-atric disorders, such as depression and anxi-ety. The risk of not treating a severe comor-bid psychiatric disorder predisposes thepatient to relapse; the decision needs to beweighed against the risk of prescribing medi-cations when the clinician is not entirely cer-tain that a comorbid condition exists. If aperiod of recent extended abstinence exists,the patient’s mental condition when abstinentcan be better evaluated.

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 bestinterest of the patient. Abrupt cessation ofpsychotherapeutic medications may causewithdrawal symptoms or the re-emergence ofthe psychiatric disorder. As a general rule,

136 Chapter 5

The effects of

drug toxicity and

withdrawal often

can mimic

psychiatric

disorders.

therapeutic doses of medications should becontinued through any withdrawal if thepatient has been taking the medication as pre-scribed. Decisions about discontinuing medi-cations should be deferred until after theindividual has completed detoxification. If,however, the patient has been abusing a medi-cation or the psychiatric symptoms wereclearly caused by substance abuse, then therationale for discontinuing the medication isstrengthened. Finally, practitioners shouldconsider withholding medications that lowerthe seizure threshold (e.g., bupropion or con-ventional antipsychotics) during the acutealcohol withdrawal period, or at a minimumprescribing a loading dose or scheduled taperof benzodiazepine.

During detoxification, some patients decom-pensate and lapse into psychosis, depression,or severe anxiety. In such cases, carefulobservation of the withdrawal medication reg-imen is of paramount importance. If thedecompensation is a result of inadequate dos-ing with withdrawal medication, the appro-priate response is to increase the dose of med-ication. If it appears that the withdrawalmedication is adequate, other medicationsmay be needed. Before choosing such analternative, it is important to take intoaccount additional considerations, such as theside effects of the added medication and thepossibility of interaction with the withdrawalmedication.

A patient with psychosis may need to takeneuroleptics. Medications that have a minimaleffect on the seizure threshold are recom-mended, particularly if the patient is beingwithdrawn from alcohol or benzodiazepines.Small, frequent doses of Haldol, such as 1mgevery 2 hours, may be used until the patient’ssymptoms of psychosis begin to disappear.The case for emergency use of antidepres-sants is weaker than for other psychiatricmedications because of the 2- to 3-week lagtime between initiation of medication andtherapeutic response. After detoxification,the patient’s need for medication should bereassessed. A trial without medications some-

times is the best way to assess the patient’sneed for the medication; however, it may notbe the best practice or in the best interest ofthe patient, particularly for those with a seri-ous mental illness. For more information onworking with patients with co-occurring sub-stance use and mental disorders, see TIP 42,Substance Abuse Treatment for Persons WithCo-Occurring Disorders (CSAT 2005c).

Treatment for Co-OccurringConditionsThe treatment of substance use disorders canbe difficult without adequate treatment of anyco-occurring mental disorders. For instance,a patient with schizophrenia who is halluci-nating and delusional, but who also abusessubstances, cannot participate in substanceabuse treatment without adequate controlover the psychosis. Likewise, patients withmania who are euphoric and delusional,patients who are depressed, or patients withagoraphobia who also have a substance usedisorder, will have difficulty cooperating withsubstance abuse treatment. Treatment of thesubstance use disorder is necessary toimprove the course of both the substanceabuse and co-occurring mental disorder.Psychotherapy should serve as one aspect ofrehabilitation, initially focused aroundrelapse prevention (Aviram et al. 2001).Highly effective treatment programs mayinclude a combination of therapeutic tech-niques. Programs should be long-term andapproach recovery in stages. Drake and col-leagues (2001) suggest that treatment for co-occurring substance use and other mental dis-orders include skill building, illness manage-ment, cultural sensitivity, and support topatients for the pursuit of practical goals.

Limitations of pharmacologi-cal agents in persons withsubstance dependencePharmacologic agents have limitations in thepopulation of persons with substance use dis-

137Co-Occurring Medical and Psychiatric Conditions

orders. Medications may impair cognition andblunt feelings, sometimes subtly. Clinicianstreating substance use disorders advocatethat clients need clear thinking and access toemotions in order to make fundamentalchanges in themselves. A person recoveringfrom a substance use disorder must take anactive part in changing attitudes and aban-doning a long-held belief that alcohol or otherdrugs can “treat” life problems and uncom-fortable psychological states. Although theseare potential risks, the intent of pharma-cotherapy is to enhance a person’s ability tosustain abstinence and benefit fully from con-current psychosocial interventions and treat-ments. Still, many psychiatric disorders, ifuntreated, result in mood, anxiety, or thoughtdisorders that prevent or retard the behav-ioral changes necessary to recover from sub-stance use disorders.

Risks versus benefits of pharmacologicalagents need to be considered carefully.Untreated anxiety, mood, or thought disor-ders can be powerful relapse triggers, espe-cially for people with a long-standing patternof relying on alcohol or other drugs to man-age their symptoms. In many instances, thebenefits and reduced relapse risk that appro-priate pharmacotherapy can provide far out-weighs the risk of taking medications. Someclinicians believe that the “no pain, no gain”approach has far greater risk of interferingwith recovery than of promoting it. Symptomssuch as anxiety and depression in personsrecovering from substance use disordersmight be vital to recovery, and pharma-cotherapy to treat such symptoms needs to beconsidered carefully in this context.Clinically, anxiety and depression can pro-vide the motivation to change when thepatient otherwise has little awareness of theneed to alter behavior.

Standard of Care forCo-OccurringPsychiatric ConditionsAfter detoxification and stabilization withpharmacologic agents, the current treatmentof choice for substance use disorders is non-pharmacologic. Further, several studies haveshown that treating substance use disorderswith abstinence alone results in improvementof the psychiatric syndromes associated withthe substance use (Anderson and Kiefer2004). Severe syndromes induced by alcoholthat may otherwise meet criteria for majordepressive and anxiety disorders are bestclassified as substance-induced disorders ifthey resolve within days to weeks with absti-nence. Likewise, manic syndromes induced bycocaine resolve within hours to days, andschizophrenia-like syndromes (e.g., hallucina-tions and delusions) induced by cocaine andPCP often resolve within days to weeks withabstinence.

Further studies are needed to confirm theclinical experience that psychiatric symptoms(including anxiety, depression, and personali-ty disorders) respond to specific treatment ofthe addiction. For example, cognitive–behav-ioral techniques employed in the 12-Steptreatment approach have been effective in themanagement of anxiety and depression associ-ated with addiction. Although challenging,treatment of both addiction and co-occurringpsychiatric conditions has proven cost-effec-tive in some studies (Goldsmith 1999).

Psychotropics for Co-OccurringPsychiatric Conditions

General aspectsBecause alcohol and other drugs can inducealmost any psychiatric symptom or sign ormimic any psychiatric disorder, their effectsalways must be considered before a co-occur-ring condition diagnosis is established ortreated.

138 Chapter 5

With an understanding of the interactionsbetween substance use and other mental dis-orders, a rational approach can be applied tothe use of pharmacologic therapies in co-occurring conditions. The use of medicationsfor psychiatric symptoms should begin onlyafter the knowledge of the natural history ofthe addictive disorder and other psychiatricdisorders is clarified. Further, it is importantto be able to identify the respective roles ofsubstance use and other mental disorders inthe generation of psychiatric symptoms.

Generally, substance-induced psychiatricsymptoms resolve within days to weeks ofabstinence. In many studies, the prevalencerates for anxiety and affective disorders inpersons dependent on alcohol were notgreater than those for persons not dependenton alcohol (Schneider et al. 2001).

A retrospective history of psychiatric symp-toms often can lead to an inflated diagnosis ofthese conditions because of rationalizationsregarding drinking and drug use by the indi-vidual. Typically, psychiatric symptoms areemphasized by both the patient and the psy-chiatric examiner.

Longitudinal observation frequently clarifiesthe role of alcohol and other drugs in the pro-duction of anxiety, affective, psychotic, orpersonality symptoms, particularly if objec-tive criteria are relied on in addition to thesubjective report of the person who is addict-ed. Also, specific treatment of substance usedisorders can result in improvement of mood,psychotic behavior, and personality distur-bances if related to the alcohol or other druguse. Mood lability and personality states canbe a manifestation of substance use disorders,and treatment of the addictive disorder canlead to stabilization of these psychiatricsymptoms.

Furthermore, treatment plans and efficacymay rely on the gender of the patient. Womenwith a substance use disorder appear to havehigher rates of co-occurring mental disorders,such as depression and anxiety, as well ashigher rates of physical and sexual abuse,

panic and phobia disorders, posttraumaticstress disorder, victimization, and eating dis-orders. Deficits in the management of mooddisturbances may be self-medicated throughalcohol consumption in females. It has beenproposed that the outcomes of substanceabuse in women are different when comparedto those of men. For these reasons, the effica-cy of treatment for substance use disordersneeds to be assessed independently for bothgenders (Becker and Walton-Moss 2001;Brady and Randall 1999).

AnxietyDisorders

GeneralapproachPrevalence rates forthe co-occurrence ofanxiety and sub-stance use disordersin the general popu-lation range from 5to 20 percent in epi-demiologic and clini-cal studies(Merikangas et al.1996).

Some antianxietyagents can overse-date and dull theindividual’s reactionto internal and external influences. Becauseanxiety in recovery can be critically impor-tant for emotional growth, the individual willfeel a certain amount of anxiety to motivatechange in behavior, attitudes, and emotions.(The expression “emotional growth” is relatedto the anxiety or discomfort a recovering indi-vidual feels while undergoing the process ofchange to reach a more mature state.) It isimportant for the clinician to distinguishbetween anxiety that can promote growth andanxiety that can impair a person’s ability tomake change. Adapting behavior in responseto anxiety or other emotion requires coping

139Co-Occurring Medical and Psychiatric Conditions

Major depressive

and anxiety

disorders are best

classified as

substance-induced

disorders if they

resolve within

days to weeks with

abstinence.

skills that may not be available to persons inearly recovery. A fully symptomatic anxietydisorder may significantly limit a person’scapacity to learn nonpharmacological copingstrategies. Medications with minimal addic-tion potential can be helpful and in somecases necessary if patients are to makeprogress in their recovery.

Depressants (e.g., alcohol) can produce anxi-ety during withdrawal, and stimulants (e.g.,cocaine) can produce anxiety during intoxica-tion. Because people with substance use dis-orders are in a relatively constant state of

withdrawal (it isimpossible to main-tain a constantblood level), theyregularly experi-ence anxiety as theresult of pharmaco-logical withdrawalfrom dependence.As the substanceabuse becomesmore chronic, theanxiety producedby withdrawal frompharmacologicdependence canbecome increasinglysevere. Relapseand/or periods ofabstinence (some-times prolonged—for weeks ormonths) should beconsidered (confirm

abstinence with laboratory drug testing, ifnecessary) before the effects of depressant orstimulant drugs in inducing anxiety can beruled out. It can take weeks or months forthese effects to subside completely, although aperiod of only a few days to weeks often issufficient in clinical practice.

Treatment is indicated when the anxiety per-sists after adequate effort in a substanceabuse treatment program, or when the clini-cian suspects that anxiety is preventing the

patient from participating in treatment. Athorough evaluation to assess whether theindividual is abstinent, involved in continuingtreatment, and/or attending self-help meetingsusually is necessary before a diagnosis of aco-occurring psychiatric condition can be def-initely established. After such an evaluation,treatment of the anxiety disorder can proceedseparately from similar symptoms arisingfrom the addictive disorder.

Pharmacologic therapiesThe ideal medication works against abnormalanxiety but not against the “normal” anxietyneeded for recovery. Some of the physicalsymptoms of anxiety include sweating,tremors, palpitations, muscle tension, andincreased urination. Psychological symptomsinclude nervousness, feelings of dread orimpending doom, unpleasant tenseness, andmany more.

The most common agents used in anxiety dis-orders are benzodiazepines and antidepres-sants. The benzodiazepines most frequentlyused are alprazolam and lorazepam.Diazepam and clonazepam are used lessoften. Because the benzodiazepines can causesignificant problems in patients who areaddicted as well as in patients who are notaddicted, they generally are not recommend-ed for people with substance use disorders orfor long-term treatment of anxiety or depres-sive disorders.

Antidepressants may be considered sooner ifdepression is a known pre-existing conditionor historical experience and collateral infor-mation suggests a comorbid depression. Againthe risk of treating prematurely needs to beweighed against the risk of not treating a con-dition that may prevent recovery from a sub-stance use disorder. Antidepressants such asimipramine and nortriptyline and selectiveserotonin reuptake inhibitors (SSRIs) such asfluoxetine (Prozac) have a low addictionpotential and can be used with relative safety.They differ in their tendency to producesedation and anxiety and have a withdrawal

140 Chapter 5

Medication is

indicated when

the anxiety is

preventing the

patient from

participating in

treatment.

syndrome of their own. Because of its anti-cholinergic properties, imipramine is moresedating, but nortriptyline and the SSRIs canproduce anxiousness in some individuals andsedation in others. Not all individuals reactthe same way to these medications.

When medications are used, a specific targetsymptom should be the focus. Also, medica-tions should be tried in time-limited intervals,such as weeks to months. A “drug holiday”(i.e., a brief period where the patient stopstaking medications) should then be attemptedto see if the medication is still necessary.

The patient should be instructed that themedications will not “cure” the addiction,that treatment of anxiety will not control theaddiction, and that treatment of the addictionwill not necessarily ameliorate the anxiety dis-order. In essence, the substance use disordermust be treated independently of the anxietydisorder and vice versa.

Depressive Disorders

General approachPrevalence rates for the co-occurrence ofdepressive and addictive disorders rangefrom 5 to 25 percent in epidemiologic andclinical studies. Depressive disorders includemajor depressive and dysthymic disorders,which can occur independently with addictivedisorders, or similar depressive symptomscan be induced by substance use disorders.Major depressive disorder is more common inolder individuals and in women and can bedifficult to distinguish from substance-induced depression.

Depression can be viewed as protective andcan be associated with “healing” in many con-ditions involving emotions. For example, agrief reaction is an expected experience afterloss, with depression an essential emotion inthis process. Recovery from a substance usedisorder has been compared to a grief reac-tion because of losses (e.g., of the substanceor relationships based on substance use) suf-

fered by the patient with an addictive disor-der. Likewise, and analogous to the role ofanxiety, depression also is a part of the heal-ing process that the patient with a substanceuse disorder experiences during recovery.

Depressant drugs (e.g., alcohol) can producedepression during intoxication which oftenresolves following abstinence. A survey of 69adults with alcohol use disorders showed astrong correlation between the reduction incravings for alcohol over 2 weeks of absti-nence and the lifting of depressive mood. Thepatients’ cravings were assessed with theObsessive-Compulsive Drinking Scale (OCDS)and their depressive symptoms measured withthe Self-rating Depressive Scale (SDS).Between day 1 and day 14, their cravingsscore dropped nearly a third, while the scoresfor severity of depression fell by about onefourth. The correlation between the reductionin cravings and the lifting of depression per-sisted after controlling for sex, age, durationand extent of alcohol abuse, and the amountof clomethiazole administered (Anderson andKiefer 2004).

Stimulant drugs (e.g., cocaine) can producedepression during withdrawal. These effectsmay be prolonged with certain drugs thatlinger in the body (i.e., are stored in fat),such as cannabis and benzodiazepines. Thesedrugs can produce depression or anxiety thatis indistinguishable from other psychiatriccauses of depression. Therefore, they must beconsidered causative whenever depression ispresent, and the possibility of addiction needsto be assessed when these drugs are identi-fied. While depression may persist for weeksor months, it often resolves within days withabstinence from these drugs.

Pharmacologic therapiesThe use of medication is recommended if thedepression persists beyond a few weeks ofdrug withdrawal or arises during confirmedabstinence (laboratory drug testing may benecessary to confirm abstinence). The risk ofsuppressing normal depressive processes dur-

141Co-Occurring Medical and Psychiatric Conditions

ing recovery versus the benefit from sup-pressing depression that is interfering withfunction should be weighed, as is the casewith anxiety disorders.

Antidepressants are the main treatment fordepression. The target symptoms are a sadmood, tearfulness, appetite and sleep distur-bances, and other neurovegetative symptoms.Depression can be found in many conditions,including a variety of psychiatric and medicalconditions. SSRIs are the drug of choice formany physicians treating depressed patientswith substance use disorders. Although someare costly, they provide adequate treatmentof depression with fewer side effects thanother medications commonly used (Thase etal. 2001).

Depressive disorders are thought to have asignificant biological component, includingdeficiencies in such central nervous systemneurotransmitters as serotonin, nore-pinephrine, and dopamine. Interestingly,these neurotransmitters are also affected bysubstances of abuse. These agents are thoughtto act by increasing the activity of these neu-rotransmitters, ultimately alleviating depres-sion and stabilizing mood.

Bipolar Disorders

General approachPrevalence rates for the co-occurrence ofbipolar and addictive disorders range from 30to 60 percent, depending on the populationstudied, in epidemiologic and clinical studies(Chen et al. 1998; Sallom and Thase 2000;Sonne and Brady 1999; Strakowski andDelBello 2000).

Mania is a condition associated with elevatedmood, grandiosity, hyperactive behavior,poor judgment, and lack of insight. Thepatient with mania will show excess such asspending sprees, sexual promiscuity, intru-siveness, and abnormal alcohol and drug use.A manic episode can follow, precede, or alter-nate with depressive moods.

Bipolar disorder may be complicated by theinfluence of substances (Sonne and Brady1999). The manic state can be produced bystimulants (e.g., cocaine) during intoxication,and from depressants (e.g., alcohol) duringwithdrawal. A period of confirmed abstinenceusually is necessary before mood-stabilizingdrugs are started. Generally, a period of aweek or two may be required for the role ofdrugs in inducing manic symptoms to beproperly assessed.

Pharmacologic therapiesMood stabilizers control bipolar disorders inpatients with or without co-occurring sub-stance use disorder. These medications cancontrol either the manic or depressed phase,or both.

Manic episodes can occur cyclically, alterna-tively, and concurrently with depressiveepisodes. One theory of the pathogenesis ofbipolar disorder involves the neurotransmit-ter norepinephrine (i.e., excessive in maniaand deficient in depression).

Lithium is a natural salt, available in the car-bonate form and slow release preparations.Its exact mechanism of action is unknown,but it can be effective in reducing or prevent-ing the recurrence of manic and depressiveepisodes. Lithium carbonate must be takendaily in doses of 600 to 2,400mg to achieveplasma levels in the 0.5 to 1.5-m equiv/Lrange. It should be noted that studies haveshown that lithium has no conclusively posi-tive effect on rates of abstinence in eitherdepressed or nondepressed patients.

Anticonvulsant mood stabilizers, such asdivalproex sodium and carbamazepine, canbe effective in controlling mania and, someevidence suggests, in co-occurring addictiveconditions as well. Carbamazepine is knownto be as effective as some benzodiazepines ininpatient treatment of alcohol withdrawaland, because of its anticonvulsant properties,it may be a good choice for treating thosepatients at high risk of withdrawal seizures

142 Chapter 5

(Malcolm et al. 2001). One theoretical expla-nation for the mechanism of action for carba-mazepine involves suppression of mood cen-ters in the limbic system that act like seizurefoci. In this context, a “kindling” model hasbeen proposed for both mood and addictivedisorders (Gelenberg and Bassuk 1997).

Psychotic Disorders

General approachPrevalence rates for co-occurrence ofschizophrenic and addictive disorders rangefrom 40 to 80 percent, depending on the pop-ulation studied, in epidemiologic and clinicalstudies.

Schizophrenia is a chronic illness character-ized by bizarre thinking and behavior.Hallucinations and delusions are “positive”symptoms of the psychotic process, whilesymptoms such as social withdrawal andpoverty of emotions are “negative” symptoms(or deficit syndrome). Conventional neurolep-tics are more effective for positive symptoms,whereas behavioral, group, and individualpsychotherapy are more effective for negativesymptoms. New agents such as clozapine andrisperidone may be more effective in treatingboth the positive and negative symptoms.

Psychosis can be caused by stimulant druguse during intoxication and depressantdrug/alcohol use during withdrawal. A periodof weeks or months may be necessary toassess the effects of substances of abuse, butas with anxiety, depression, or mania, medi-cations can be started at almost any time asthe psychosis is persistent and waiting is notpossible. Moreover, the greater the number ofpsychiatric admissions, the greater the proba-bility of a chronic mental disorder associatedwith the co-occurring psychiatric disorder.

High- or moderate-potency neuroleptics (e.g.,haloperidol or atypical agents) generally arethe agents of choice in the treatment ofschizophrenia. The clinical potency correlateswith the drug’s ability to block the action of

the neurotransmitter dopamine at its postsy-naptic receptor sites.

AdverseEffects

AntianxietyagentsWhile benzodi-azepines are usefulin the short term,their efficacy waneswith long-term use,probably because ofthe development ofpharmacologic toler-ance and depen-dence. It should benoted that benzodi-azepines can beaddicting, particu-larly in those alreadyaddicted to othersubstances.

Antipsychotic agents Antipsychotics can produce sedation andhypotension (at times causing lightheadednessin some individuals), particularly with postu-ral changes. Conventional neuroleptics pro-duce acute extrapyramidal reactions, whichinclude pseudoparkinsonism, dystonia, andakathisia. Dystonia usually responds to treat-ment with anticholinergic drugs such as ben-ztropine or diphenhydramine. Akathisia isthe subjective feeling of anxiety and tension,causing the patient to feel compelled to moveabout restlessly. This symptom usuallyrequires beta blocker, as a decrease in theantipsychotic dose does not have the desiredeffect. Alternatively, switching to risperidonemay accomplish the intended effect whileavoiding intolerable neurologic syndromes.

143Co-Occurring Medical and Psychiatric Conditions

A period of

confirmed

abstinence usually

is necessary

before mood-

stabilizing drugs

are started.

AntidepressantsAntidepressants, particularly the tricyclics,can produce sedation, hypotension, syncope,and other anticholinergic effects. The SSRIscan produce anxiousness, sedation, insomnia,and gastrointestinal upset. A withdrawal syn-drome also has been reported with mostantidepressant medications.

The SSRIs are preferred in patients withaddiction and co-occurring psychiatric condi-tions because of their reduced side effect pro-file and low risk of dangerous drug interac-tions; for example, there are no anticholiner-gic effects on the senses and no risk of lethaleffects from overdose.

Cognitive State in RecoveryA person recovering from a substance use dis-order must have a clear mind and a stablemood. Medications have a tendency, some-times subtly and other times obviously, to dullthe senses and thinking and blunt or disruptthe emotions. People with substance use dis-orders must eventually change and controlfeelings to remain abstinent and also to com-ply with psychiatric management. The abilityof a person with a substance use disorder to

use the 12 steps of Alcoholics Anonymous(AA) and to accept psychiatric advice willdepend on clear thinking and emotional bal-ance, which is stressed as central to therecovery process in AA. In other cases—suchas patients with traumatic brain injuries—treatment venues should be adaptable to theircognitive abilities.

Accordingly, the use of medications should beconservative, taking into consideration thepros and cons of their expected positive andnegative effects. Unfortunately, few psychi-atric medications are totally free of mood-altering properties. However, the cognitivestate of individuals who have a serious mentalillness often is more distorted when not medi-cated appropriately. The very nature of theirillness is a disruption to their cognitive pro-cesses.

DosingBecause of inherent susceptibility to drugeffects by people with substance use disorders,it is important to use the lowest effective dosespossible. Also, the intervals for administrationshould be selected to reduce effects on cogni-tion and feelings.

144 Chapter 5

6 Financing andOrganizationalIssues

In ThisChapter…

Preparing andDeveloping a

Program

Working inToday’s Managed

Care Environment

Preparing for theFuture

Preparing and Developing aProgramDeveloping a detoxification program is a major financial challenge,whether the program requires building an entirely new organizationor is part of an existing treatment entity. The process of programdevelopment requires careful planning, especially to ensure adequatefinancial support for the operation. The decision to develop a detoxifi-cation program should be based on a well-developed strategic plan-ning process (see chapter 2) and a clear understanding of what adetoxification program entails. Because the new program will incurmajor costs for office space, furniture, staff, computers, and otherequipment before clients can be provided with services and paymentcan be received, significant amounts of initial capital may be needed.

As soon as the administrator or planner identifies a market need fordetoxification services, potential fiscal support and other resourcesshould be identified and checked to see if such support is likely andsufficient. Both implementation and initial operating costs must becovered. It may be possible to find strategic partners who will provideresources, work with the program planner, provide office space, orhelp obtain funding. Community organizations that see a need forestablishing detoxification and treatment services are likely partners.Locally based foundations and businesses also may be approached forassistance with developing a program, especially if a case can be madeto the potential funder that ongoing costs can be covered from opera-tions.

It is important to have documented assurance from major referraland payment sources that they will refer patients with information onpayment sources; that is, by the referral source, by a third party, or

145

by patients who have the documented finan-cial resources to pay for detoxification treat-ment themselves. Signed contracts withexpected payors may be useful to ensure ade-quate cash flow and to establish a budget forthe new program’s fee structure.

Identifying and recruiting strategic partnersis one of the most important steps in the pro-gram development process. Before and duringthe program development process, adminis-trators and planners should work closely withpotential referral and payment sources todetermine their needs and to see if the detoxi-fication program will fit those needs.Programs also will need to learn whetherreferral sources are open to new partners, thetypes of contracts they utilize, their time-frames for reimbursement, and the processfor negotiating a contract. Among useful tac-tics to employ is holding focus groups andstrategy meetings with individuals frompotential referral sources; these groups cansuggest the types of services they need and forwhich they will reimburse. Potential referralsources will be more invested in the programif they are involved throughout the planningprocess. All potential stakeholders should beinformed regularly of the developing plansand milestones achieved.

Program planners should follow up on allpotential leads for both funding sources andpotential referral sources. Relationships withreferral sources are important to build andmaintain. Obviously, referral sources need tobe carefully assessed to ensure that they canprovide patients who have needs andresources appropriate for the services theprogram will provide. Leads for potentialsources of funding and referrals may includethe contacts made during a focus group pro-cess, public system payors and planners, pri-vate insurance plans, contracting agents forprivate insurance (e.g., managed care organi-zations [MCOs]), and local employers largeenough to have employee assistance programs(EAPs) or managed behavioral health plansthat cover detoxification services. Direct con-tact with the EAPs or managed behavioral

health plans may be necessary to ensure bothprivate sector demand for services andappropriate reimbursement of the services.

Forming strategic alliances with other compo-nents of the treatment environment can beboth an important source for referrals and aresource for clients with needs other thandetoxification. Vertical alliances facilitatereferrals up and down the continuum of care.An alliance with a larger organization canincrease leverage when negotiating with anMCO.

The Dramatically ChangingPattern of Utilization ofDetoxification ServicesThe settings for detoxification services havechanged dramatically over the last decade, ashave patients’ primary substances of abuse. Asthe setting for detoxification services has shift-ed from inpatient to outpatient, the primarysubstance abuse problem of clients has shiftedfrom alcohol and cocaine/crack to heroin andother opioids. This shift has created significantopportunities in the market for detoxificationservices for community-based andentrepreneurial providers that are not part ofhospitals, or for freestanding detoxificationfacilities that are owned by hospitals.

Changes in practice patterns and in the epi-demiology of substance abuse in the lastdecade have been dramatic. Between 1993and 2000, the number of admissions to hospi-tal inpatient settings for detoxification ofpatients with a primary problem of alcoholabuse declined by 79.6 percent. During thesame period, the total admissions to inpatienthospital detoxification services declined by69.3 percent, from 23.5 percent of totaldetoxification admissions in 1993 to 8.8 per-cent of total detoxification admissions in2000, while admissions to 24-hour free-stand-ing detoxification units increased by the same14.7 percentage points, from 60.5 percent oftotal admissions in 1993 to 75.1 percent oftotal admissions for detoxification services in

146 Chapter 6

2000. During this same period, the number ofalcohol admissions to free-standing clinicsdecreased by 32.0 percent and the number ofcocaine/crack admissions decreased by 42.5percent. Concurrently, heroin admissions (tofree-standing clinics) increased substantiallyfrom just under a quarter of total detoxifica-tion admissions in 1993 to just over a third oftotal admissions in 2000.

Of course, these statistics reflect nationaltrends and regional differences in patterns ofboth practice and substance abuse. Changesin specific geographic areas will vary.Prospective programs should carefullyresearch their own local market for detoxifi-cation services and should obtain data oncurrent utilization of and demand for detoxi-fication in their local area before proceedingwith program development.

Funding Streams and OtherResources in the SubstanceAbuse Treatment EnvironmentSubstance abuse treatment and detoxificationservices in the United States are financedthrough a diverse mix of public and privatesources, with substantially more being spentby the public sector. Public sources accountfor 64 percent of all substance abuse treat-ment spending, a much higher percentagethan public expenditure for the rest of healthcare (Coffey et al. 2001). The existence ofdiverse funding streams presents both man-agement challenges and opportunities for pro-gram independence and stability. However, aprogram with only one major funding sourceis financially and clinically vulnerable tochanges in its major source’s budget and pri-orities, and this situation should be avoided.Diversification of funding sources should be amajor goal for detoxification programs.

Usually, each funding stream has differentapproval and reporting requirements.Because of this, any new or existing detoxifi-cation program requires a fairly sophisticatedmanagement and accounting system to meet

the reporting needs and performance require-ments of each purchaser, to provide informa-tion that meets their requirements, and togenerate the appropriate bills/invoices.Detoxification program administrators mustbe knowledgeable about efficient businesspractices, the use of data-based performancemeasures, accounting, budgeting, financing,and financial and clinical reporting.

It also is important to reach out to otherpotential sources of support such as founda-tions, board mem-bers, and local ornational corporatedonation programsfor any assistancethat will help toreduce costs,increase revenue, orimprove productivityand effectivenessand aid in the suc-cess of the organiza-tion. Searching forsupport does not endwith ensuring initialfunding. Plannersmust make good useof the Internet touncover potentialcash and in-kinddonations that cansupplement major funding sources, discussedbelow.

Entrepreneurial, for-profit programs may beable to attract private capital. Not-for-profitentities that are similarly entrepreneurialmay be able to take advantage of this poten-tial source of funding through establishmentof a for-profit subsidiary. Detoxification pro-grams in particular, as opposed to some otherareas of substance abuse treatment, may beattractive candidates for private financingbecause of their potential to serve privatelyinsured and self-pay patients. However,acceptance of private capital usually carrieswith it requirements for rapid growth in rev-

147Financing and Organizational Issues

Identifying and

recruiting

strategic partners

is one of the most

important steps in

the program

development

process.

enues and profitability that may be difficultto meet and may limit operational flexibility,at least in the short term. In the longer term,successful detoxification programs may beable to generate profits.

Funding streams associated with public andprivate health insurance often provide bene-fits to covered individuals that vary accordingto whether or not the services are facility-

based and accord-ing to the level orsetting of care.Complexity arisesbecause coverageand reimbursementdepend both onwhether a service isconsidered to be amedical service or asubstance abusetreatment serviceand whether a ser-vice is facilitybased.

Many public andprivate benefitplans still classifysubstance abusedetoxification as amedical rather thana substance abusetreatment service.In general, andespecially foremployer-based

coverage, benefits under a medical plan areprovided at higher reimbursement rates withfewer limits and restrictions than are benefitsfor substance abuse treatment (Merrick et al.2001). Requirements for out-of-pocket pay-ments by those covered under these planstypically are lower under the medical portionof a plan than under the substance abusetreatment portion. However, it is importantto note that benefit plan features are but onecomponent of coverage; utilization manage-ment procedures continue to play a veryimportant role in a patient’s access to specific

services. Any episode of detoxification may bedenied reimbursement under a plan if medi-cal necessity is not demonstrated to the satis-faction of the plan or if the service is provid-ed at a higher level of care than is judgedmedically necessary.

It is important to decide whether to make anew detoxification program hospital-based,facility-based, or office-based. Services thatare considered hospital- or facility-based, likethose in hospital outpatient departments,often are eligible for higher payment ratesthan office-based services to reflect theirgreater capital and other overhead costs.Similarly, hospital inpatient services often arereimbursed at a higher payment rate thanoutpatient services, but medical necessitydeterminations also require patients to needmore intensive services. Sometimes, patientcopayments or coinsurance rates may behigher for office-based services than facility-based services. This is true for Medicare aswell as for other health insurance plans.Detoxification programs that are parts of hos-pitals, affiliated with a hospital, or consid-ered as a licensed facility themselves may beeligible for higher rates of reimbursementthan are those that are considered to be out-patient programs with no facility license.However, utilization management criteria toauthorize payment for admission to and con-tinued stay in a hospital inpatient settingrequire a significantly greater severity ofpatient diagnosis than do criteria for admis-sion and continued stay in a freestanding oroutpatient program. On the other hand, oftenthere are high barriers to obtaining a facilitylicense to open a freestanding 24-hour facilityor licensed outpatient detoxification facility.Programs that are part of or affiliated withhospitals also must contend with overheadcost allocations from the hospital as well aswith oversight from hospital administratorswho may know little about substance abusetreatment or detoxification. In addition, somehealth insurance plans actually exclude cov-erage for hospital-based or freestanding facil-ity-based detoxification programs and othersmay subject admissions to such programs to

148 Chapter 6

The Substance

Abuse Prevention

and Treatment

Block Grant

program is the

cornerstone of

Federal funding

for substance

abuse treatment

and detoxification

programs.

more intensive review than admissions tonon–facility-based detoxification programs.Program planners should consider carefullyall alternatives; decisions concerning affilia-tion with a hospital or pursuit of a facilitylicense have far-reaching financial and politi-cal ramifications and should be made with asmuch information as possible.

Following is a discussion of the key fundingstreams and resources that are available forprograms providing detoxification services.

SAPT Block GrantThe Substance Abuse Prevention andTreatment (SAPT) Block Grant program isthe cornerstone of Federal funding for sub-stance abuse treatment and detoxificationprograms. These funds are sent to the State’sSingle State Agency (SSA) for substanceabuse for distribution to counties, municipali-ties, and designated programs. Some of thefunds are subject to required set-asides forspecial populations. Each program shouldcheck to see if the clients it intends to serveare eligible for block grant funding, either forset-asides or for other funds. Each Statemaintains its own criteria for eligibility andthe criteria and definitions vary greatlyamong States. Multistate providers will needto check specifically in each State in whichthey operate.

The Substance Abuse and Mental HealthServices Administration (SAMHSA) providesfunding for substance abuse treatment andprevention through the block grants as well asa large variety of other mechanisms, includ-ing both discretionary grants and contracts.A portion of the SAMHSA Web site is devotedto various funding opportunities. (Seewww.samhsa.gov/budget/index.aspx.)

The most recent available data indicate thatthe SAPT Block Grant accounts for approxi-mately 40 percent of public funds nationallyexpended for prevention and treatment ofsubstance abuse (U.S. Department of Healthand Human Services 2003). Funds from theblock grant may come directly from the SSA

or be channeled through regional or countyintermediary agencies. Services may be paidfor through grants, contracts, fee-for-service,and/or managed care arrangements. TheChildren’s Health Act of 2000 mandated agradual transition from SAPT Block Grantsto Performance Partnership Grants (PPGs).Providers should follow developmentsthrough their SSA, which include•Changes in reimbursement. Treatment

purchasing systems may evolve over time;managed care arrangements and require-ments are increasingly common.

•Performance outcome data. In accordancewith Federal legislation, PPGs eventuallywill replace SAPT Block Grants and willprovide more flexibility for States as well asrequire more accountability based on out-come and other performance data. TheCenter for Substance Abuse Treatment(CSAT) and the States are establishing per-formance outcome measures for fundingprograms under the block grants. All datafor core measures are collected from Statesreceiving PPG dollars.

MedicaidMedicaid, administered by the Centers forMedicare and Medicaid Services (CMS) inconjunction with the States, provides finan-cial assistance to States to pay for medicalcare of specifically defined eligible persons.Medicaid is being used by many States as avehicle for experimentation with public sectormanaged care in an effort to expand medicalcoverage to the uninsured. About 2 percent oftotal Medicaid expenditures nationally are forsubstance abuse treatment services (Mark etal. 2003a) but Medicaid supports about 20percent of national expenditures for sub-stance abuse services (Coffey et al. 2001). Thelevel of expenditure varies greatly by State.Medicaid is an entitlement program with sev-eral distinct eligible groups: low-income chil-dren, pregnant women, the elderly, and peo-ple who are blind or disabled, all or some ofwhom can be enrolled in a detoxification pro-gram population. Some substance abusetreatment programs will want to target pro-

149Financing and Organizational Issues

grams to the Medicaid population; if theState’s coverage and payment rates are mini-mal, however, other funders should beexplored in greater depth.

The reason for substantial variation in StateMedicaid expenditures and coverage is thatsubstance abuse treatment and rehabilitationis an optional benefit under Medicaid thatStates have the discretion to include or notinclude in their Medicaid program. Medicaidmay pay for substance abuse treatment eitherdirectly through fee-for-service arrangementsor through a managed behavioral health careor other MCO with which it contracts. Morethan one type of arrangement may exist with-in the same State. Rates of payment/reim-bursement are determined by each State inde-pendently and may vary within the Stateamong the various coverage arrangements. Ifa State decides to include benefits for sub-stance abuse treatment in its Medicaid pro-gram, it can choose the precise services andlevels of care that will be reimbursed. Theservices provided under managed care maydiffer from those under fee-for-servicearrangements. Although most States offersome coverage for detoxification servicesunder their Medicaid program (Office of theInspector General 1998), not all types or set-tings for detoxification programs are coveredin those States that do provide coverage.Therefore, a State Medicaid program maycover certain substance abuse treatment ser-vices but not cover detoxification services.For more information, readers should contacttheir State Medicaid office, orwww.cms.hhs.gov/home/medicaid.asp.

An important distinction of the Medicaid ben-efit structure since its inception has been theexclusion of coverage for services provided inan Institute for Mental Disorders (IMD),defined as a facility with more than 16 bedsthat treats mental disorders, including sub-stance abuse, for individuals between the agesof 21 and 64 (Rosenbaum et al. 2002).Although services furnished by outpatientdetoxification programs are not excluded,detoxification programs should be aware of

the IMD exclusion in their program planningprocess.

The Medicaid Early Periodic ScreeningDetection and Treatment (EPSDT) mandaterequires States to screen all children and ado-lescents on Medicaid for physical and behav-ioral health disorders. Further, EPSDTrequires that any needed medical treatment isprovided to children, even if the service is notin the State’s Medicaid plan submitted toCMS. Although the procedures and screeningtools vary by State, and there is significantvariation in their identification of substanceabuse issues, the EPSDT program is animportant entrance to substance abuse treat-ment for children and adolescents (Semanskyet al. 2003).

When available, Medicaid coverage offers thefollowing advantages:•It can provide significant treatment funding

for certain high-risk groups, such as low-income mothers and adolescents.

•Client copays traditionally have not beenrequired so the program receives the entirenegotiated fee without having to collect fundsfrom clients. (However, some States havechanged this provision due to budget crises.)

•A Medicaid contract can provide a usefullower limit for rate negotiations with com-mercial payors by essentially prohibitingacceptance of contract terms with any otherpurchaser at rates lower than those estab-lished for Medicaid.

•Certification as a Medicaid provider also canposition the program to receive patients fromother public sector referral sources, makingit possible to obtain patients from sourcessuch as social services, indigent care funds,and criminal justice systems.

•The criminal justice and juvenile justice sys-tems and drug court administrators typicallyfavor providers that are eligible for Medicaidreimbursement because treatment of someoffenders can then be billed to Medicaid insome States.

150 Chapter 6

Medicaid link toSupplemental SecurityIncomeSupplemental Security Income (SSI) is a pro-gram financed through general tax revenues.SSI recipients are one of the mandated popu-lations for Medicaid, but specific provisionsvary by State. SSI disability benefits arepayable to adults or children who are blindor have certain other disabilities that make itimpossible for them to work, who have limit-ed income and resources, who meet the livingarrangement requirements, and who are oth-erwise eligible. Congress has excluded a pri-mary diagnosis of substance abuse as a quali-fying disability under the Social SecurityAdministration’s programs, but if there isanother primary disability that qualifies theperson for SSI, a secondary substance abusediagnosis remains acceptable. Many SSIrecipients with a mental disorder diagnosishave a co-occurring substance abuse diagnosis.

MedicareMedicare provides coverage to individualsover age 65, people under the age of 65 withcertified disabilities, and people with end-stage renal disease. Medicare supports about8 percent of national expenditures for sub-stance abuse treatment services. Medicaremay provide Part A coverage to clients indetoxification programs that are based in hos-pitals certified by Medicare. However, detoxi-fication programs that provide only a struc-tured environment, socialization, and/orvocational rehabilitation are not covered byMedicare. Medicare imposes very strictreview requirements for detoxification pro-grams based in hospitals and detoxificationprograms that are considered to be partialhospitalization programs, and for patients inthose detoxification programs. Alternatively,Medicare may provide Part B coverage toclients in detoxification programs withMedicare-certified medical practitioners;however, clients whose services are reim-

bursed under Part B are required to pay 50percent of Medicare-approved amounts. Formore information, contact the Social SecurityAdministration, Medicare provider enroll-ment department, State Medicare services, orsee www.cms.hhs.gov/home/medicare.asp.

Medicare link to SocialSecurity Disability InsuranceThe Social Security Administration providesSocial Security Disability Insurance (SSDI) toindividuals and certain members of their fam-ily if they haveworked long enoughand paid SocialSecurity taxes.Recipients of SSDIbenefits are coveredby Medicare follow-ing a 2-year waitingperiod. SSDI is aprogram financedwith Social Securitytaxes paid by work-ers, employers, andself-employed per-sons. In order to beeligible for a SocialSecurity benefit, theworker must earnsufficient creditsbased on taxablework. Disabilitybenefits are payableto disabled workers,disabled widow(er)s,or adults disabledsince childhood, who are otherwise eligible. Asubstance abuse diagnosis was excluded byCongress as a qualifying disability for SSDI,but a secondary substance abuse diagnosis isacceptable if the person is qualified by anoth-er primary diagnosis, such as mental illness,which often co-occurs. For more informationsee the Social Security Administration’s Website at www.ssa.gov/dibplan/index.htm.

151Financing and Organizational Issues

Medicaid supports

about 20 percent

and Medicare

supports about

8 percent

of national

expenditures for

substance abuse

treatment

services.

State Children’s HealthInsurance ProgramThe State Children’s Health InsuranceProgram (SCHIP) provides funds for sub-stance abuse treatment of children and ado-lescents in many States. This program pro-vides low-cost health insurance for children

of low-income fami-lies who are not eli-gible for Medicaid.States have theoption of providingSCHIP benefitsunder their existingMedicaid programor designing a sepa-rate children’shealth insuranceprogram entirelyseparate fromMedicaid. If theprogram is part ofMedicaid, then thesubstance abusebenefits will mirrorthose underMedicaid. If theState designs itsown program, CMShas promulgated aset of rules to

ensure that coverage meets minimum stan-dards. A State’s Alcohol and Drug AbuseAgency also may be able to provide informa-tion on resources available for treatment oftransition-age youth who have exceeded themaximum age for the SCHIP program in theState. For more information seewww.cms.hhs.gov/home/schip.asp or the StateSCHIP program office.

TRICARETRICARE is a regionally managed healthcare program for active duty and retiredmembers of the uniformed services and theirfamilies and survivors. TRICARE supple-ments the healthcare resources of the Army,

Navy, and Air Force with networks of civilianhealthcare professionals. TRICARE consistsof TRICARE Prime, where MilitaryTreatment Facilities are the principal sourceof health care; TRICARE Extra, a preferredprovider option; and TRICARE Standard, afee-for-service option that replaced the pro-gram formerly known as CHAMPUS. TheTRICARE Extra and Standard benefitsinclude treatment for substance abuse, sub-ject to preauthorization requirements, butprograms will need to check to see if detoxifi-cation programs are eligible or preauthorizedunder TRICARE managed care arrange-ments. TRICARE is run by managed carecontractors, each of whom may have differentauthorization procedures. For more informa-tion see www.tricare.osd.mil.

Indian Health ServiceThe Indian Health Service (IHS) is an agencywithin the Department of Health and HumanServices that operates a comprehensive healthservice delivery system for approximately 1.6million of the Nation’s estimated 2.6 millionAmerican Indians and Alaska Natives. MostIHS funds are appropriated for AmericanIndians who live on or near reservations.Congress also has authorized programs thatprovide some access to care for Indians wholive in urban areas. IHS services are provid-ed directly and through tribally contractedand operated health programs. Health ser-vices also include health care purchased frommore than 9,000 private providers annually.The IHS behavioral health program supportsalcoholism and other drug dependency treat-ment, detoxification, rehabilitation, and pre-vention services for individuals and theirfamilies. For more information seewww.ihs.gov.

Department of VeteransAffairsThe Department of Veterans Affairs providesthe Civilian Health and Medical Program of theVeterans Administration to eligible beneficia-

152 Chapter 6

Substance abuse

treatment and

detoxification

services in the

United States are

funded through a

diverse mix of

public and private

sources.

ries. Medically necessary treatment of sub-stance abuse is a covered benefit; beneficiariesare entitled to three substance use disordertreatment benefit periods in their lifetimes. Formore information see http://www.va.gov/hac/forbeneficiaries/champva/champva.asp.

Social Services

Funding for substance abuse treatment,which may include detoxification services,also may be available through arrangementswith agencies funded by the U.S. Depart-ments of Labor, Housing and UrbanDevelopment (HUD), and Education (ED).Some Federal sources of funding for sub-stance abuse treatment under these programsmay prohibit use of funds for “medical” ser-vices. However, services performed by thosenot in the medical profession (e.g., coun-selors, technicians, social workers, psycholo-gists) and services not provided in a hospitalor clinic (including 24-hour care programs)may be considered nonmedical. The precisedefinition of “medical” under some of theseFederal programs may be determined by eachState individually, so administrators need tocheck with their State authorities to deter-mine exactly which services may be fundedthrough these sources. Even if funding fordetoxification services is not availablethrough these programs, programs may beable to link their clients to them for supportfor services that enable them to initiate andcomplete treatment successfully. Oppor-tunities include the following:•Temporary Assistance to Needy Families

(TANF). Under the TANF programs, eachState receives a Federal block grant to fundtreatment for eligible unemployed personsand their children, usually women withdependent children. Services that overcomebarriers to employment (e.g., substanceabuse treatment) are eligible for formulagrants—with one quarter of the money allo-cated to local communities through a com-petitive grant process. The funding chan-nels vary by State. Funds may be directedthrough Private Industry Councils,Workforce Investment Boards, Workforce

Development Boards, and similar bodies atthe State and community levels. AlthoughStates may not use TANF funds for “medi-cal” services, States have considerable lati-tude in the definition of “medical,” andhave used TANF funds to support the fol-lowing substance abuse treatment services:screening/assessment, detoxification, outpa-tient treatment, non-hospital residentialtreatment, case management, education/prevention, housing, employment services,and monitoring (Rubinstein 2002). Even ifthese funds are not available for substanceabuse treatment in a State or program, theprogram’s clients may be able to access thissource of assistance for employment train-ing, child care, and other support needs.For more information on TANF, seewww.acf.hhs.gov/programs/ofa/.

•Social Services Block Grant. Under TitleXX of the Social Security Act, theAdministration for Children and Familiesprovides a block grant to each State for thepurpose of furnishing social services. Fundsmay not be used for medical services(except initial detoxification of an individu-al who is alcohol or drug dependent). In2002, these funds provided close to $8 mil-lion for substance abuse treatment in 14States (Administration for Children andFamilies 2002).

•Public housing. HUD funds substanceabuse treatment of public housing residentsunder the Public Housing Drug EliminationProgram. HUD awards grants to publichousing authorities, tribes, or tribally des-ignated housing entities to fund treatment.Funds are channeled to local public housingauthorities, which contract with serviceproviders. In addition, special housing pro-grams are available for people who arehomeless and have substance use disorders.For more information see www.hud.gov.

•Vocational rehabilitation. Federal EDfunds support services that help people withdisabilities participate in the workforce.Treatment of substance use disorders is eli-gible for funding. Funds are channeled to

153Financing and Organizational Issues

the State agencies responsible for vocationalrehabilitation. For more information seewww.ed.gov.

•Children’s protective services. Title IV ofthe Social Security Act provides funding forfoster care and services to prevent childabuse and neglect. Eligible services includesubstance abuse treatment for parents whoare ordered by a court to obtain treatmentand are at risk for losing custody of theirchildren. Medicaid also covers these chil-dren, as they are a mandatory eligibilitygroup. For more information seewww.acf.hhs.gov/programs/cb/index.htm.

•Ryan White. The Federal Ryan WhiteCARE Act, enacted in 1990, provideshealth care for people with HIV disease.Under Title I of the Ryan White CARE Act,which provides emergency assistance toEligible Metropolitan Areas that are mostseverely affected by the HIV/AIDS epidem-ic, funds are available for substance abusetreatment. Over 500,000 people are servedthrough this program each year. For moreinformation see www.hab.hrsa.gov.

Criminal justice/juvenile justice (CJ/JJ) systemsBoth State and local CJ/JJ systems purchasesubstance abuse treatment services. The man-ner in which these systems work varies acrosslocales. The following are common componentsof these systems:•State corrections systems may provide

funds for treatment of offenders who arereturning to the community, through paroleoffices, halfway houses, or residential cor-rectional facilities.

•Community corrections systems mayinclude a system of presentence diversion orparole services, including drug court, thatmay mandate substance abuse treatment inlieu of incarceration.

•Community drug courts may send low-risk,nonviolent offenders to substance abusetreatment in lieu of incarceration—pro-

grams can be under contract to provide thistreatment.

•Correctional residential facilities serveoffenders returning from a State correction-al system; the programs may extend con-tracts for substance abuse treatment to pre-vent relapse of treated offenders.

•Juvenile court systems may provide con-tracts to programs with expertise in treatingadolescents to treat juvenile offenders incorrectional facilities or who are otherwiseinvolved in the criminal justice system.

Providers should understand the culture, val-ues, and needs of the CJ/JJ system so theycan develop responsive services for this spe-cial needs population. For more information,see TIP 21, Combining Alcohol and OtherDrug Abuse Treatment With Diversion forJuveniles in the Justice System (CSAT1995b), TIP 30, Continuity of OffenderTreatment for Substance Use Disorders FromInstitution to Community (CSAT 1998b), andTIP 44, Substance Abuse Treatment forAdults in the Criminal Justice System (CSAT2005b).

Byrne Formula GrantProgramThe Byrne Formula Grant Program awardsgrants to States to improve the functioning ofthe criminal justice system. Grants may beused to provide rehabilitation of offenderswho violate State and local laws. One of the26 Byrne Formula Grant purpose areas isproviding programs that identify and meetthe treatment needs of adult and juvenileoffenders who are drug and alcohol depen-dent. However, the availability of ByrneFormula Grant funds depends on annualCongressional appropriations and declineshave been proposed for funding in recentyears. For more information seewww.ojp.usdoj.gov/BJA/grant/byrne.html.

154 Chapter 6

County and local governmentsCounty and local governments often contractfor the delivery of substance abuse treatmentservices using locally available funds. Theannual availability of these funds depends inpart on State fiscal conditions.

SchoolsLocal public schools may be a source of fund-ing for assessments; however, they rarely payfor ongoing treatment. Some services may bereimbursable under the special entitlements forchildren with disabilities.

Private PayorsPrivate sources of revenue include a range ofentities from large MCOs to local or self-insured national employers. Most healthplans offered by large employers operateunder managed care arrangements.Sometimes, a health plan may cover somesubstance abuse treatments under the mentalhealth benefit portion of their plan; othersmay provide coverage through the medicalcomponent. In many cases, substance abusetreatment benefits, when offered, are provid-ed through Managed Behavioral HealthcareOrganizations (MBHOs) (see “Working InToday’s Managed Care Environment,” p.157, for a more detailed discussion of man-aged care arrangements). Because substanceabuse coverage is a minor cost to employers,accounting for about 0.4 percent of the costof health insurance overall (Schoenbaum etal. 1998), it may be difficult to get employers’attention, despite the high profile that sub-stance abuse problems sometimes present. Ingeneral, three broad categories of privatefunding may be distinguished:•Contracts with health plans, MCOs, and

MBHOs.

•Direct service contracts with local employers.Local employers may contract directly withsubstance abuse services providers if the ben-

efits offered by their health plans are inade-quate.

•Contracts with EAPs. Some employers haveEAPs that can provide direct service con-tracts for a particular detoxification pro-gram.

ContributionsBy developing relationships with people in thecommunity, an administrator can find newsources for support of capital and operations.Even if a source is reluctant to provide funds tosupport treatmentservices directly,other aspects of pro-gram development,organizationalgrowth, and opera-tions or equipmentmay be eligible forsupport. A variety ofsupport may beavailable fromsources in the com-munity, ranging fromfinancial support todonations of time,expertise, used orlow-cost furnitureand equipment, andspace for a variety ofactivities. Somepotential sourcesinclude•Fundraisers. People who do fundraising

can help the program develop a campaign.Many States and the District of Columbiarequire that charitable organizations regis-ter and report to a governmental authoritybefore they solicit contributions in theirjurisdiction (a list of State regulatingauthorities is available atwww.labyrinthinc.com/index.asp).

•Foundations and local charities. A pro-gram may qualify as a recipient of funds forcapital, operations, or other types of sup-port such as board development from foun-

155Financing and Organizational Issues

Many public and

private benefit

plans still classify

detoxification as a

medical rather

than a substance

abuse treatment

service.

dations, the Community Chest, United Way(national.unitedway.org), or other charities. For more information seewww.fdncenter.org.

•Alumni. Graduates from a program maydonate money to the program or providesupport for clients.

•Internships. Local colleges and universitiesmay need internship slots for their studentswho are planning careers in human ser-vices.

•Volunteers. Some programs use volunteersin various capacities. Sources include localretirement organizations and faith-basedagencies.

•Community groups. Faith-based agenciesand community centers may let the programuse rooms for meetings, alumni groups,recovery support groups, or classes.Community groups can contribute readingmaterials, clothes, toys for clients’ children,furniture, or computers.

•Local stores and vendors. Local businessesmay contribute useful supplies such assnacks, office supplies, or even computers.

Research fundingIn addition to SAMHSA’s other roles, such astechnical assistance, helping communities useresearch findings to implement effective treat-ment programs, and funding of prevention andtreatment, the institutes of the NationalInstitutes of Health conduct research on bestpractices in substance abuse treatment. The Research Assistant (www.theresearchassistant.com) may be a help-ful source for information. For current fundingopportunities, visit the National Institute onDrug Abuse Web site (www.nida.nih.gov) andthe National Institute on Alcohol Abuse andAlcoholism Web site (www.niaaa.nih.gov).

GrantsGovernment agencies and private foundationsoffer funding through competitive grants.Grant money usually is designated for discrete

projects, such as creating a videotape on familyissues, providing childcare services in a pro-gram for women, enhancing the cultural com-petence of staff members, or treating under-served populations.

Writing grant applications requires specialskills. A program can hire a consultant towrite the application or use its own planningor research staff, if available. Successfulgrant applications address areas of genuineneed, propose ideas worthy of support,express these ideas well, and explicitly followthe requirements of the request for applica-tion or proposal. To design a fundable pro-ject, the program may need to establish linkswith other resources. Each donor agency orfoundation has its own application formatand requirements that should be followedexactly. It is especially important when usinga consultant to have program staff closelyinvolved in the process of developing a grantapplication to ensure that affirmations in theapplication are completely aligned with agen-cy capabilities. Programs that fail to involvetheir own staff in the grant application pro-cess risk falling into the “implementationtrap” when a grant is awarded for projectsthey are not prepared to perform. SAMHSAoffers a variety of resources to assist commu-nity-based organizations and others in devel-oping successful grant applications. See thetext box on page 157 for sources of informa-tion on grants for treatment and detoxifica-tion programs.

Self-pay patientsSome patients pay for some or all of a courseof treatment themselves, without seekingreimbursement from a third-party payor.These patients may have no or inadequatethird-party coverage for substance abusetreatment and are not eligible for public pay-ment sources. Some patients who have cover-age may prefer to pay out of their own pock-ets due to concerns about the confidentialityof their information with their employer orothers.

156 Chapter 6

Working in Today’sManaged CareEnvironmentAll healthcare providers, including those whoprovide substance abuse treatment services,increasingly operate in a world in which careis managed in all sectors, both public and pri-vate. Among individuals covered by employ-er-sponsored benefits in 2003, 95 percentwere covered under managed care arrange-ments (Kaiser Family Foundation and HealthResearch and Educational Trust 2003). Thepenetration of managed care into employer-sponsored health plans is relatively new; asrecently as 1993, 46 percent were covered byindemnity plans. It is estimated that morethan 160 million Americans have their behav-ioral health care (treatment for substance useand mental disorders) covered by a managedbehavioral health care organization (Oss andClary 1999). Although managed care penetra-tion is lower in public programs than inemployer-sponsored programs, it is still sig-nificant; in 2002, 58 percent of the Medicaidpopulation was enrolled in managed carearrangements (CMS 2002). Many States alsooperate MCOs not connected with Medicaid

for provision of substance abuse treatmentservices.

Behavioral health care carve-outs, so namedbecause management of substance abusetreatment and mental health benefits are sep-arated (carved out) from the provision andmanagement of other healthcare services, arenow the dominant approach to managed carefor mental health treatment. However, this isnot the case for substance abuse; manybehavioral health carve-outs retain substanceabuse coverage in the medical MCO. The“carve-in” approach, which theoreticallyintegrates traditional medical services withservices for substance use and other mentaldisorders, is re-emerging but as of 2004 wasstill relatively rare. Even when health planscarve-in substance abuse services, they oftenuse a subcontracted specialty vendor or aseparate internal division with specialtyexpertise to manage the carve-in benefits.

MCOs are becoming more prevalent in thepublic sector. In 2002, 51 percent of all sub-stance abuse treatment facilities had con-tracts with MCOs and even 39 percent offacilities owned by State and local govern-ments had such contracts (Office of AppliedStudies 2002b). By 1998, all but four Stateshad implemented some form of managed

157Financing and Organizational Issues

Where To Get Information on Grants

•SAMHSA provides information about the grants it provides at www.samhsa.gov/grants/index.html.Information on grants throughout the Federal government is available from www.grants.gov.

•The Web site www.cybergrants.com provides information about corporate foundations.

•The National Center on Addiction and Substance Abuse at Columbia University’s Web site atwww.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 or on the Web atwww.cdpublications.com/pubs/.

•Several useful publications on grant seeking and grant writing can be ordered from www.grantsand-funding.com.

•The Grantsmanship Center at www.tgci.com offers some useful information.

•The Non-Profit Resource Center, www.not-for-profit.org, has information on a variety of fundingsources.

behavioral health care in their public sectortreatment programs. However there is widevariation among States and large counties inthe extent and form of reliance on managedcare and in the vendors who operate suchprograms on behalf of government or privateentities.

A distinct terminology has evolved in themanaged care industry—terms such as capi-tation, network, or staff-model as well as ahost of acronyms.

ContractsAre PrimaryToolsManaged carearrangements havefour fundamentalaspects with whichall program admin-istrators should befamiliar. First, anarrangement beginswith a managedcare contract thatspecifies the obliga-tions of each party.It should be notedthat small communi-ty providers mayhave little or nonegotiating leveragein the contractingprocess; their onlydecision may bewhether or not toaccept what isoffered, includingthe rate of paymentand all other con-tract provisions.

Nevertheless, a clear and detailed under-standing of the contract is required to ensuresuccessful performance. One key aspect ofany managed care contract is the financialarrangement between the parties, includingthe basis for payment and the amount of risk

assumed by each party, if any. Of course,some managed care contracts are not risk-based. It is important to have someone withexpertise and experience in managed carecontracts and financing examine any pro-posed contract and make certain that thefinancial components of the arrangement arewell understood by the program staff whohave financial responsibilities.

Secondly, by negotiating and signing a man-aged care contract, a detoxification programor its parent agency becomes a member ofthat MCO’s managed care network. MCOsgenerally have a network of contracted andcredentialed providers who supply services ata negotiated rate to members who areenrolled in the plans. Each organizationalmember of the network must satisfy theMCO’s minimum requirements for licensureof staff, programs, and facilities to be eligiblefor a managed care contract.

The third fundamental aspect of managedcare arrangements is the requirement for per-formance measurement and reporting. AllMCOs apply a wide range of standard perfor-mance measures to each of their contractedproviders and may have financial or referralincentives or disincentives associated withmeasured performance.

Finally, the fourth aspect involves utilizationmanagement and case management. Thesetasks generally are performed by MCO staff,typically nurses or social workers, withsupervision from Ph.D. clinicians or physi-cians. The staff makes a determination ofwhat services are “medically necessary” andtherefore eligible for health plan reimburse-ments. Utilization management compares aprovider’s proposed treatment plan with simi-lar or expected plans for individuals with sim-ilar conditions and diagnoses. The utilizationmanagement approach may vary not just byMCO but by MCO customer, with some cus-tomers preferring that utilization be highlyscrutinized and meet the test of medicalnecessity and others preferring that the MCOuse a light touch in managing utilization. If atreatment plan from a detoxification program

158 Chapter 6

It is estimated that

more than 160

million Americans

have their

behavioral health

care (treatment

for substance use

and mental

disorders) covered

by a managed

behavioral health

care organization.

does not meet criteria for medical necessity, itis likely to be denied and referred to a higherlevel clinician for review, delaying approvaland payment. It makes sense to obtain eachMCO’s protocols, as well as any specificarrangements and benefit plans for customerswhose employees or enrollees are in thedetoxification program’s client population.

Case management programs operated in theprivate sector often are utilization reviewprograms rather than the clinical case man-agement programs typical in the public sec-tor. Moreover, the process of case manage-ment in the private sector often differs fromthe one found in traditional public sectormental health or substance abuse treatmentagencies. Instead, it primarily involves tele-phone contact, usually with a nurse, in high-risk or high-cost cases. Case managementusually is not performed onsite or in personin MCOs unless under contract to a publicagency that requires this. If a detoxificationprogram client has a public sector and a man-aged care case manager, the detoxificationprogram will have to interact with both toobtain initial and continuing approvals oftreatment in what is called a case or utiliza-tion management program.

In general, programs will be required toobtain utilization management approvaland/or case management approval for anyproposed treatment plan before they can billthe MCO. Programs will have to bear the costof pursuing denials and requesting exceptionsas well. The more the program’s staff candevelop a relationship with the MCO’s utiliza-tion management and case management staff,the more they will learn about the internalcriteria and protocols that drive approval ordenial decisions and the more latitude theywill have to request special arrangements fora particular client. Most MCOs and MBHOshave Web sites with provider portals. Once aprogram identifies the name of the managedcare plan from which payment is to berequested staff should be sure to check itsWeb site. Some managed care plans offer

electronic data interchange with networkproviders to facilitate claims submission.

Elements of Financial Risk inManaged Care Contracts

Cost of servicesTo assess and negotiate a managed care con-tract and to monitor a program’s perfor-mance under that contract, it is imperative toknow what it costs the detoxification programto provide each unit of service that is pro-duced. The cost of services includes staff timespent with clients, administrative time spenton meetings and paperwork, and capital andoperating expenses. Only when the actual costof delivering a unit of a particular service isknown can an agency negotiate a reasonablerate for specific services when negotiatingcontracts and a fiscally prudent arrangement.Determining the cost of services often entailsmany challenges but is absolutely essential inthe current environment of accountability.See the text box on page 160 for a list ofresources from the literature. Following arethe recognized but evolving cost methodolo-gies developed specifically for substanceabuse services:•The first systematic cost data collection

method, the Drug Abuse Treatment CostAnalysis Program (DATCAP) (French 2003a,b), was developed in the early 1990s byeconomists at Research Triangle Institute(French et al. 1997). The Treatment ServicesReview used with DATCAP provides unit ser-vice costs (French et al. 2000).

•The Uniform System of Accounting andCost Reporting for Substance AbuseTreatment Providers is a cost estimationmethod developed about the same time byCSAT (1998d).

•Another estimation approach has beendeveloped by Yates (1996, 1999): theCost–Procedure–Process–OutcomeAnalysis.

•Anderson and colleagues (1998) have devel-oped a cost of service methodology.

159Financing and Organizational Issues

160 Chapter 6

Resources on Service CostsAnderson, D.W., Bowland, B.J., Cartwright, W.S., and Bassin, G. Service-level 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: AnOverview. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998.

Center for Substance Abuse Treatment. Uniform System of Accounting and Cost Reporting forSubstance Abuse Treatment Providers. Rockville, MD: Substance Abuse and Mental Health ServicesAdministration, 1998. http://www.icpsr.umich.edu/SAMHDA/SATCAAT/system-accounting.pdf.

Center for Substance Abuse Treatment. Summary Report on Assessment and Measurement ofTreatment Costs. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000.http://www.icpsr.umich.edu/SAMHDA/SATCAAT/summaryreport.pdf.

Dunlap, L.J., and French, M.T. A comparison of two methods for estimating the costs of drug abusetreatment. Journal of Maintenance in the Addictions 1(3):29–44, 1998.

Flynn, P.M., Porto, J.V., Rounds-Bryant, J., and Kristiansen, P.L. Costs and benefits of methadonetreatment in DATOS—Part 1: Discharged versus continuing patients. Journal of Maintenance in theAddictions 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. http://www.datcap.com/program.htm.

French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): User’s Manual. 8th ed. Miami,FL: University of Miami, 2003. http://www.datcap.com/usersmanual.htm.

French, M.T., Dunlap, L.J., Zarkin, G.A., and Karuntzos, G.T. The costs of an enhanced employeeassistance 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 CostAnalysis 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 Reviewbe used to estimate the costs of addiction and ancillary services? Journal of Substance Abuse12(4):341–361, 2000.

French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefit-cost analysis of amodified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning25(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 & Medicine55(12):2267–2282, 2002.

Yates, B.T. Analyzing Costs, Procedures, Processes, and Outcomes in Human Services. Applied socialresearch methods series v. 42. Thousand Oaks, CA: Sage, 1996.

Yates, B.T. Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance AbuseTreatment Programs: A Manual. NIH Publication No. 99-4518. Rockville, MD: National Institute onDrug Abuse, 1999. http://www.nida.nih.gov/PDF/Costs.pdf.

Zarkin, G.A., and Dunlap, L.J. Implications of managed care for methadone treatment. Findings fromfive case studies in New York State. Journal of Substance Abuse Treatment 17(1-2):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 Planning27(1):35–43, 2004.

•The Substance Abuse Services Cost AnalysisProgram (Zarkin et al. 2004) is an emergingtreatment services cost estimation method.

•Variants of these methods have been appliedto several treatment studies (Flynn et al.2003; Koenig et al. 1999; Mojtabai andZivin 2003).

Three major categories of financial arrange-ments may be distinguished in managed carecontracts: (1) fee-for-service agreements, (2)capitation agreements, and (3) case rateagreements. Program administrators need tounderstand the differences among these typesof arrangements so they can manage financialrisk. Sometimes, administrators may thinkthat the contract itself is the goal. However,the existence of a contract is no guarantee ofa referral; it only enables referrals that aremedically necessary. The closer the relation-ship the program staff can develop with agiven MCO, the easier it will be for them tounderstand their clinical criteria, to obtainmore than intermittent referrals, and to nego-tiate a financial arrangement for the programthat is reasonable and fair.

Managed care contracts vary according to twoprincipal dimensions: (1) the method of pay-ment and the corresponding type of riskassumed by the provider, and (2) the amountof payment. Each of the three major types offinancial arrangements or methods of pay-ment (described in Figure 6-1, p. 162) is asso-ciated with major financial risks thatproviders should be aware of in negotiatingeach type. Risk, of course, is a continuousvariable, so that no arrangement is devoid ofany risk whatsoever. The key is to ensure thata program has the tools and capabilities tomanage the risks it assumes. Many managedcare systems rely on fee-for-service arrange-ments with providers, so that most providersare paid on a discounted fee-for-service basis,based on a schedule of fees described in thecontract. Capitation agreements usually arereserved for very large networks ofproviders, who in turn pay individualproviders on a fee-for-service basis.

For more information on managed care pur-chasing and negotiation from the perspectiveof a purchaser, see TAP 22, Contracting forManaged Substance Abuse and Mental HealthServices: A Guide for Public Purchasers(CSAT 1998c).

Networks, Accreditation, andCredentialingTo join an MCO’s network of providers andnegotiate a contract specific MCO minimumstandards for staff credentials and programaccreditation must be met. These minimumstandards generally are not negotiablebecause they have their basis in that MCO’saccreditation requirements. The providercredentialing requirements vary by MCO andby customer within the MCO and ofteninclude primary verification of specific aca-demic degrees or specific levels of licensurefor staff, as well as verified minimum levels ofmalpractice insurance. Some MCOs may usewhat are called independent CredentialingVerification Organizations (CVOs) for thisprocess. These CVOs verify the credentials ofproviders on behalf of MCOs to ensure, forexample, that their licenses are valid and upto date.

MCOs sometimes are not familiar with sub-stance abuse treatment and, moreover, typi-cally include only those types of providersthat are licensed by a given State to engage inprivate practice in their provider networks.Usually such providers are licensed in psy-chology, nursing, medicine, or social work.MCOs explain that this has to do with mal-practice insurance issues. This credentialingpractice has a disproportionate impact onthose substance abuse treatment providersthat do not have as many staff with these cre-dentials as do mental health providers, bypresenting an obstacle to contracting withthese MCOs. However, it is not an insur-mountable obstacle. Substance abuse treat-ment providers often must help MCOs under-stand the substance abuse treatment environ-ment, the types of providers that deliver ser-

161Financing and Organizational Issues

vices, and the qualifications and standardsthey must meet so that the MCO can modifyits policies appropriately. MCOs often aremore willing to contract with organizationsthat have a facility license from their Statethan with individual substance abuse treat-ment providers who may not possess creden-tials that meet the MCO’s licensure criteria.

Many managed care plans have separateprovider networks for behavioral health ser-vices. It is important for detoxificationproviders to participate in both medical andbehavioral health networks, given that detoxi-

fication benefits may be considered eithermedical or behavioral benefits.

In addition to the credentials of the staff andpractitioners, the program itself may have tobe accredited by one of the major nationalhealthcare accrediting organizations. Theseinclude the Commission on Accreditation ofRehabilitation Facilities (CARF;www.carf.org), the National Committee forQuality Assurance (NCQA;www.ncqa.org/index.htm) and the JointCommission on Accreditation of HealthcareOrganizations (JCAHO; www.jcaho.org/). Ingeneral, accreditation from CARF is consid-

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Figure 6-1Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Fee-for-Service Agreement. Fee-for-service pro-grams are the least risky to providers. They gen-erally require precertification and utilizationmanagement for some or all procedures and ser-vices. The client’s benefit plan document or thepublic payor’s contract dictate the services thatmay be approved. In a fee-for-service contract, arate is received for the services provided; typical-ly, a standard program session with specific ser-vices bundled in. This is referred to as an “all-inclusive rate.”

Some common bundled services are urine drugscreens and group, family, and individual counsel-ing. Thus the payment rate for one visit mayinclude a 50-minute group counseling session anda urine drug screen. The rate for a day of treat-ment could include, for example, one-fifth of a 25-minute psychologist visit, one-half of a urine drugscreen, one-half of a vocational training session,and two sessions of group counseling. Theassumption is that these services will occur at aspecified frequency during the course of theclient’s treatment. Psychiatric services can beincorporated into the bundled services, but usual-ly they are negotiated separately and treated as anadditional service.

When negotiating a fee-for-service contract, anadministrator needs to ensure that the rate is suf-ficient to cover the actual costs to a program ofproviding the specified services. During negotia-tions, the MCO has the option of saying that it willnot pay for some of the bundled services. All ser-vices should be costed out prior to negotiation, soactual costs of treatment components are knownand can be compared to the reimbursementoffered. Programs must understand that even if afee-for-service contract is successfully negotiated,referrals may or may not follow.

163Financing and Organizational Issues

Figure 6-1 (continued)Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Capitation Agreement. A managed care companymay establish a stipulated dollar amount to covertreatment costs for a group of people using oneper-person rate for everyone, which is the MCO’scapitation rate. The MCO may then subcapitate astipulated dollar amount to a treatment provideror organization, and the MCO and the treatmentprovider negotiate an agreement in which theprovider is paid a fixed amount per subscriberper month, rather than billing on a fee-for-servicebasis. The provider agrees to provide all or someof the treatment services for an expected numberof managed care “covered lives” (e.g., for 100,000subscribers). Usually only large service providershave the assets and volume of services to engage incapitated agreements.

The two critical elements are the per member/permonth (pm/pm) rate and the utilization rate. Ifmany more people than are predicted requiretreatment, the provider may not be able to coverservice delivery costs, much less make a profit/sur-plus. The key is to have reliable information onthe historical use rates of a given managed careplan’s enrollees. If the provider bears in mindthese caveats, this regular, guaranteed paymentcan be an excellent arrangement but carries with itthe risks of both “overutilization” (when com-pared to the assumption used in developing therate) and the need for a greater intensity of treat-ment than the capitation rate can cover. In somecases a program may want to accept a somewhatspeculative capitation rate in order to join a paneland then renegotiate that rate after the programhas collected data that show that it needs a higherrate to cover its costs. In any case, it is crucial totrack actual dollars against the budget in real timeto avoid unexpected deficits.

Case Rate Agreement. The case rate is a fixedrate per client paid for delivery of specific ser-vices to specified types of consumers. For this fee,a provider such as a clinic covers all the servicesthat a client requires for a specific period. Inessence, the MCO is saying, “You provide theclient what he needs from this set of services and Iwill pay you this set amount.” What usually dis-tinguishes case rate from capitation is that essen-tially all of the case rate clients are anticipated tobe receiving some service; that is, at least casemanagement. Usually those receiving servicesunder capitation are a small minority of thosecovered. The case rate may be “risk-adjusted” tocompensate for the higher costs of serving clientswho predictably need more services than average.

A case rate agreement removes some of the utiliza-tion risk from the service provider. However, therisk remains that clients will need services morefrequently or at higher levels than the case ratecovers. It is essential that programs track costs byspecific client in order to assess the adequacy of aproposed case rate. However, it is a mistake toconsider a case rate as a cap for any specificpatient; the goal is to ensure that the average costper case is lower than the negotiated case rate, notthat the cost for each case is less than the negotiat-ed rate. Once again, it is crucial to track actualaverage dollars per case against the contractedcase rate in real time to avoid unexpected deficits.

ered most important by substance abusetreatment providers for their programs.However, providers that wish to offer inpa-tient detoxification services generally mustobtain accreditation from JCAHO to meet therequirements of most MCOs.

Organizational PerformanceMeasurementPerformance measurement is becoming anincreasingly important component of man-aged and fee-for-service care in both the pub-lic and private sectors. SAMHSA’s SAPTBlock Grants now require the collection ofmeasures of program performance and out-comes. MCOs have their own performancemeasures established by the agencies thataccredit them, such as the NCQA. Their cus-tomers, employers, or public purchasers mayuse adequacy of performance on these mea-sures in their decisions to acquire or retaintheir plans for their employees. NCQA hasestablished a set of measures specificallyrelating to substance abuse and mental healthtreatment services for all the MCOs that itaccredits, including new measures of the iden-tification of enrollees with substance abusediagnoses, the rate of initiation of treatment,and a measure of treatment engagement.Programs will be asked to participate in mea-suring these indicators and report that infor-mation to the MCO, and doing so will likelybe a condition of the contract. The MCO mayreward good performance with an additionalfee.

Similarly, MCOs evaluate the performance ofthe members of their provider network. EachMCO has its own measures and proceduresfor implementation, some of which are pre-scribed by the organizations that accreditthem. Not all MCOs are diligent about thisprovider evaluation process. Only a fewMCOs have implemented sophisticated mea-surement systems, and some of the methodsused today may be crude but they still arerequired. Nevertheless, regardless of howsimple or complex they may be, the results of

external performance measures implementedby MCOs can be extremely important to aprogram’s financial and organizational suc-cess, affecting a program’s ability to remain aviable, respected network provider. Someperformance management systems implement-ed by MCOs also use financial incentivesand/or disincentives keyed to performance.

Regardless of the specific measures imple-mented by particular MCOs, well-managedorganizations will also develop and use theirown internal performance measures and con-stantly strive to improve their own perfor-mance. Among these should be measures ofboth process and outcomes, such as •The percentage of clients who complete a

defined treatment regimen that meets theirindividual needs

•The percentage of clients who drop out oftreatment in the first 7 days following treat-ment initiation

•The percentage of clients who remain in doc-umented but less intensive treatment 30 daysafter discharge from the program

•The percentage of clients who are employedor attending school 6 months after dischargefrom the program

When using performance measures, it is impor-tant for programs to account for differencesamong clients that may affect measured results,such as a client’s previous history of abuse ormedical conditions. Nevertheless, it is equallyimportant to recognize that employing mea-surement is an integral component of externaland internal accountability as well as continu-ous clinical improvement.

One of the primary independent entitiesinvolved in the construction of national per-formance measures for substance abuse treat-ment is the Washington Circle Group (WCG)(see www.washingtoncircle.org). NCQA’s newsubstance abuse performance measures onidentification and initiation of treatment andtreatment engagement were developed by theWCG over a 4-year period. They have identi-

164 Chapter 6

fied four major “domains” for substanceabuse treatment measures:1. Prevention/Education

2. Recognition or Identification of SubstanceAbuse

3. Treatment

•Initiation of alcohol and other plan ser-vices

•Linkage of detoxification and alcohol andother drug plan services

•Treatment engagement

•Use of interventions for family membersand significant others

4. Maintenance of Treatment Effects

These and other substance abuse performancemeasures are now used in NCQA’s MCOaccreditation process. The WCG and othershave defined a variety of such measures andadministrators should think of these measuresas ways to improve their own performance, asan essential element in the reporting system,and as a means for documenting success totheir customers and other stakeholders.

Performance measurement is becomingincreasingly important outside of managed carecontracts as well as inside them. For example,as mentioned in the previous section on fund-ing, SAMHSA began integrating performancemeasurement into the SAPT Block Grant as offiscal year 2004. Each State will expect pro-grams to understand and be able to measurethe required indicators accurately and in atimely way.

One of the most important performance mea-sures in the future for detoxification programsis likely to be linkages to substance abuse treat-ment following detoxification (Mark et al.2002). Research has shown that patients whoreceive continuing care following detoxificationhave better outcomes in terms of drug absti-nence and readmission rates than those who donot receive continuing care. This focus on link-ages is a likely result of research indicating thatmany people who undergo detoxification do notreceive subsequent substance abuse services

from the formal treatment system and that thelack of substance abuse treatment followingdetoxification has been getting worse instead ofbetter (Mark et al. 2002). It is incumbent onproviders of detoxification services to ensurethat clients are linked to substance abuse treat-ment following detoxification.

Recordkeeping and manage-ment information systemsLike indemnity insurers, MCOs also requiredetailed records of services provided toclients in order forthem to pay for ser-vices received. Theprogram’s account-ing system needs totrack counselors’time spent on thephone, on paper-work, and directlywith clients. Clinicalrecords shouldreflect accuratelythe claims recordssubmitted to theMCO. Periodically,payors and MCOsmay audit the clini-cal records toensure that the ser-vices billed for actu-ally have been pro-vided. Failure toadequately docu-ment clinical ser-vices can result innonpayment andput a contract in jeopardy. On the otherhand, individuals’ private information andidentity must be handled in a confidentialmanner pursuant to the Health InsurancePortability and Accountability Act (HIPAA)and Federal confidentiality requirements forpersons with substance abuse (for more infor-mation on HIPAA seewww.hipaa.samhsa.gov).

165Financing and Organizational Issues

Performance

measurement is

becoming an

increasingly

important compo-

nent of managed

and fee-for-service

care in both the

public and private

sectors.

Managing multiple contracts requires sophis-ticated management, a fiscal managementinformation system (MIS), and constantscrutiny. The need for information is evenmore crucial for capitation-based arrange-ments that place risk on the service providerthan it is for fee-for-service arrangements. Inessence, the MIS needs to be capable of two-way information transfer between the MCOand the program. Data such as membership,benefits, copays, deductible amounts, andother financial information must be passed

between the pro-gram and theinsured entity orpayor. The MISalso should be ableto analyze key per-formance data forinternal and exter-nal reports. TheMIS must pass use-ful data to staffmembers responsi-ble for managingbenefits and pro-viding services.

Program data willneed to meet Statedata requirementsas well as require-ments by eachpayor, whilerespecting confiden-tiality.

Managing payment frommultiple funding streamsEspecially in the public arena, multiple con-tracts with and grants from several fundingstreams and payors may be used to supportservices for a single client. These contractswill specify order of payment. The providerneeds to manage the funds carefully andappropriately to be in compliance with con-tracts and grants. For example, a contractwith a drug court may specify that Medicaid

should be billed as payor number one and thedrug court as payor number two. Any unpaidportion might then be billed to the blockgrant agency as payor of last resort, if it is aneligible service under the block grant. Someproviders have successfully used the strategyof first using the reimbursement of those pay-ors with the most restrictive array of services;later, the more flexible funds can be used tocover the remaining services. A clearly docu-mented strategy for managing payment that iscommunicated effectively to the accountspayable staff is critical and will help pro-grams be successful in this important area.

Utilization and CaseManagementAll MCOs use methods to manage the serviceutilization of their members and ensure thatthey are receiving the most appropriate arrayof services in the most appropriate environ-ment or level of care for the appropriatelength of time. Although technically, utiliza-tion management focuses on a single type ofservice and case management focuses on thecoordination of the appropriate array of ser-vices needed by a specific individual, in prac-tice the same individual professionals may beresponsible for both types of management.Utilization and case management staff at anMCO authorize specific services for purposesof payment. A wide variety of specific criteriaand protocols may be used to determinewhether services may be authorized for sub-stance abuse, typically including theAmerican Society of Addiction Medicine(ASAM) patient placement criteria (ASAM2001) (see www.asam.org/ppc/ppc2.htm) andother level of care or diagnosis-based criteriasets.

Successfully addressing the needs of the uti-lization and case management staff at MCOsresponsible for authorizing care is a criticalelement in the relationship with an MCO andin maintaining the program’s clinical andfinancial viability. To do so, program staffmust understand what their counterparts do

166 Chapter 6

Successfully

addressing the

needs of the

utilization and

case management

staff at MCOs is a

critical element in

the relationship

with an MCO.

and be well trained in conducting professionalrelationships over the telephone, be familiarwith the criteria and protocols employed bythe MCOs with which the program has con-tracts, and have easy access to the multitudeof clinical and service information requiredby an MCO to help them complete a reviewand authorize services. Excellent records areessential. Program staff also should be famil-iar with each MCO’s appeal or exceptionsprocess for those occasions when the outcomeof a first-level review is unsatisfactory.

Utilization management cannot proceed if theprogram is not recognized as an eligible net-work provider; the program will have toensure that it is an accepted networkprovider before it can participate in the uti-lization management or case managementprocess.

Strengthening the FinancialBase and Market Position of aProgramThe following strategies may strengthen themarket position of a detoxification program tofacilitate both larger numbers of patients andgreater revenues per patient:

•Achieve recognition for the quality andeffectiveness of services. If a program hasa reputation for providing effective care,then managed care enrollees and otherpotential clients will want to use it. A pro-gram can be of value to a client, a purchas-er, and/or an MCO if it can reduce repeateddetoxification, repeated treatment, and re-admissions, and thus manage unnecessarycosts and interventions. Effective substanceabuse treatment provided promptly mayreduce medical care and hospitalizationcosts in the long run. A program that effec-tively manages the care of high-utilizationsubstance abuse clients by also providingpsychiatric treatment, case management,and housing support is a good candidate for“preferred” or “core” status with one orseveral MCOs or MBHOs. Of course, the

additional costs of these services need to bea component of a program’s rate and con-tract. Having highly reputable, recognized,and efficient providers is a major marketingand regulatory advantage for the healthplan, as well as for the program. All theseprogram characteristics can be marketingadvantages. Programs also may apply toSAMHSA’s National Registry of Evidence-based Programs and Practices, which rec-ognizes model, effective, and promising pro-grams. Check SAMHSA’s Web site(www.modelprograms.samhsa.gov) to findout how to apply for this status, which is amajor achievement and marketing asset.

•Serve specific populations. Providing low-cost, high-quality treatment to a populationno other program serves (e.g., adolescents,clients with HIV/AIDS, clients with co-occurring mental disorders, pregnantwomen, women with young children, clientswho are deaf) also is a possible marketingadvantage. Treating these clients can resultin client referrals from a larger geographicarea and multiple sources. Such clients maybring with them higher reimbursement ratestoo, but this also may simply reflect highercosts to provide care to the population.Using special capabilities to attract clients isa good idea, but not at the cost of inade-quate payment for services.

•Develop economies of scale. Adding clinicsites or increasing the number of branchclinics may permit spreading some fixedcosts (e.g., management, information,financial systems, executive staff) among alarger number of patients, thus drivingdown a program’s per capita costs.However, larger size requires greateradministrative coordination, which itselfcan be costly.

•Gain community visibility and support.Having governmental, community agencyexecutives, or political figures (e.g., themayor, council members) as board membersraises the program’s profile in the commu-nity. Of course, programs should be sure toinclude board members who have specific

167Financing and Organizational Issues

skills and connections that will advance thepurposes of the detoxification program.

•Form alliances with other treatmentproviders. Setting up coalitions to competewith or work with MCOs and other pur-chasers such as Medicaid may be useful.However, consultation with an attorney isstrongly advised prior to developing such acoalition or other collaboration with localtreatment providers as the laws regardingantitrust and other matters related to suchrelationships are complex. For programsserving publicly funded clients, technicalassistance may be available through CSAT;the SSA can provide details.

Preparing for theFuture Major forces that shape and limit providerfinancing are unlikely to change substantiallyin the near future. Careful strategic planning

and assurance of funding from reputable andvaried referral sources are essential for newand existing programs. As a buffer againstshrinking budgets, all programs should con-sider broadening their funding streams andreferral sources, expanding the range ofclients they can serve, and promptly referringclients for other services not provided on site.Partnerships can be a critical factor to thefinancial success of a program. To operateeffectively, administrators and other staffmust thoroughly understand the managedcare and community political environmentincluding its terminology, contracts, negotia-tions, payments, appeals, and priority popu-lations. A successful working relationshipwith an MCO, a health plan, other pur-chasers, or with another agency or group ofagencies depends on day-to-day interactionsin which staff members serve as informed,professional advocates for their clients andthe program.

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Center for Substance Abuse Treatment.Intensive Outpatient Treatment forAlcohol and Other Drug Abuse. TreatmentImprovement Protocol (TIP) Series 8.DHHS Publication No. (SMA) 99-3306.Rockville, MD: Substance Abuse andMental Health Services Administration,1994d.

Center for Substance Abuse Treatment.Screening and Assessment for Alcohol andOther Drug Abuse Among Adults in theCriminal Justice System. TreatmentImprovement Protocol (TIP) Series 7.DHHS Publication No. (SMA) 94-2076.Rockville, MD: Substance Abuse andMental Health Services Administration,1994e.

Center for Substance Abuse Treatment.Simple Screening Instruments forOutreach for Alcohol and Other DrugAbuse and Infectious Diseases. TreatmentImprovement Protocol (TIP) Series 11.DHHS Publication No. (SMA) 94-2094.Rockville, MD: Substance Abuse andMental Health Services Administration,1994f.

Center for Substance Abuse Treatment.Alcohol and Other Drug Screening ofHospitalized Trauma Patients. TreatmentImprovement Protocol (TIP) Series 16.DHHS Publication No. (SMA) 95-3041.Rockville, MD: Substance Abuse andMental Health Services Administration,1995a.

Center for Substance Abuse Treatment.Combining Alcohol and Other DrugTreatment with Diversion for Juveniles inthe Justice System. TreatmentImprovement Protocol (TIP) Series 21.DHHS Publication No. (SMA) 95-3051.Rockville, MD: Substance Abuse andMental Health Services Administration,1995b.

Center for Substance Abuse Treatment.Developing State Outcomes MonitoringSystems for Alcohol and Other DrugAbuse Treatment. TreatmentImprovement Protocol (TIP) Series 14.DHHS Publication No. (SMA) 95-3031.Rockville, MD: Substance Abuse andMental Health Services Administration,1995c.

Center for Substance Abuse Treatment.Detoxification From Alcohol and OtherDrugs. Treatment Improvement Protocol(TIP) Series 19. DHHS Publication No.(SMA) 95-3046. Rockville, MD: Center forSubstance Abuse Treatment, 1995d.

Center for Substance Abuse Treatment.LAAM in the Treatment of OpiateAddiction. Treatment ImprovementProtocol (TIP) Series 22. DHHSPublication No. (SMA) 95-3052. Rockville,MD: Substance Abuse and Mental HealthServices Administration, 1995e.

Center for Substance Abuse Treatment.Matching Treatment to Patient Needs inOpioid Substitution Therapy. TreatmentImprovement Protocol (TIP) Series 20.DHHS Publication No. (SMA) 95-3049.Rockville, MD: Substance Abuse andMental Health Services Administration,1995f.

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Center for Substance Abuse Treatment.Substance Use Disorder Treatment forPeople With Physical and CognitiveDisabilities. Treatment ImprovementProtocol (TIP) Series 29. DHHSPublication No. (SMA) 98-3249. Rockville,MD: Substance Abuse and Mental HealthServices Administration, 1998g.

Center for Substance Abuse Treatment. BriefInterventions and Brief Therapies forSubstance Abuse. Treatment ImprovementProtocol (TIP) Series 34. DHHSPublication No. (SMA) 99-3353. Rockville,MD: Substance Abuse and Mental HealthServices Administration, 1999a.

Center for Substance Abuse Treatment.Cultural Issues in Substance AbuseTreatment. DHHS Publication No. (SMA)99-3278. Rockville, MD: Substance Abuseand Mental Health ServicesAdministration, 1999b.

Center for Substance Abuse Treatment.Enhancing Motivation for Change inSubstance Abuse Treatment. TreatmentImprovement Protocol (TIP) Series 35.DHHS Publication No. (SMA) 99-3354.Rockville, MD: Substance Abuse andMental Health Services Administration,1999c.

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222 Appendix A

Appendix B: CommonDrug IntoxicationSigns and WithdrawalSymptoms

223

Cocaine Alcohol Heroin Cannabis (marijuana)

Intoxication

Action Stimulant Sedative Sedative, euphori-ant, analgesic

Euphoriant, athigh doses mayinduce hallucina-tions

Characteristics ofintoxication

↑ BP, HR, temp, ↑energy, ↑paranoia,↑fatigue,↓appetite, move bowels/urinate

• Sedation, ↓respiration,

• Depresses CNSsystem, canresult in coma,death

Drowsiness, “nod-ding,” euphoria(happy giddiness)

↓BP, ↑HR,↓intraocular pres-sure (pressure inthe eyes) conjunctival injec-tion (reddening ofthe eyes)

Withdrawal

Onset Depends upontype of cocaineused: for crackwill begin withinhours of last use

24–48 hours afterblood alcohol leveldrops

Within 24 hoursof last use

Some debateabout this, may bea few days

Duration 3–4 days 5–7 days 4–7 days May last up toseveral weeks

224 Appendix B

Cocaine Alcohol Heroin Cannabis (marijuana)

Characteristics Sleeplessness orexcessive restlesssleep, appetiteincrease, depres-sion, paranoia,decreased energy

↑BP, ↑HR, ↑temp,nausea/vomiting/ diarrhea, seizures, delirium,death

Nausea, vomiting,diarrhea, goosebumps, runnynose, teary eyes,yawning

Irritability,appetite distur-bance, sleep dis-turbance, nausea,concentrationproblems, nystag-mus, diarrhea

Medical/psychiatric issues

Stroke, cardiovas-cular collapse,myocardial andother organ infarc-tion, paranoia,violence, severedepression, suicide

Virtually everyorgan system isaffected (e.g., car-diomyopathy, liverdisease, esophagealand rectalvarices); fetal alco-hol syndrome andother problemswith fetus

During withdrawalindividual maybecome dehydrat-ed

Appendix C: Screeningand AssessmentInstruments

Please note that this list of screening and assessment instruments hasbeen divided into two sections. The first section comprises those instru-ments used for patients with suspected alcohol abuse or dependenceonly; the second lists instruments used to screen and assess for abuse ofor dependence on any substances. Thus those tools that screen for allsubstances of abuse are listed in section II.

Section I: Screening andAssessment for Alcohol AbuseThis section of the appendix lists common screening and assessmentinstruments specifically used in cases where abuse of or dependenceupon 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 orreferral to specialized treatment for patients who show evidence ofmore 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 inthe armed forces; workers receiving help from employee assistanceprograms and in industrial settings.

225

Norms: Yes, heavy drinkers and people withalcohol use disorders

Format: A 10-item screening questionnairewith 3 questions on the amount and frequen-cy of drinking, 3 questions on alcohol depen-dence, and 4 on problems caused by alcohol.

Administration time: Two minutes

Scoring time: One minute

Computer scoring? No

Administrator training and qualifications:The AUDIT is administered by a health pro-fessional or paraprofessional. Training isrequired for administration. A detailed user’smanual and a videotape training moduleexplain proper administration, procedures,scoring, interpretation, and clinical manage-ment.

Fee for use: No

Available from: Can be downloaded fromProject Cork Web site: http://www.project-cork.org/clinical_tools/index.html

Brief Michigan AlcoholismScreening Test (BMAST)Purpose: Used to screen for alcoholism with avariety of populations.

Clinical utility: The BMAST can save clini-cians time when integrated with instrumentsused to screen for other behavioral healthproblems (Pokorny et al. 1972).

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: Ten-item questionnaire; interview orpaper-and-pencil

Administration time: Five minutes

Scoring time: Two to 3 minutes

Computer scoring? No

Administrator training and qualifications: Notraining required.

Fee for use: No

Available from: Can be downloaded fromProject Cork Web site: http://www.project-cork.org/clinical_tools/index.html

CAGE QuestionnairePurpose: Used to detect alcoholism.

Clinical utility: The CAGE Questionnaire is avery useful bedside, clinical desk instrumentand has become the favorite of many familypractice and general internists and amongnurses.

Groups with whom this instrument has beenused: Adults and adolescents (over 16 yearsold)

Norms: Yes

Format: Very brief, relatively nonconfronta-tional questionnaire for detection of alco-holism, usually directed “have you ever” butmay be focused to delineate past or presentuse.

Administration time: Less than 1 minute

Scoring time: Instantaneous

Computer scoring? No

Administrator training and qualifications: Notraining required for administration; it iseasy to learn, easy to remember, and easy toreplicate.

Fee for use: No

Available from: Can be downloaded fromProject Cork Web site: http://www.project-cork.org/clinical_tools/index.html

226 Appendix C

Clinical Institute WithdrawalAssessment (CIWA-Ar)Purpose: Converts DSM-III-R items intoscores to track severity of withdrawal; mea-sures severity of alcohol withdrawal.

Clinical utility: Aid to adjustment of carerelated to withdrawal severity.

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: A 10-item scale for clinical quantifi-cation of the severity of the alcohol withdraw-al syndrome.

Administration time: Two minutes

Scoring time: Four to 5 minutes

Computer scoring? No

Administrator training and qualifications:Training is required; the CIWA-Ar can beadministered by nurses, doctors, researchassociates, and detoxification unit workers.

Fee for use: No

Available from: Center for Substance AbuseTreatment. A Guide to Substance AbuseServices for Primary Care Clinicians.Treatment Improvement Protocol (TIP)Series 24. DHHS Publication No. (SMA) 97-3139. Rockville, MD: Substance Abuse andMental Health Services Administration, 1997.

Michigan AlcoholismScreening Test (MAST)Purpose: Used to screen for alcoholism with avariety of populations.

Clinical utility: A 25-item questionnairedesigned to provide a rapid and effectivescreen for lifetime alcohol-related problemsand alcoholism.

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: Consists of 25 questions

Administration time: Ten minutes

Scoring time: Five minutes

Computer scoring? No

Administrator training and qualifications: Notraining required.

Fee for use: Fee for a copy, no fee for use

Available from: Can be downloaded fromProject Cork Web site: http://www.project-cork.org/clinical_tools/index.html

TWEAKPurpose: Screens for heavy drinking andalcohol dependence in the past year in maleand female samples of the general householdpopulation and hospital clinic outpatients(Chan et al. 1993).

Clinical utility: The TWEAK provides aquick and easy method of targeting outpa-tients and inpatients in need of more thor-ough assessments of their alcohol use patternsand problems to determine whether treatmentis needed. The TWEAK has also been used toscreen for periconceptional risk drinkingamong obstetric outpatients (Russell et al.1994), which may improve pregnancy out-come among high-risk drinkers.

Groups with whom this instrument has beenused: Adults

Norms: Yes

Format: Five items; pencil and paper self-administered, administered by interview, orcomputer self-administered.

Administration time: Less than 2 minutes

Scoring time: Approximately 1 minute

Computer scoring? No

227Screening and Assessment Instruments

Administrator training and qualifications: Notraining required.

Fee for use: No

Available from: Can be downloaded fromProject Cork Web site: http://www.project-cork.org/clinical_tools/index.html

Section II: Screeningand Assessment forAlcohol and OtherDrug AbuseThis section of the appendix lists commonscreening and assessment instruments used incases where abuse of or dependence upon sub-stances (including alcohol) is in question.

Addiction Severity Index (ASI)Purpose: The ASI is most useful as a generalintake screening tool. It effectively assesses aclient’s status in several areas, and the com-posite score measures how a client’s need fortreatment changes over time.

Clinical utility: The ASI has been used exten-sively for treatment planning and outcomeevaluation. Outcome evaluation packages forindividual programs or for treatment systemsare available.

Groups with whom this instrument has beenused: Designed for adults of both sexes whoare not intoxicated (on illicit drugs or alcohol)when interviewed. It is also available inSpanish.

Norms: The ASI has been used with malesand females with substance use disorders inboth inpatient and outpatient settings.

Format: Structured interview

Administration time: Fifty minutes to 1 hour

Scoring time: Five minutes for severity rating

Computer scoring? Yes

Administrator training and qualifications: Aself-training packet is available as well asonsite training by experienced trainers.

Fee for use: No cost; minimal charges forphotocopying and mailing may apply

Available from:A. Thomas McLellan, Ph.D.Building 7PVAMC University Avenue Philadelphia, PA 19104 Phone: (800) 238-2433

Cocaine Selective SeverityAssessment (CSSA)Purpose: Measures early cocaine abstinencesigns and symptoms.

Clinical utility: The CSSA is able to predict apatient’s response to treatment and could beused to identify patients at greater risk fortreatment failure so that these patients couldbe targeted for additional interventions. Thisinstrument could also be used to evaluate theeffectiveness of medications intended to treatcocaine abstinence symptoms.

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: Eighteen items

Administration time: Less than 10 minutes

Scoring time: N/A

Computer scoring? No

Administrator training and qualifications:Requires little training; clinician-adminis-tered

Available from: Kampman, K.M., Volpicelli,J.R., McGinnis, D.E., Alterman, A.I.,Weinrieb, R.M., D’Angelo, L., andEpperson, L.E. Reliability and validity of the

228 Appendix C

Cocaine Selective Severity Assessment.Addictive Behaviors 23(4):449–461, 1998.

Objective Opiate WithdrawalScale (OOWS)Purpose: Used to record symptoms of opiatewithdrawal.

Clinical utility: Allows staff to share informa-tion about a client’s withdrawal, especiallyobjective signs observed by staff.

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: Thirteen manifestations of with-drawal; observer scores

Computer scoring? No

Administrator training and qualifications:Staff must be familiar with withdrawal signs(e.g., registered nurse, physician) or trained.

Available from: Handelsman, L., Cochrane,K.J., Aronson, M.J., Ness, R., Rubinstein,K.J., and Kanof, P.D. Two new rating scalesfor opiate withdrawal. American Journal ofAlcohol Abuse. 13:293–308, 1987.

Structured Clinical Interviewfor DSM-IV Disorders (SCID)Purpose: Obtains Axis I and II diagnosesusing the DSM-IV diagnostic criteria forenabling the interviewer to either rule out orto establish a diagnosis of “drug abuse” or“drug dependence” and/or “alcohol abuse” or“alcohol dependence.”

Clinical utility: A psychiatric interview

Groups with whom this instrument has beenused: Psychiatric, medical, or community-based normal adults.

Norms: No

Format: A psychiatric interview form inwhich diagnosis can be made by the examinerasking a series of approximately 10 questionsof a client.

Administration time: Administration of Axis Iand Axis II batteries may require more than 2hours each for patients with multiple diag-noses. The Psychoactive Substance UseDisorders module may be administered byitself in 30 to 60 minutes.

Scoring time: Approximately 10 minutes

Computer scoring? No. Diagnosis can bemade by the examiner after the interview.

Administrator training and qualifications:Designed for use by a trained clinical evalua-tor at the master’s or doctoral level, althoughin research settings it has been used by bach-elor’s level technicians with extensive train-ing.

Fee for use: Yes

Available from:American Psychiatric Publishing, Inc.1400 K Street, N.W.Washington, DC 20005www.appi.org/

Stages of Change Readinessand Treatment EagernessScale (SOCRATES)Purpose: Designed to assess client motivationto change drinking- or drug-related behavior.Consists of five scales: precontemplation, con-templation, determination, action, and main-tenance. Separate versions are available foralcohol and illicit drug use.

Clinical utility: The SOCRATES can assistclinicians with necessary information aboutclient motivation for change, an importantpredictor of treatment compliance and out-come, and aid in treatment planning.

Groups with whom this instrument has beenused: Adults

229Screening and Assessment Instruments

Norms: N/A

Format: Forty items; paper-and-pencil

Administration time: Five minutes

Computer scoring? No

Administrator training and qualifications: Notraining required.

Fee for use: No

Available from: Center for Substance AbuseTreatment. Enhancing Motivation for Changein Substance Abuse Treatment. TreatmentImprovement Protocol (TIP) Series 35.DHHS Publication No. (SMA) 99-3354.Rockville, MD: Substance Abuse and MentalHealth Services Administration, 1999.

Subjective Opiate WithdrawalScale (SOWS)Purpose: Used to record client’s impressionsor complaints of opiate withdrawal symptoms.

Groups with whom this instrument has beenused: Adults

Norms: N/A

Format: Sixteen-item questionnaire; interviewor paper-and-pencil

Computer scoring? No

Available from: Handelsman, L., Cochrane,K.J., Aronson, M.J., Ness, R., Rubinstein,K.J., and Kanof, P.D. Two new rating scalesfor opiate withdrawal. American Journal ofAlcohol Abuse. 13:293–308, 1987.

University of Rhode IslandChange Assessment (URICA)Purpose: The URICA operationally definesfour theoretical stages of change (precontem-plation, contemplation, action, and mainte-nance), each assessed by eight items.

Clinical utility: Assessment of stages ofchange/readiness construct can be used as apredictor, and for treatment matching anddetermining outcome variables.

Groups with whom this instrument has beenused: Both inpatient and outpatient adults

Norms: Yes, for an outpatient alcoholismtreatment population

Format: The URICA is a 32-item inventorydesigned to assess an individual’s stage ofchange located along a theorized continuumof change.

Administration time: Five to 10 minutes tocomplete

Scoring time: Four to 5 minutes

Computer scoring? Yes, using computerscannable forms

Administrator training and qualifications:N/A

Fee for use: No—the instrument is in thepublic domain

Available from: Center for Substance AbuseTreatment. Enhancing Motivation for Changein Substance Abuse Treatment. TreatmentImprovement Protocol (TIP) Series 35.DHHS Publication No. (SMA) 99-3354.Rockville, MD: Substance Abuse and MentalHealth Services Administration, 1999.

230 Appendix C

Appendix D: Resource Panel

Brad Austin Public Health Advisor Division of State and Community Assistance PPG Program Branch Center for Substance Abuse TreatmentRockville, 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 BranchOffice of Evaluation, Scientific Analysis and Synthesis Center for Substance Abuse TreatmentSubstance Abuse and Mental Health Services AdministrationRockville, Maryland

Hendree E. Jones, M.A., Ph.D. Assistant Professor CAP Research Director Department of Psychiatry and Behavioral Sciences Johns Hopkins University CenterBaltimore, Maryland

231

Robert Lubran, M.S., M.P.A. Director Division of Pharmacologic Therapies Center for Substance Abuse Treatment Substance Abuse and Mental Health

Services Administration Rockville, Maryland

James J. Manlandro, D.O., FAOAAM,FACOFP

Medical Director Family Addiction Treatment Services, Inc.Somers Point, New Jersey

Carol Rest-Mincberg State Project Officer Center for Substance Abuse TreatmentSubstance Abuse and Mental Health

Services AdministrationRockville, Maryland

Dennis Scurry, M.D. Chief Medical Officer Addiction of Prevention and Recovery

Administration Government of the District of Columbia Department of HealthWashington, DC

Alan Trachtenberg, M.D., M.P.H. Medical Officer Division of Pharmacologic Therapies Center for Substance Abuse Treatment Substance Abuse and Mental Health

Services Administration Rockville, Maryland

232 Appendix D

Appendix E: Field ReviewersKaren C.O. Batia, M.A., Ph.D.

Senior Director Mental Health and Addiction Services Heartland Health OutreachChicago, Illinois

Thomas P. Beresford, M.D. Professor Department of Psychiatry University of Colorado School of MedicineDenver, Colorado

Barry Blood, LCPC Addiction Counselor Family Service FoundationColumbia, Maryland

Patricia T. Bowman Probation Counselor Fairfax Alcohol Safety Action ProgramFairfax, Virginia

Barry S. Brown, M.S., Ph.D. Adjunct Professor University of North Carolina at WilmingtonCarolina Beach, North Carolina

Louis Cataldie, M.D. Office for Addictive Disorders Department of Health and HospitalsBaton Rouge, Louisiana

233

David A. Chiriboga, Ph.D. Professor Department of Aging and Mental Health Florida Mental Health Institute University of South FloridaTampa, Florida

Carol J. Colleran, CAP, ICADC Director of Primary Programs Center of Recovery for Older Adults Hanley-Hazelden CenterWest Palm Beach, Florida

Joy Davidoff Coordinator of Addiction Medicine New York State Office of Alcoholism and

Substance Abuse Services Albany, New York

John P. de Miranda, Ed.M. Executive Director National Association on Alcohol, Drugs

and Disability, Inc.San Mateo, California

B.J. Dean Executive Director Island Grove Regional Treatment Center,

Inc. Greeley, Colorado

Ralph W. Edwards, M.P.H., M.P.A. Director Office of Citizen Leadership Massachusetts Department of Mental

Health and Retardation Boston, Massachusetts

Michael I. Fingerhood, M.D. Associate Professor of Medicine Johns Hopkins Bayview Medical CenterBaltimore, Maryland

Michael M. Galer, D.B.A. Chair Graduate School of Business University of Phoenix Greater Boston

CampusBraintree, Massachusetts

Robert Holden, M.A. Program Director Partners in Drug Abuse Rehabilitation

Counseling Washington, DC

Kyle M. Kampman, M.D. Associate Professor of Psychiatry Medical Director Treatment Research Center University of PennsylvaniaPhiladelphia, Pennsylvania

Michael Warren Kirby, Jr., M.A., Ph.D. Chief Executive Officer Arapahoe House, Inc.Thornton, Colorado

James J. Manlandro, D.O., FAOAAM,FACOFP Medical Director Family Addiction Treatment Services, Inc.Somers Point, New Jersey

Ethan Nebelkopf, Ph.D., MFCC Director Family and Child Guidance Clinic Native American Health CenterOakland, California

Robert E. Olson, M.S. Project Director California Alcohol, Drug and Disability

Technical Assistance Project National Association on Alcohol, Drugs

and Disability, Inc.Belmont, California

Christopher Pond Director of Adult Services Arapahoe House, Inc.Thornton, Colorado

Anthony B. Radcliffe, M.D. Chief of Addiction Medicine Fontana SCPMG Kaiser Permanente/CDRPFontana, California

234 Appendix E

Jay Renaud Member/Editor J & M Reports Guidepoints: Acupuncture in RecoveryVancouver, Washington

Joseph P. Reoux, M.D. Assistant Professor Department of Psychiatry and Behavioral

Sciences VA Puget Sound Health Care System University of Washington School of

MedicineSeattle, Washington

Timothy M. Scanlan, M.D. Medical Director Addiction Specialists of Kansas Wichita, Kansas

Lawrence Schonfeld, Ph.D. Professor Louis de la Parte Florida Mental Health

Institute Department of Aging and Mental Health University of South FloridaTampa, Florida

Steven Shevlin Executive Director Signs of Sobriety, Inc.Ewing, New Jersey

Carla Shird, M.A., CSC-AD Counselor Mental Health Center Gallaudet University Kellogg Conference

CenterWashington, 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 WorkersWashington, DC

Leslie R. Steve, M.A. Native American Coordinator Center for the Application of Substance

Abuse Technologies University of NevadaReno, Nevada

Richard T. Suchinsky, M.D. Associate Chief for Addictive Disorders and

Psychiatric Rehabilitation Mental Health and Behavioral Sciences

Services Department of Veterans AffairsWashington, DC

Nancy R. VanDeMark, M.S.W. Director Research and Program Evaluation Arapahoe House, Inc.Thornton, Colorado

Melvin H. Wilson, M.B.A., LCSW-C Baltimore HIDTA Coordinator Maryland Department of Parole and

ProbationClinton, Maryland

Ann S. Yabusaki, M.Ed., M.A., Ph.D. Substance Abuse Director Psychologist Substance Abuse Programs and Training Coalition for a Drug-Free HawaiiKaneohe, Hawaii

235Field Reviewers

Because the entire volume is about detoxifica-tion and substance abuse treatment, the useof these terms as entry points has been mini-mized in this index. Commonly knownacronyms are listed as main headings. Pagereferences for information contained in fig-ures appear in italics

Aacupuncture, 103–104, 113acute care inpatient settings, 19–20adolescents, 30–31, 118

and club drugs, 97Adult Detoxification levels of care, 13adults, older, 109–110African Americans, 113–115aggressive behavior, 27

strategies for de-escalating, 28alcohol withdrawal

and benzodiazepine treatment, 58–61contraindications to using benzodiazepines

during, 61management with medication, 57–58management without medication, 55medical complications, 54and seizures, 64–65signs and symptoms, 52–54

alternative treatment, 34, 103–104and disabilities, 113

American Indians, 116–117American Medical Association, position on

alcoholism, 3Americans With Disabilities Act, 110amphetamines. See stimulantsanabolic steroid withdrawal, 96

management, 97medical complications of, 96–97patient care and comfort, 97signs and symptoms, 96

anticonvulsants, 62antipsychotics, 62anxiety disorders, 139–141

antianxiety agents, 143Asians and Pacific Islanders, 115–116assessment

and determining rehabilitation plans, 40of psychosocial needs, 39of severity of nicotine dependence, 86–87

audience for this TIP, 2

Bbarbiturates, 61–62barriers to treatment

access, 43–44administrative, 39

benzodiazepinecontraindications, 61limitations in outpatient treatment, 60–61and phenobarbital withdrawal equivalents, 77and pregnant women, 106, 108symptom-triggered therapy, 58–59tapering dosages, 59and treatment of alcohol withdrawal, 58–61

benzodiazepine withdrawalmanagement with medication, 75–76medical complications of, 75signs and symptoms, 74–75

biochemical markers, 48biomedical evaluation domains, 25bipolar disorders, 142–143blood alcohol content, 48–49breath alcohol levels, 50buprenorphine

and opioid withdrawal, 71–72and pregnant women, 107

bupropion, 92Byrne Formula Grant Program, 154

Ccarve-outs, 157case management, 44case studies, 48, 102CDT levels, 51central nervous system depression, 66children’s protective services, 154Civilian Health and Medical Program of the

Veterans Administration, 152–153client advocates, 33clinically managed residential detoxification, 17Clinical Practice Guidelines for Detoxification of

Chemically Dependent Inmates, 119clonidine

detoxification, 72and opioid withdrawal, 70–71and pregnant women, 107and rapid detoxification, 73

club drugs, 97ecstasy, 99–100GHB, 98–99hallucinogens, 98

237Index

Index

ketamine and PCP, 100–101and pregnant women, 109

cocaine. See stimulantsCommission on Accreditation of Rehabilitation

Facilities, 17, 27Community Reinforcement and Family Training

(intervention), 34complementary medicine. See alternative

treatmentconfidentiality, 28, 165confrontation, 35Contracting for Managed Substance Abuse and

Mental Health Services: A Guide for Public Purchasers, 161

contracts, managed care, 158–159co-occurring medical conditions, 24–26, 26,

110–113acute trauma, 135cancer, 134–135cardiovascular disorders, 125–127diabetes, 135gastrointestinal disorders, 122–125general principles of care, 122hematologic disorders, 127–128infectious disease, 132–134neurologic system effects, 129–132pulmonary disorders, 128–129

co-occurring psychiatric conditions, 27–28, 136–137anxiety disorders, 139–141bipolar disorders, 142–143depressive disorders, 141–142and pharmacologic agents, 137–138psychotic disorders, 143and psychotropic medications, 138–139substance induced, 139

cost methodologies, 159–161criminal justice systems, 118–119, 154cultural competence, 32–33, 44

questions to guide practitioners, 32

Ddecisional balancing strategies, 37definitions, 6

detoxification, 4disabilities, 111evaluation, 4fostering entry to treatment, 5maintenance, 6regarding disabilities, 111social detoxification, 17stabilization, 4substance, 5substance intoxication, 5

substance-related disorder, 5substance withdrawal, 5treatment/rehabilitation, 5–6

delirium, 63–66delirium tremens, 63

depressive disorders, 27, 141–142antidepressants, 144

detoxificationbuilding a program, 145–146clinically managed residential, 17definition of, 4as distinct from substance abuse treatment, 4history of services, 2–3inpatient versus outpatient programs, 20, 21linkage with substance abuse treatment, 8medical model of, 3outpatient, 13principles for care during, 24rapid, ultrarapid, 73service setting changes, 146social model of, 3, 55strengthening market position of program,

167–168disabilities, 110–113, 112

definitions, 111locating expert assistance, 114

domestic violence, 31Drug Addiction Treatment Act of 2000, 72drug-free environment, maintaining, 34

Eecstasy, 99–100enhancing motivation, 34ERs, and urgent care facilities, 15evaluation

definition of, 4initial, 24

FFetal Alcohol Syndrome, 108, 117fostering entry to treatment, definition of, 5freestanding substance abuse treatment

facility, 16–17funding issues, 147–148, 155, 162–163

grant funding, 156, 157multiple funding streams, 166

Ggays and lesbians, 117–118GGT levels, 51GHB, 98–99grant funding, 156, 157guiding principles, 7

238 Index

Hhallucinogens, 98hepatitis, and GGT levels, 51Hispanics/Latinos, 117history of detoxification services, 2–3HIV/AIDS, 134

detoxification as a means to inhibit spread of, 3

homeless patients, 43

Iincarcerated persons, 118–119Indian Health Service, 152infectious disease, 26–27, 132–134inhalant/solvent withdrawal

management with medication, 83management without medication, 82medical complications of, 82patient care and comfort, 83–84signs and symptoms, 82

inhalants/solvents, commonly abused, 83–84inpatient detoxification programs, versus

outpatient programs, 20, 21instruments, for dependence and withdrawal, 49intensive outpatient programs, 18–19interventions

Community Reinforcement and Family Training, 34

Johnson Intervention, 35intoxication, signs and symptoms, 52, 53

JJohnson Intervention, 35Joint Commission on Accreditation of

Healthcare Organizations, 17, 27

Kketamine, 100–101kindling effect, 54, 56

Lleast restrictive care, 12levels of care, 39

acute care inpatient settings, 20Adult Detoxification, 13ambulatory detoxification, 14clinically managed residential detoxification, 17intensive outpatient programs, 18–19medically monitored inpatient detoxification, 17urgent care facilities and ERs, 16

linkagesto followup medical care, 45to ongoing psychiatric services, 44to treatment and maintenance activities, 42

Mmalnutrition, 28managed care

accreditation, 161–162contracts, 158–159financial risk in, 159–161performance measurement, 164–165recordkeeping, 165–166

marijuana, 95and pregnant women, 109

market position, strengthening, 167–168MCV levels, 51Medicaid, 149–150medically monitored inpatient detoxification, 17medical model of detoxification, 3Medicare, 151methadone

detoxification, 72and opioid withdrawal, 69–70and pregnant women, 106

motivational enhancements, 34

Nnicotine, 84–85

assessing severity of dependence, 86–87Fagerstrom Test for Nicotine Dependence, 87Glover-Nilsson Smoking Behavioral

Questionnaire, 88and pregnant women, 108–109Treating Tobacco Use and Dependence:

Clinical Practice Guidelines, 90, 93nicotine replacement therapy, 91–92

combining, 93–94and pregnant women, 109

nicotine withdrawal, 86effects of abstinence on blood levels of

psychiatric medications, 90interventions, 90–91, 91management with medication, 91–94management without medication, 89–90medical complications of, 87–89patient care and comfort, 94signs and symptoms, 85–86, 89

nutritiondeficits, 29–30evaluation, 28–29

239Index

Ooffice-based detoxification. See detoxification,outpatientolder adults, 109–110opioid withdrawal

and buprenorphine, 71–72and clonidine, 70–71management with medication, 68–69management without medication, 68and methadone, 69–70signs and symptoms, 66–68, 67

outpatient programs, versus inpatient programs, 20, 21

Pparents, 31partial hospitalization programs. See intensive

outpatient programspatient care and comfort, 66, 73–74

anabolic steroid withdrawal, 97inhalant/solvent withdrawal, 83–84nicotine withdrawal, 94stimulant withdrawal, 81

patient education, 33Patient Placement Criteria, ASAM, 12–13, 39performance measurement, 164–165pharmacotherapy

and anxiety disorders, 140–141and bipolar disorders, 142–143and depressive disorders, 141–142nonnicotine, 92–93

phenobarbital withdrawaland benzodiazepine, 77and sedative-hypnotics, 78

physicians, and preparing patients to enterdetoxification, 13

placement matching, challenges to, 11–12polydrug abuse, 101–102

prioritizing substances of abuse, 102–103pregnant women, 43, 105–106

and alcohol, 106and marijuana, 109and nicotine, 108–109and opioids, 106–108and solvents, 108and stimulants, 108

principles for care during detoxification, 24Provider’s Introduction to Substance Abuse

Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, A, 118

psychiatric services, linkages to, 44psychosocial evaluation domains, 25psychotic disorders, 143

public housing, 153public intoxication, prior to 1970s, 2–3

Rrapid detoxification, 73recordkeeping, 165–166referral sources, 146Rehabilitation Act of 1973, 110reimbursement systems, 8relapse

chronic, 33prevention, 62–63

research funding, 156rohypnol, 101Ryan White CARE Act, 154

Sscope of this TIP, 2sedative-hypnotics, and phenobarbital

withdrawal equivalents, 78seizures, 63–66

alcohol withdrawal, 64–65, 130what to do in the event of, 65

self-pay patients, 156service costs, resources on, 160service delivery, pitfalls of, 8social detoxification, 3, 17, 55–57Social Security Disability Insurance, 151social services, 153–154Social Services Block Grant, 153solvents, and pregnant women, 108stabilization, definition of, 4staffing issues

acute care inpatient settings, 20inpatient detoxification programs, 18intensive outpatient programs, 19in outpatient detoxification, 14

stages of change, 35–37, 36State Children’s Health Insurance Program, 152steroids, anabolic, 96stimulants, 76

and pregnant women, 108stimulant withdrawal

management with medication, 81management without medication, 80medical complications of, 80, 81patient care and comfort, 81symptoms, 79–80

substancechanging patterns of use, 3definition of, 5dependence, chronic, 45-induced psychiatric conditions, 139

240 Index

intoxication, definition of, 5-related disorder, definition of, 5withdrawal, definition of, 5

substance abuse epidemiology, 146–147Substance Abuse Prevention and Treatment

Block Grant, 149substance abuse treatment

as distinct from detoxification, 4funding issues, 147–148, 155, 156, 157,

162–163linkage with detoxification, 8

suicide, 27Supplemental Security Income, 151support systems, 33–34symptom-triggered benzodiazepine therapy,

58–59

Ttapering dosages, benzodiazepine, 59Temporary Assistance to Needy Families, 153THC abstinence syndrome, 95therapeutic alliance, 37–38

and clinician characteristics, 38TIPs cited

Clinical Guidelines for the Use ofBuprenorphine in the Treatment of OpioidAddiction (TIP 40), 71

Combining Alcohol and Other Drug AbuseTreatment With Diversion for Juveniles inthe Justice System (TIP 21), 119, 154

Comprehensive Case Management forSubstance Abuse Treatment (TIP 27), 44, 45

Continuity of Offender Treatment forSubstance Use Disorders From Institution toCommunity (TIP 30), 119, 154

Detoxification From Alcohol and Other Drugs(TIP 19), 1

Enhancing Motivation for Change in SubstanceAbuse Treatment (TIP 35), 34, 35

Improving Cultural Competence in Substance Abuse Treatment (in development), 7, 44,114, 116, 117

Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs(TIP 43), 58, 69, 107

Role and Current Status of Patient PlacementCriteria in the Treatment of SubstanceUse Disorders, The (TIP 13), 13, 41

Screening and Assessing Adolescents forSubstance Use Disorders (TIP 31), 31, 118

Screening for Infectious Diseases Among Substance Abusers (TIP 6), 132

Substance Abuse Among Older Adults (TIP 26),110

Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (in development), 19

Substance Abuse Treatment: Addressing the Specific Needs of Women (in development),39, 106, 108, 109

Substance Abuse Treatment and Domestic Violence (TIP 25), 32

Substance Abuse Treatment for Adults in theCriminal Justice System (TIP 44), 119, 154

Substance Abuse Treatment for Persons WithChild Abuse and Neglect Issues (TIP 36), 44

Substance Abuse Treatment for Persons WithCo-Occurring Disorders (TIP 42), 27, 45, 93,112, 121, 137

Substance Abuse Treatment for Persons WithHIV/AIDS (TIP 37), 134

Substance Abuse Treatment: Men’s Issues (indevelopment), 39

Substance Use Disorder Treatment for PeopleWith Physical and Cognitive Disabilities (TIP29), 44, 110

Treatment of Adolescents With Substance UseDisorders (TIP 32), 31, 118

Tuberculosis Epidemic: Legal and Ethical Issuesfor Alcohol and Other Drug AbuseTreatment Providers, The (TIP 18), 133

transtheoretical model. See stages of changeTreating Tobacco Use and Dependence: Clinical

Practice Guidelines, 90, 93treatment

definition of, 5–6initiation of, 42settings, 41

TRICARE, 152

Uultrarapid detoxification, 73Uniform Alcoholism and Intoxication Treatment

Act, 3urgent care facilities, and ERs, 15urine drug screens, 50utilization and case management, 166–167

Vviolence, 27

domestic, 31vocational rehabilitation, 153–154

241Index

WWashington Circle Group, 4, 164Web sites

American Cancer Society, 94American Lung Association, 94Byrne Formula Grant Program, 154children’s protective services, 154Civilian Health and Medical Program of the

Veterans Administration, 152–153Commission on Accreditation of

Rehabilitation Facilities, 17, 20, 21, 27, 162grant funding sources, 157Health Insurance Portability and

Accountability Act, 165Indian Health Service, 152Joint Commission on Accreditation of

Healthcare Organizations, 17, 20, 21, 27, 162legal aspects of prescribing buprenorphine, 72Medicaid, 150Medicare, 151model programs, 167National Committee for Quality Assurance,

162National Institute on Alcohol Abuse and

Alcoholism, 156

National Institute on Drug Abuse, 156Patient Placement Criteria, ASAM, 166public housing, 153Research Assistant, The, 156Ryan White CARE Act, 154SAMHSA funding opportunities, 149Social Security Disability Insurance, 151State Children’s Health Insurance Program,152Temporary Assistance to Needy Families, 153TRICARE, 152vocational rehabilitation, 154Washington Circle Group, 164

withdrawal, 24–26, 33. See also alcohol with-drawal; anabolic steroid withdrawal; benzodi-azepine withdrawal; inhalant/solvent withdraw-al; nicotine withdrawal; opioid withdrawal;stimulant withdrawal

women, pregnant, 43, 105–106wraparound services, 43

ZZyban, 92

242 Index

TIP 1 State Methadone Treatment Guidelines—Replaced byTIP 43

TIP 2* Pregnant, Substance-Using Women— BKD107

Quick Guide for Clinicians QGCT02

KAP Keys for Clinicians KAPT02

TIP 3 Screening and Assessment of Alcohol- and OtherDrug-Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol- and OtherDrug-Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed Infants—BKD110

TIP 6 Screening for Infectious Diseases Among SubstanceAbusers—BKD131

Quick Guide for Clinicians QGCT06

KAP Keys for Clinicians KAPT06

TIP 7 Screening and Assessment for Alcohol and OtherDrug Abuse Among Adults in the Criminal JusticeSystem—Replaced by TIP 44

TIP 8* Intensive Outpatient Treatment for Alcohol and OtherDrug Abuse—BKD139

TIP 9 Assessment and Treatment of Patients With CoexistingMental Illness and Alcohol and Other Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine-AbusingMethadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach forAlcohol and Other Drug Abuse and InfectiousDiseases— BKD143

Quick Guide for Clinicians QGCT11

KAP Keys for Clinicians KAPT11

TIP 12 Combining Substance Abuse Treatment WithIntermediate Sanctions for Adults in the CriminalJustice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient PlacementCriteria in the Treatment of Substance UseDisorders—BKD161

Quick Guide for Clinicians QGCT13

Quick Guide for Administrators QGAT13

KAP Keys for Clinicians KAPT13

TIP 14 Developing State Outcomes Monitoring Systems forAlcohol and Other Drug Abuse Treatment—BKD162

TIP 15 Treatment for HIV-Infected Alcohol and Other DrugAbusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of HospitalizedTrauma Patients—BKD164

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16

TIP 17 Planning for Alcohol and Other Drug AbuseTreatment for Adults in the Criminal Justice System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issuesfor Alcohol and Other Drug Abuse TreatmentProviders—BKD173

Quick Guide for Clinicians QGCT18

KAP Keys for Clinicians KAPT18

TIP 19 Detoxification From Alcohol and Other Drugs—Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in OpioidSubstitution Therapy—Replaced by TIP 43

CSAT 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 treat-ment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of theNation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide isdivided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page num-bers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and sum-maries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within atreatment provider’s reach and consulted frequently. The Keys allow you—the busy clinician or program administrator—to locateinformation easily and to use this information to enhance treatment services.

*Under revision

243

TIP 21 Combining Alcohol and Other Drug Abuse TreatmentWith Diversion for Juveniles in the Justice System—BKD169

Quick Guide for Clinicians and AdministratorsQGCA21

TIP 22 LAAM in the Treatment of Opiate Addiction—Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating Substance AbuseTreatment With Legal Case Processing—BKD205

Quick Guide for Administrators QGAT23

TIP 24 A Guide to Substance Abuse Services for PrimaryCare Clinicians—BKD234

Concise Desk Reference Guide BKD123

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24

TIP 25 Substance Abuse Treatment and Domestic Violence—BKD239

Linking Substance Abuse Treatment andDomestic Violence Services: A Guide for TreatmentProviders MS668

Linking Substance Abuse Treatment and DomesticViolence Services: A Guide for Administrators MS667

Quick Guide for Clinicians QGCT25

KAP Keys for Clinicians KAPT25

TIP 26 Substance Abuse Among Older Adults— BKD250

Substance Abuse Among Older Adults: A Guide for Treatment Providers MS669

Substance Abuse Among Older Adults: A Guide for Social Service Providers MS670

Substance Abuse Among Older Adults: Physician’s Guide MS671

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26

TIP 27 Comprehensive Case Management for SubstanceAbuse Treatment—BKD251

Case Management for Substance Abuse Treatment: AGuide for Treatment Providers MS673

Case Management for Substance Abuse Treatment: AGuide for Administrators MS672

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27

TIP 28 Naltrexone and Alcoholism Treatment—BKD268

Naltrexone and Alcoholism Treatment: Physician’sGuide MS674

Quick Guide for Clinicians QGCT28

KAP Keys for Clinicians KAPT28

TIP 29 Substance Use Disorder Treatment for People WithPhysical and Cognitive Disabilities—BKD288

Quick Guide for Clinicians QGCT29

Quick Guide for Administrators QGAT29

KAP Keys for Clinicians KAPT29

TIP 30 Continuity of Offender Treatment for Substance UseDisorders From Institution to Community—BKD304

Quick Guide for Clinicians QGCT30

KAP Keys for Clinicians KAPT30

TIP 31 Screening and Assessing Adolescents for SubstanceUse Disorders—BKD306See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance UseDisorders—BKD307

Quick Guide for Clinicians QGC312

KAP Keys for Clinicians KAP312

TIP 33 Treatment for Stimulant Use Disorders—BKD289

Quick Guide for Clinicians QGCT33

KAP Keys for Clinicians KAPT33

TIP 34 Brief Interventions and Brief Therapies for SubstanceAbuse—BKD341

Quick Guide for Clinicians QGCT34

KAP Keys for Clinicians KAPT34

TIP 35 Enhancing Motivation for Change in Substance AbuseTreatment—BKD342

Quick Guide for Clinicians QGCT35

KAP Keys for Clinicians KAPT35

TIP 36 Substance Abuse Treatment for Persons With ChildAbuse and Neglect Issues—BKD343

Quick Guide for Clinicians QGCT36

KAP Keys for Clinicians KAPT36

Helping Yourself Heal: A Recovering Woman’s Guideto Coping With Childhood Abuse Issues—PHD981

Available in Spanish: PHD981S

Helping Yourself Heal: A Recovering Man’s Guide toCoping With the Effects of Childhood Abuse—HD1059

Available in Spanish: PHD1059S

TIP 37 Substance Abuse Treatment for Persons WithHIV/AIDS—BKD359

Fact Sheet MS676

Quick Guide for Clinicians MS678

KAP Keys for Clinicians KAPT37

*Under revision244

TIP 38 Integrating Substance Abuse Treatment andVocational Services—BKD381

Quick Guide for Clinicians QGCT38

Quick Guide for Administrators QGAT38

KAP Keys for Clinicians KAPT38

TIP 39 Substance Abuse Treatment and Family Therapy—BKD504

Quick Guide for Clinicians QGCT39

Quick Guide for Administrators QGAT39

TIP 40 Clinical Guidelines for the Use of Buprenorphine inthe Treatment of Opioid Addiction—BKD500

Quick Guide for Physicians QGPT40

KAP Keys for Physicians KAPT40

TIP 41 Substance Abuse Treatment: Group Therapy—BKD507

Quick Guide for Clinicians QGCT41

TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders—BKD515

Quick Guide for Clinicians QGCT42

Quick Guide for Administrators QGAT42

KAP Keys for Clinicians KAPT42

TIP 43 Medication-Assisted Treatment for Opioid Addictionin Opioid Treatment Programs—BKD524

Quick Guide for Clinicians QGCT43

KAP Keys for Clinicians KAPT43

TIP 44 Substance Abuse Treatment for Adults in the CriminalJustice System—BKD526

Quick Guide for Clinicians QGCT44

KAP Keys for Clinicians KAPT44

TIP 45 Detoxification and Substance Abuse Treatment—BKD541

Quick Guide for Clinicians QGCT45

KAP Keys for Clinicians KAPT45

Quick Guide for Administrators QGAT45

245

Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health ServicesAdministration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT)

Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below.

___TIP 2* BKD107___QG+ for Clinicians QGCT02___KK+ for Clinicians KAPT02

___TIP 5 BKD110

___TIP 6 BKD131___QG for Clinicians QGCT06___KK for Clinicians KAPT06

___TIP 8* BKD139

___TIP 11 BKD143___QG for Clinicians QGCT11___KK for Clinicians KAPT11

___TIP 13 BKD161___QG for Clinicians QGCT13___QG for Administrators QGAT13___KK for Clinicians KAPT13

___TIP 14 BKD162

___TIP 16 BKD164___QG for Clinicians QGCT16___KK for Clinicians KAPT16

___TIP 18 BKD173___QG for Clinicians QGCT18___KK for Clinicians KAPT18

___TIP 21 BKD169___QG for Clinicians & Administrators

QGCA21

___TIP 23 BKD205___QG for Administrators QGAT23

___TIP 24 BKD234___Desk Reference BKD123___QG for Clinicians QGCT24___KK for Clinicians KAPT24

___TIP 25 BKD239___Guide for Treatment Providers MS668___Guide for Administrators MS667___QG for Clinicians QGCT25___KK for Clinicians KAPT25

___TIP 26 BKD250___Guide for Treatment Providers MS669___Guide for Social Service Providers

MS670___Physician’s Guide MS671___QG for Clinicians QGCT26___KK for Clinicians KAPT26

___TIP 27 BKD251___Guide for Treatment Providers MS673___Guide for Administrators MS672___QG for Clinicians QGCT27___QG for Administrators QGAT27

___TIP 28 BKD268___Physician’s Guide MS674___QG for Clinicians QGCT28___KK for Clinicians KAPT28

___TIP 29 BKD288___QG for Clinicians QGCT29___QG for Administrators QGAT29___KK for Clinicians KAPT29

___TIP 30 BKD304___QG for Clinicians QGCT30___KK for Clinicians KAPT30

___TIP 31 BKD306(see products under TIP 32)

___TIP 32 BKD307___QG for Clinicians QGC312___KK for Clinicians KAP312

___TIP 33 BKD289___QG for Clinicians QGCT33___KK for Clinicians KAPT33

___TIP 34 BKD341___QG for Clinicians QGCT34___KK for Clinicians KAPT34

___TIP 35 BKD342___QG for Clinicians QGCT35___KK for Clinicians KAPT35

___TIP 36 BKD343___QG for Clinicians QGCT36___KK for Clinicians KAPT36___Brochure for Women (English)

PHD981___Brochure for Women (Spanish)

PHD981S___Brochure for Men (English)

PHD1059___Brochure for Men (Spanish)

PHD1059S

___TIP 37 BKD359___Fact Sheet MS676___QG for Clinicians MS678___KK for Clinicians KAPT37

___TIP 38 BKD381___QG for Clinicians QGCT38___QG for Administrators QGAT38___KK for Clinicians KAPT38

___TIP 39 BKD504___QG for Clinicians QGCT39___QG for Administrators QGAT39

___TIP 40 BKD500___QG for Physicians QGPT40___KK for Physicians KAPT40

___TIP 41 BKD507___QG for Clinicians QGCT41

___TIP 42 BKD515___QG for Clinicians QGCT42___QG for Administrators QGAT42___KK for Clinicians KAPT42

___TIP 43 BKD524___QG for Clinicians QGCT43___KK for Physicians KAPT43

___TIP 44 BKD526___QG for Clinicians QGCT44___KK for Clinicians KAPT44

___TIP 45 BKD541___QG for Clinicians QGCT45___QG for Administrators QGAT45___KK for Clinicians KAPT45

*Under revision+QG = Quick Guide; KK = KAP Keys

Name:

Address:

City, State, Zip:

Phone and e-mail:

You can either mail this form or fax it to (301) 468-6433. Publications also can be ordered by calling SAMHSA’s NCADI at(800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.

TIPs can also be accessed online at www.kap.samhsa.gov.

SAMHSA’s National Clearinghouse for Alcohol and Drug InformationP.O. Box 2345

Rockville, MD 20847-2345

STAMP

FOLD

FOLD

This TIP is a revision of TIP 19, Detoxification From Alcohol andOther Drugs, and was created by a panel of experts with diverseexperience in detoxification services—physicians, psychologists,counselors, nurses, and social workers. This revision provides up-to-date information about changes in the role of detoxificationin the continuum of services for patients with substance use dis-orders, increased knowledge of the physiology of withdrawal,pharmacological advances in the management of withdrawal,patient placement procedures, and new issues in the manage-ment of detoxification services within comprehensive systems ofcare. It also expands on the administrative, legal, and ethicalissues commonly encountered in the delivery of detoxificationservices and suggests performance measures for detoxificationprograms.

Collateral ProductsBased on TIP 45

Quick Guide for CliniciansKAP Keys for Clinicians

Detoxification andSubstance Abuse Treatment

DHHS Publication No. (SMA) 06-4131Printed 2006

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

Deto

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DETOXIFI-CATION