Title : QGcover tip19 8-31-01ph.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 19 Detoxification from Alcohol And Other Drugs ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 Detoxification Settings and Patient Matching . . . . . . . . . . . . . . . . . . . . . 7 Clinical Detoxification Protocols . . . . . . . . . . 9 Special Populations . . . . . . . . . . . . . . . . . . 14 Improving Quality and Measuring Outcomes of Substance Abuse Detoxification Services . . . . . . . . . . . . . . . . 17 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . .20 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 19, published in 1995 and based on information updated through approximately 1993. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 19 Detoxification from Alcohol and Other Drugs ----------------------------------------------- 2 Detoxification from Alcohol and Other Drugs WHY A QUICK GUIDE? This Quick Guide was developed to accompany Detoxification from Alcohol and Other Drugs, Number 19 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 19 and is designed to meet the needs of the busy clini cian for concise, easily accessed "how-to" informa tion. The Guide is divided into six sections (see Contents) to help readers quickly locate relevant material. Terms related to detoxification from alcohol and other drugs are listed on pages 20–21 in the Glossary. These terms are included to enable cli nicians to talk knowledgeably with their clients and clients' medical providers. For more information on the topics in this Quick Guide, readers are referred to TIP 19. ----------------------------------------------- What is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest. TIP 19, Detoxification from Alcohol and Other Drugs • Addresses concerns of a broad range of readers including clinicians, social workers, medical per sonnel, mental health workers, program admin istrators, and policymakers • Includes extensive research • Is a comprehensive reference for clinicians on detoxification from alcohol and other drugs See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 Detoxification from Alcohol and Other Drugs INTRODUCTION In the context of treating patients who are physi cally dependent on alcohol or illicit drugs, detoxifi cation includes the period of time during which the body's physiology is adjusting to the absence of such substances. Usually, the detoxification period is defined as the period during which the patient receives detoxification medication. The Role of Detoxification in Substance Abuse Treatment Detoxification is the beginning phase of treatment for many substance-dependent patients and entails more than a period of physical readjust ment. It can also be a time when patients make the psychological readjustments necessary for ongoing treatment. People who have problems that predate their substance dependence or addiction—such as family disintegration, lack of job skills, illiteracy, or psychiatric disorders—may continue to have these problems after detoxifica tion and specific services will need to be available to help them deal with these factors. Immediate Goals of Detoxification • Provide a safe withdrawal from the substance(s) of dependence and enable the patient to become substance free. ----------------------------------------------- Introduction 5 • Provide a withdrawal that is humane and pro tects the patient's dignity. • Prepare the patient for ongoing treatment of his or her dependence. Repeated Detoxification During certain expected phases of recovery, addicted persons are at increased risk of relapse. Relapse prevention is a legitimate area for patient education and the relapsed patient is appropriate for clinical treatment. Treatment services designed precisely for this stage of the disease may facilitate the individual's return to abstinence. Effects of Substance Abuse Exposure and Withdrawal Sudden removal of alcohol or drug of abuse from the system of a person who is physically depend ent produces either an abstinence or withdrawal syndrome. The abstinence syndrome for each sub stance follows a predictable time course and has predictable symptoms. The signs and symptoms of withdrawal are usually the reverse of the direct pharmacological effects of the substance. Barriers to Care • Managed care criteria may present barriers to appropriate detoxification. Inpatient treatment often must be certified as medically necessary. ----------------------------------------------- 6 Detoxification from Alcohol and Other Drugs • Many substance abusing patients have inade quate treatment coverage and resources. If they relapse, they risk being fired or losing their health benefits. Responsibility for substance abuse treatment does not lie in the hands of physicians alone. A multidis ciplinary, coordinated approach is essential. To ensure high-quality care, providers will need to establish referral networks and linkages among var ious modalities. ----------------------------------------------- Detoxification Settings and Patient Matching 7 DETOXIFICATION SETTINGS AND PATIENT MATCHING Fundamental principles of high-quality patient care are • The patient's needs should drive the election of the most appropriate setting • Detoxification should be viewed as the gateway to ongoing treatment Medical Model Programs Medical model programs range from hospital- based inpatient programs to free-standing med ically based residential programs in hospitals that draw on various medical resources. Social Model Programs Social model substance abuse treatment pro grams concentrate on providing psychosocial serv ices, and such programs usually do not have med ical services onsite. Patients must be properly medically evaluated when they enter a social model program, for those with a severe depend ence on alcohol or sedative-hypnotics require medical management during the detoxification period. These programs should not provide detoxi fication for people who have severe dependence on alcohol or sedative-hypnotics, as withdrawal can be life threatening in certain cases. ----------------------------------------------- 8 Detoxification from Alcohol and Other Drugs Inpatient and Outpatient Detoxification Settings Detoxification may occur in either an inpatient or outpatient setting. Both settings initiate recovery programs that may include referrals for problems such as medical, legal, psychiatric and family issues. Inpatient detoxification is offered in medical hospi tals, psychiatric hospitals, and medically managed residential treatment programs. Outpatient detoxi fication is usually offered in community mental health centers, substance abuse treatment clin ics, and private clinics. Psychiatric hospitals occupy an important niche in the spectrum of detoxification settings because they are the preferred settings for patients who are psychotic, suicidal, or homicidal. ----------------------------------------------- Clinical Detoxification Protocols 9 CLINICAL DETOXIFICATION PROTOCOLS Principles of Detoxification • Detoxification alone is rarely adequate treat ment for substance dependencies. • When using medication regimens or other detoxification procedures, clinicians should use only protocols of established safety and efficacy. • During detoxification, providers should control patients' access to medication to the greatest extent possible. • Initiation of withdrawal should be individualized. • Whenever possible, clinicians should substitute long-acting medication for short-acting drugs of addiction. • The intensity of withdrawal cannot always be predicted accurately. • Every means possible should be used to recog nize and alleviate the patient's symptoms of withdrawal. • Patients should begin participating as soon as possible in followup support therapy such as peer group therapy, family therapy, individual counseling or therapy, 12-Step recovery meet ings, and substance abuse recovery educational programs. ----------------------------------------------- 10 Detoxification from Alcohol and Other Drugs Alcohol Detoxification Alcohol-dependent individuals can be detoxified in a modified medical setting, providing assessment is comprehensive, medical backup is available, and staff members know when to obtain a med ical consultation. Signs and symptoms of the acute phase of alcohol abstinence syndrome may include • Restlessness, irritability, anxiety, agitation • Anorexia, nausea, vomiting • Tremors, elevated heart rate, increased blood pressure • Insomnia, intense dreaming, nightmares • Impaired concentration, memory and judgment • Increased sensitivity to sounds, alteration in tac tile sensations • Delirium (disorientation to time, place, situation) • Hallucinations (auditory, visual or tactile) • Delusions (usually paranoid) • Grand mal seizures • Elevated temperature ----------------------------------------------- Clinical Detoxification Protocols 11 Suicidal patients can be detoxified, but they should be placed in an acute inpatient psychiatric setting rather than in an outpatient detoxification setting. Outpatient Treatment Concerns When designing treatment plans for outpatients, providers should take the following considerations into account: • Patients may have access to alcohol and other drugs at home. • Patients may continue to use alcohol in addition to the prescribed detoxification medicine. • Patients may have difficulty getting to their pro grams each day. • Patients who are undergoing detoxification may experience side effects or "breakthrough with drawal." Psychiatric Comorbidity Although medical concerns should be addressed first for detoxification, underlying psychiatric disor ders should be dealt with as well. For more information on psychiatric comorbidity, refer to the section on special populations in this Quick Guide or Chapter 4 of TIP 19. ----------------------------------------------- 12 Detoxification from Alcohol and Other Drugs Opiate Abstinence There are both early and advanced signs and symptoms of opiate abstinence. Early Signs and Symptoms • Anxiety • Increased respiratory rate • Sweating • Lacrimation (tearing or crying) • Yawning • Runny nose • Goosebumps • Restlessness • Anorexia • Irritability Advanced Signs and Symptoms • Insomnia • Nausea and vomiting • Diarrhea • Weakness • Abdominal cramps • Tachycardia • Hypertension ----------------------------------------------- Clinical Detoxification Protocols 13 • Muscle spasms • Muscle and bone pain Withdrawal from Benzodiazepines and Other Sedative-Hypnotics Dependence on benzodiazepines and other seda tive-hypnotics usually develops in the context of medical treatment. Benzodiazepines have many therapeutic uses. Dependency on benzodi azepines and other sedative-hypnotics can devel op even when patients take the prescribed doses. Polydrug abusers often misuse these families of medications. Management of withdrawal from these types of drugs must take into consideration a wide variety of considerations, such as high- dose or low-dose withdrawal and questions asso ciated with substance use, abuse, or dependency. Moreover, as with serious alcohol detoxification, withdrawal from benzodiazepines and other seda tive-related hypnotic drugs can be severe, even life-threatening, and complex. Consequently, the reader is referred to TIP 19, pp. 29–35, for a com plete description of the issues that need to be addressed. For more detailed information, refer to TIP 19, pp. 15–35. ----------------------------------------------- 14 Detoxification from Alcohol and Other Drugs SPECIAL POPULATIONS Persons in several groups need special considera tion during detoxification because of their specific needs. Such persons include women, adoles cents, the elderly, persons who are HIV-positive or have other medical conditions. Women Women will benefit from a comprehensive physi cal examination, including a gynecological and obstetrical evaluation. Special attention should be given to the detoxification setting. Establishing dis tance from the environment in which the sub stance abuse has been taking place may be more critical for women than for men. Pregnant and Nursing Women There are special concerns surrounding detoxifica tion during pregnancy. The Treatment Improvement Protocol (TIP) titled Pregnant, Substance-Using Women addresses the issues involved in treating this population in great detail. Adolescents Adolescents undergoing detoxification need nur turing, support, and structure. Treatment providers must be sensitive to their developmental stages. Therefore, adolescents should be housed separately from adults. Decisions about involving ----------------------------------------------- Special Populations 15 the family in the treatment should be made on a case-by-case basis, based on an assessment of family functioning. Elderly Persons Substance abuse-related disorders in elderly per sons tend to be more severe than those in younger persons, and there is an increased likeli hood of medical comorbidity in the elderly. Patients Who Are HIV-Positive Substance abuse and HIV infection often coexist and the patient is also at risk of contracting other sexually transmitted diseases or tuberculosis. A diagnosis of HIV does not change the indications for medication used to treat substance abuse, and the detoxification process need not be altered by the presence of HIV. Persons with Psychiatric Comorbidity • It is difficult to accurately assess underlying psychopathology in a person undergoing detoxification. • Drug toxicity may mimic psychiatric disorders and for this reason, treatment providers need to conduct a psychiatric evaluation after several weeks of abstinence. • Abrupt cessation of psychotherapeutic medica tions may cause withdrawal symptoms or ----------------------------------------------- 16 Detoxification from Alcohol and Other Drugs reemergence of symptoms of the underlying psychopathology. • After detoxification is complete, a patient's need for medication should be reassessed. Treatment providers should exercise caution when prescribing medication for chronic pain to patients with a history of substance abuse. Pain patients do not require detoxification from prescribed medica tions unless they meet the criteria for opiate abuse or dependence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. ----------------------------------------------- Improving Quality and Measuring Outcomes of Substance Abuse Detoxification Services 17 IMPROVING QUALITY AND MEASUR ING OUTCOMES OF SUBSTANCE ABUSE DETOXIFICATION SERVICES Effective measurement of treatment outcomes has long been a critical issue in the development of the Nation's substance abuse treatment sys tem. A more detailed discussion on quality improvement and outcomes measurement can be found in TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment. It is intended as an aid in devel oping, implementing, and managing outcome monitoring systems. Patient-Based Quality Improvement Indicators Admission Procedures • Document the level of withdrawal • Develop an individualized treatment plan • Develop and initiate a plan for discharge and aftercare • Conduct formal assessment Primary services • Evaluate the patient's physical and psychologi cal status (must include a medical history and ----------------------------------------------- 18 Detoxification from Alcohol and Other Drugs physical examination within 24 hours, if these were not performed at admission) • Develop a plan documenting the anticipated course of medical and social management • Develop a plan for continuing care (involving the patient's family or significant others in treat ment, where possible) • Perform routine drug screens • Flag files to indicate (1) previously treated patients and (2) patients with special medical problems, such as insulin-dependent diabetes, a history of seizures, drug sensitivities, or psy chiatric comorbidity • Consult previous admission data and treatment plans, if available Financial information • Obtain at admission; seek reauthorization as required • Provide assistance in obtaining entitlements such as Medicaid Discharge and aftercare • Identify patient's continuing needs for medical care, legal assistance, food stamps, child care, or other services ----------------------------------------------- Improving Quality and Measuring Outcomes of Substance Abuse Detoxification Services 19 • Address legal problems (for example, for court- referred patients) • Comply with legal mandates and reporting requirements For more detailed information, refer to TIP 19, pp. 41–42. ----------------------------------------------- 20 Detoxification from Alcohol and Other Drugs GLOSSARY Acute abstinence syndrome: The aggregate of withdrawal signs and symptoms that occur shortly after a person who is physically dependent on alcohol or a drug stops taking it. The adjective "acute" distinguishes the variant from the "pro tracted" or "chronic" substance withdrawal or abstinence syndrome. Delirium: A state of mental confusion character ized by difficulty in responding to stimuli and an absence of orientation to place and time. May be accompanied by auditory, visual, or tactile halluci nations. May be caused by substance withdrawal or severe intoxication with phencyclidine. Medical comorbidity: Presence of two serious ill nesses at once; for example, drug addiction and acquired immunodeficiency syndrome. Medically-managed: Substance abuse medical care center where specialized services are provid ed by medical staff under the direction of a quali fied physician with knowledge of and skills in addiction treatment. Modified medical setting: Social model programs that provide medical detoxification services under medical supervision. ----------------------------------------------- Glossary 21 Physical dependence: A condition in which the brain cells have adapted as a result of repeated exposure to alcohol or a drug and consequently require the drug in order to function. If the sub stance is suddenly made unavailable, the cells become hyperactive. The hyperactive cells pro duce the signs and symptoms of drug withdrawal. Signs: Observable or measurable changes in a patient's physiology; for example, increased blood pressure or dilated pupils. Such changes may not be perceived by the patient. Social Model programs: A substance abuse treat ment program that concentrates on providing psy chosocial services. Symptoms: Subjective changes in mood, feelings, or bodily sensations. ----------------------------------------------- 22 Detoxification from Alcohol and Other Drugs ----------------------------------------------- Ordering Information TIP 19 Detoxification from Alcohol and Other Drugs TIP 19-Related Products KAP Keys for Clinicians based on TIP 19 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT’s Web site at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3573 Printed 2001 TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (1994) BKD138 TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Use (1994) BKD139 TIP 9, Assessment and Treatment of Patients With Coexisiting Mental Illness and Alcohol and Other Drug Abuse (1994) BKD134 TIP 22, LAAM in the Treatment of Opiate Addiction (1995) BKD170 TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (1997) BKD234 TIP 28, Naltrexone and Alcoholism Treatment (1998) BKD268 TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (1999) BKD306 TIP 32, Treatment of Adolescents With Substance Abuse Disorders (1999) BKD307 TIP 33, Treatment for Stimulant Use Disorders (1999) BKD289