Detoxification From Alcohol and Other Drugs
Treatment Improvement Protocol (TIP) Series 19
Donald R. Wesson, M.D.
Consensus Panel Chair
U.S. Department of Health and Human Services
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 95-3046
Printed 1995.
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Sandra Clunies, M.S., served as the CSAT Government project officer. Dorynne Czechowicz, M.D., served as the Government content advisor. Carolyn Davis, Betsy Earp, Jo Lane Gregory-Thomas, Linda Harteker, Lise Markl, and Gail Martin served as writers.
The opinions expressed herein are the views of the consensus panel members and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions.
CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources.
The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice.
Once a topic has been selected, CSAT creates a Federal resource panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic. This group, known as a non-Federal consensus panel, meets in Washington for 5 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus.
The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the chair approves the document for publication. The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment.
This TIP, Detoxification From Alcohol and Other Drugs, describes detoxification care in a number of settings. Detoxification and patient matching are discussed. The TIP provides clinical guidelines for detoxification from specific classes of drugs such as sedative-hypnotics, stimulants, and opiates. Detoxification needs of special populations are addressed. The TIP also includes information helpful to planners and policymakers about costs, quality improvement, outcome criteria, health care reform, and linking detoxification -- often the gateway to ongoing treatment -- to the larger continuum of care in the substance abuse treatment system. Legal and ethical issues of concern to detoxification programs are also examined.
This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment.
Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889).
Donald R. Wesson, M.D.
Scientific Director
MPI Treatment Services
Summit Medical Center
Oakland, California
Mary R. Haack, R.N., Ph.D.
Senior Research Scientist
Center for Health Policy Research
The George Washington University
Washington, D.C.
Karen Larson, R.N., B.S.N.
Assistant Director
Division of Alcohol and Drug Abuse
North Dakota Department of Human Services
Bismarck, North Dakota
Dorothy B. North, N.C.A.C. II, C.E.A.P.
Chief Executive Officer
Vitality Center
Elko, Nevada
Bonnie Baird Wilford, M.S.
Director
Pharmaceutical Policy Research Center
Intergovernmental Health Policy Project
The George Washington University
Washington, D.C.
Margaret Kent Brooks, J.D.
Consultant
Montclair, New Jersey
Margaret A. Compton, R.N., Ph.D.
Post-Doctoral Fellow
UCLA Drug Abuse Research Center
Neuropsychiatric Institute
Los Angeles, California
Archie S. Golden, M.D., M.P.H.
Director
Adolescent Substance Abuse Program and
Chairman
Department of Pediatrics
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Richard Harris, R.C.S.W.
Director of Housing and Chemical Dependency Services
Central City Concern
Portland, Oregon
Albert E. Jones, L.C.S.W.
Program Director
New Directions, Inc.
Memphis, Tennessee
Walter Ling, M.D.
Director
Los Angeles Addiction Treatment Research Center and
Associate Chief of Psychiatry for Substance Abuse
West Los Angeles Veterans Administration Medical Center and
Professor
Chief of Substance Abuse Program
University of California, Los Angeles (UCLA)
Los Angeles, California
Carole A. Madden, R.N., B.S.N., C.D.
Coordinator of Intervention Services
North Arundel Hospital
Glen Burnie, Maryland
John Melbourne, M.D.
Medical Director
Chemical Dependency Services
Danbury Hospital
Danbury, Connecticut
David E. Smith, M.D.
Medical Director
Haight Ashbury Free Clinics
Training and Education Project
San Francisco, California
Lovetta L. Smith, R.N., D.N.Sc., F.A.A.N. 1
Associate Chief of Nursing Service
Surgical and Special Care Service
Gainesville Veterans Administration Medical Center
Gainesville, Florida
1. Lovetta Smith, R.N., D.N.Sc., F.A.A.N., was
originally cochair for this TIP but had to withdraw. Her contributions as
cochair are appreciated. Dr. Smith also served as a field reviewer for the
document.
The Treatment Improvement Protocol (TIP) series fulfills CSAT's mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel's work is reviewed and critiqued by field reviewers as it evolves.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advance our substance abuse treatment field.
Nelba Chavez, Ph.D.
Administrator
Substance Abuse and Mental Health Services Administration
David J. Mactas
Director
Center for Substance Abuse Treatment
The subject of this Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocol (TIP) is alcohol and other drug (AOD) detoxification -- the process through which a person who is physically dependent on alcohol, illegal drugs, prescription medications, or a combination of these drugs is withdrawn from the drug or drugs of dependence. Since most persons who have a substance use disorder are addicted to a combination of alcohol and/or other drugs (polydrug abuse), detoxification often involves more than one substance.
This TIP was written by a panel composed of AOD specialists in detoxification -- physicians specializing in addiction medicine, nurses, counselors, social workers, administrators, and researchers. Their goal was to develop comprehensive guidelines that would be useful to single State agency directors, physicians, nurses and other clinical staff, program administrators, staff of insurance carriers and managed care organizations, policymakers, and other individuals involved in planning, evaluating, and providing AOD detoxification services.
Panel members discussed detoxification settings and service components, and they reviewed patient assessment techniques and current detoxification protocols, as well as experimental treatments. They considered the needs of special populations; discussed issues related to measuring program outcomes, program financing, and health care reform; and identified legal and ethical issues of concern to program staff and administrators. This document reflects the panelists' consensus on these issues and incorporates many suggestions and recommendations from field reviewers.
The term detoxification implies a clearing of toxins (Alling, 1992). For many AOD-dependent people, removal of drugs from their bodies is indeed part of the detoxification process. In the context of treating patients who are physically dependent on alcohol or other drugs, detoxification also includes the period of time during which the body's physiology is adjusting to the absence of drugs. However, as Gerstein and Harwood wrote, "Detoxification . . . is not a treatment for drug-seeking behavior. Rather, it is a family of procedures for alleviating the short-term symptoms of withdrawal from drug dependence" (Gerstein and Harwood, 1990). It must also include "a period of psychological readjustment designed to prepare the patient to take the next step in ongoing treatment" (Czechowicz, 1979).
As more and more States implement health care reform, third-party payers often manage payment for AOD detoxification services separately from other phases of drug treatment, as though detoxification occurs in isolation from drug treatment. In clinical practice, this separation cannot exist. Detoxification is one component of a comprehensive treatment strategy.
This TIP focuses specifically on detoxification and does not attempt to provide guidance on issues beyond those immediately related to this subject. The panelists who developed the TIP are aware that the discussion of detoxification, apart from the larger context of substance use disorders, is somewhat incomplete. However, the scope of this TIP is determined by the need to cover one issue in depth, complementing but not duplicating information available in other TIPs in the series.
Because detoxification often entails a more intensive level of care than other types of AOD treatment, there is a practical value in defining a period during which a person is "in detoxification." There is no simple way to do this. Usually, the detoxification period is defined as the period during which the patient receives detoxification medications.
Third-party payers often manage payment for AOD detoxification services separately from other phases of drug treatment, as though detoxification occurs in isolation from drug treatment. In clinical practice, this separation cannot exist. Detoxification is one component of a comprehensive treatment strategy.
Another way of defining the detoxification period is by measuring the duration of withdrawal signs or symptoms. However, the duration of these symptoms may be difficult to determine in a correctly medicated patient because symptoms of withdrawal are largely suppressed by the medication. Chapter 3 describes the typical lengths of regimens for withdrawal.
For many AOD-dependent patients, detoxification is the beginning phase of treatment. It can entail more than a period of physical readjustment. It can also be a time when patients begin to make the psychological readjustments necessary for ongoing treatment. Offering detoxification alone, without followup to an appropriate level of care, is an inadequate use of limited resources. People who have severe problems that predate their AOD dependence or addiction -- such as family disintegration, lack of job skills, illiteracy, or psychiatric disorders -- may continue to have these problems after detoxification unless specific services are available to help them deal with these factors (Gerstein and Harwood, 1990).
Alling discussed detoxification and treatment in a text published in 1992:
Those not familiar with the chronic nature of addictive disorders often characterize detoxification programs as 'revolving doors' through which patients come and go in an endless cycle, and which have little or no impact on the recovery process. Although it is true that many people undergo detoxification more than once -- and some do so many times -- the assumption that little or no progress has been made is often false. (Alling, 1992)
Alling(1992) described a pattern in individuals who return for several detoxification episodes, observing that young people with a history of AOD dependence of short duration (a year or less) "often are unrealistically optimistic about being able to remain drug free following detoxification." When recently AOD-dependent persons return after several months for repeat detoxification, it is usually with a more realistic expectation about what is needed to remain free from AODs. Individuals who subsequently relapse and return for detoxification a third time may have an even clearer understanding of what is required to sustain recovery (Alling, 1992).
During certain expected and predictable phases of recovery, addicted persons are at increased risk of relapse. However, relapse can occur at any point in recovery. Thus, 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.
Few addicted persons enter detoxification or seek further treatment with the idea of maintaining lifelong abstinence. They may still believe they can control their abuse of AODs. Some persons enter detoxification and other treatment to satisfy the demands of their families, employers, or the courts. They may be motivated to seek treatment because attempts to relieve pressure through other means have proved futile. Clinicians should consider patient motivation when deciding upon appropriate treatment placement.
Families suffer severe consequences from the AOD abuse of their loved ones. The consequences may include obvious problems such as lost income, domestic violence, or divorce. Less obvious consequences may also occur, such as issues concerning trust and children's mirroring maladaptive ways to deal with problems encountered in everyday living. Addiction is a family disease because of the seriousness of its effects on family members and family functioning. Just as the person who abuses AODs needs support, education, and counseling, so too does the family. It is appropriate and important for treatment providers to engage the family in treatment as early as possible, even while the individual is undergoing detoxification.
Continued exposure to AODs induces adaptive changes in an individual's brain cells and neural functioning. The changes vary depending on the drug of abuse and are not completely understood. The term "neuroadaptation" is often used to refer to these changes. One result of neuroadaptation is drug tolerance; that is, increasing the amounts of the drug that are required to produce the same effect. A second consequence of neuroadaptation is physical dependence; the brain cells require the drug in order to function.
Sudden removal of alcohol or another drug of abuse from the system of a person who is physically dependent produces either an abstinence or withdrawal syndrome. The abstinence syndrome for each drug follows a predictable time course and has predictable signs and symptoms. Signs are defined by Webster's Medical Dictionary as "objective evidence of disease especially as observed and interpreted by the physician rather than by the patient or lay observer." Symptoms are defined in the same text as "subjective evidence of disease or physical disturbance observed by the patient."
There are three immediate goals of detoxification:
The signs and symptoms of drug withdrawal are usually the reverse of the direct pharmacological effects of the drug. Heroin use commonly produces elevation of mood (euphoria), a decrease in anxiety, insensitivity to pain (analgesia), and a decrease in the activity of the large intestine, often causing constipation. Heroin withdrawal, on the other hand, produces an unpleasant mood (dysphoria), pain, anxiety, and overactivity of the large intestine, often resulting in diarrhea. Alcohol usually reduces anxiety and causes sedation; large quantities may produce sleep, coma, or even death by respiratory depression. In a person who is physically dependent, cessation of alcohol use produces anxiety, insomnia, hallucinations, and seizures.
For short-acting drugs such as alcohol and heroin, the most severe signs and symptoms of withdrawal usually begin within hours of the individual's last use. With a long-acting drug or medication, such as diazepam (Valium), withdrawal symptoms may not begin for several days and usually reach peak intensity after 5 to 10 days. The most severe drug-withdrawal symptoms, during the initial stages of detoxification, constitute the acute abstinence syndrome. The adjective "acute" distinguishes the syndrome from a "chronic" or protracted abstinence syndrome, in which signs and symptoms of withdrawal may continue for weeks to months after cessation of use (Martin and Jasinski, 1969).
Protracted abstinence syndrome is the subject of considerable controversy. Providers often find it difficult to distinguish symptoms caused by drug withdrawal from those caused by a patient's underlying mental disorder, if one is present. The signs and symptoms of protracted withdrawal are not as predictable as those of acute withdrawal. Some patients may be predisposed to a protracted withdrawal. Acute withdrawal syndromes produce measurable signs that researchers can study in animals under controlled laboratory conditions; protracted withdrawal in patients, by contrast, is often confined to distress symptoms that cannot be studied in animals.
The signs and symptoms of drug withdrawal are usually the reverse of the direct pharmacological effects of the drug.
Addiction specialists and researchers categorize drugs and medications into groups such as opioids, sedative-hypnotics, and stimulants. Drugs in each group are similar pharmacologically and produce a similar withdrawal syndrome. The term opiate refers to opium and derivatives of opium, a naturally occurring substance, that have effects similar to those of morphine. Drugs such as heroin and medications such as codeine are examples of opiates. The term opioid refers to all substances, both those derived from opium and those synthetically produced, that have effects similar to the effects of morphine. Examples of synthetic opioids include Demerol, Percodan, and methadone. Sedative-hypnotics are usually prescribed medications designed to reduce anxiety or facilitate sleep. They include barbiturates such as secobarbital (Seconal) and benzodiazepines such as diazepam (Valium) and alprazolam (Xanax). Alcohol shares many pharmacological characteristics with the sedative-hypnotics. Stimulants produce increased arousal accompanied by a sense of confidence and euphoria. This category of drug includes cocaine and methamphetamine.
All drugs in a given group produce a common withdrawal syndrome; however, the intensity and time span of the withdrawal varies, depending on the specific agent. The signs and symptoms of methadone withdrawal are similar to those of heroin withdrawal; however, the signs of heroin withdrawal begin relatively quickly and peak within 24 to 48 hours after the last dose. Methadone withdrawal symptoms begin more slowly, are less intense, and last longer.
The severity of withdrawal varies by drug group. Opioid withdrawal is unpleasant and distressing to patients, but it is not medically life threatening to a person who is otherwise physically healthy. On the other hand, withdrawal from alcohol or other sedative-hypnotics can produce grand mal seizures and a life-threatening disruption of physiology, even in a patient without other medical illness. Stimulant withdrawal is characterized by such symptoms as depression, and the primary risk during withdrawal is suicidal behavior.
After detoxification, the physiological functioning of the brain cells gradually returns to its predependent state; however, the cells may not be exactly the same as they were before dependence. Should a person who has undergone detoxification resume use of any drug in the same category as that upon which he or she has been physically dependent, neuroadaptation occurs more rapidly than it did the first time (Cochin and Kornetsky, 1964).
A number of forces are reshaping the delivery of AOD detoxification and treatment services. Some managed care systems and health insurance programs have curtailed substance use disorder treatment services. A challenge for those engaged in health care reform is to achieve a balance between high-quality care and cost-effective care. Most health insurance today is provided by employers. Employers and insurers will have more incentives to offer adequate AOD abuse treatment services as a standard benefit if they are educated about the treatable nature of addictive disease and the overall cost-effectiveness of treatment. The AOD abuse treatment system can be instrumental in providing this education. To do so, it will be necessary to substantiate the effectiveness of treatment. Careful research that generates solid data showing the benefits of treatment is the most powerful way to change negative perceptions.
Results were recently published of an important long-term study conducted by the California Department of Alcohol and Drug Programs on the effectiveness of AOD abuse treatment, the costs of treatment, and the economic value of treatment to society (California Department of Alcohol and Drug Programs, 1994). This 2-year study, called the CALDATA study, followed a rigorous probability sample of 1,900 individuals, representing the nearly 150,000 persons who received AOD abuse treatment in California in 1992. The sample included patients who received treatment in therapeutic communities, social model programs, outpatient drug-free programs, and methadone maintenance programs. The cost of treating the approximately 150,000 participants in 1992 was $209 million, while the benefits accrued during treatment and in the first year afterwards were worth approximately $1.5 billion. Thus, for every dollar spent on treatment, more than $7 in future costs were saved, most significantly in the area of crime. For a smaller sample followed through the second year, results indicate that longer range cumulative benefits of treatment will be substantially higher than shorter term benefits.
In a summary of the study, its authors listed the following findings under the heading Treatment Effectiveness:
Managed care criteria may present barriers to appropriate treatment. Inpatient treatment must be certified as medically necessary. For chemical dependency treatment, insurance providers often equate medical necessity only with the detoxification phase. Unless the patient has coexisting medical or psychiatric conditions, he or she is often removed from inpatient treatment when detoxification is complete.
Research appears to indicate that, at least in the long term, there are no significant differences between the outcomes for patients who are treated as inpatients and those who are treated as outpatients. Hayashida and colleagues (Hayashida et al., 1989) wrote that "Outpatient medical detoxification should be considered as an effective, safe, and cost-saving treatment alternative for persons with mild-to-moderate symptoms of alcohol withdrawal."
The impact of managed care on patient treatment outcome has not been studied adequately. The panelists were concerned that important clinical decisions affecting patient care were often driven by economic rather than clinical considerations. Skilled clinicians consider many factors other than a diagnosis of substance use disorder when deciding the level of care for a patient. Some examples of these considerations include whether the patient is living in a supportive, drug-free environment; whether there is a high level of family discord; whether the patient has significant psychiatric comorbidity; and whether the patient has access to appropriate transportation to and from the treatment facility.
Many AOD-abusing patients have inadequate treatment coverage and resources. If they relapse to AOD abuse following treatment, they may be fired and lose their health benefits. Because preemployment screening has become common, these individuals frequently are unable to find other jobs and thereby regain health insurance coverage. As a result, many AOD abusers are unemployed and have no health insurance. Their only treatment alternative is the public sector, which in most areas does not have the capacity needed to meet requests for services.
For AOD-dependent individuals, waiting periods and other barriers to treatment are countertherapeutic. An important facet of addiction is the individual's denial of the adverse effects of his or her AOD abuse. Many patients seek detoxification only during times of crisis: a drug-related seizure, an arrest, an illness of a family member, or the death of a friend. Patients who are physically dependent may recognize the need for detoxification, but they may or may not recognize the need for ongoing treatment. For AOD abuse treatment staff, a patient's crisis creates an intervention opportunity. During the crisis and its resolution, patients may be unusually receptive to consideration of lifestyle alternatives, education, and the need for longer term treatment.
Health care reform, now on the political agendas of the Nation and the States, offers some avenues for improving access to treatment. Many populations, including the homeless, minority women, and nonregistered immigrants, have little access to treatment. Under some universal health coverage plans, more AOD-dependent persons would have access to treatment, and those with insurance would not be terminated from their policies if they relapsed.
A second area that holds promise for progress in AOD abuse treatment is the developing specialty of addiction medicine. The American Board of Psychiatry and Neurology now offers a subspecialty board certification in addiction medicine for physicians who are already board certified in psychiatry. In addition, the American Society of Addiction Medicine offers a certification of added qualification in addiction medicine for psychiatrists who are already board certified. Certification ensures that physicians who practice addiction medicine share a baseline understanding of the knowledge and skills on which their specialty is based.
Responsibility for AOD abuse treatment does not lie in the hands of physicians alone. It is increasingly shared among nurses, nurse practitioners, physicians' assistants, addiction counselors, social workers, nurses' aides, and other providers, as well as by managed care organizations. For this reason, the movement toward certification and inservice training programs for health providers should be expanded. A multidisciplinary, coordinated approach is essential. To ensure high-quality care, providers will need to establish referral networks and linkages among various treatment modalities.
Finally, unprecedented advances in the basic and behavioral sciences hold promise for the future of substance use disorder treatment. Chief among these are the recent growth in knowledge concerning how AODs affect brain cells and an appreciation of neurocognitive functioning. Some of this knowledge has direct application to AOD abuse treatment, particularly to detoxification.
This document is one in a series of CSAT TIPs. There is some overlap between topics covered in this TIP and others. Detoxification of pregnant women who abuse drugs and detoxification of neonates, although important topics, are not covered in detail in this document because each has been the subject of a previous TIP (Pregnant, Substance-Using Women [TIP 2; Center for Substance Abuse Treatment, 1993]; Improving Treatment for Drug-Exposed Infants [TIP 5; Center for Substance Abuse Treatment, 1993]). Medical, legal, and program considerations regarding infectious diseases (considerations that are important during detoxification) are covered in a TIP titled Screening for Infectious Diseases Among Substance Abusers (TIP 6; Center for Substance Abuse Treatment, 1993). These documents are cited in this publication.
Responsibility for AOD abuse treatment does not lie in the hands of physicians alone. A multidisciplinary, coordinated approach is essential. To ensure high-quality care, providers will need to establish referral networks and linkages among various treatment modalities.
This TIP covers the following areas:
Chapter 2 -- Detoxification Settings and Patient Matching. This chapter describes the treatment settings in which detoxification occurs and considerations relating to patient matching. In it, the panel proposes a new configuration for detoxification services -- the modified medical model. In considering this proposed model, the consensus panel discussed the improvement of quality of care by ensuring that persons are treated in a detoxification setting appropriate to their clinical needs. Patients should have access to all needed treatment services as well, including emergency treatment.
Chapter 3 -- Clinical Detoxification Protocols. This chapter describes drug-specific withdrawal syndromes and presents guidelines for their clinical management. Treatment guidelines are outlined in sufficient detail to be of practical use to physicians and nurses. New treatment techniques, such as rapid detoxification protocols and the use of levo-alpha-acetylmethadol, and experimental treatments such as acupuncture, are reviewed. Also included is information on the medical and legal status of medications such as methadone, which are sometimes used for detoxification.
Chapter 4 -- Special Populations. This chapter summarizes considerations that must be taken into account when providing detoxification services to individuals who are incarcerated, adolescent, elderly, or human immunodeficiency virus (HIV) positive. The chapter also addresses women's issues in detoxification.
Chapter 5 -- Improving Quality and Measuring Outcomes of AOD Detoxification Services. This chapter outlines ways in which program staff may evaluate their services and improve the quality of patient care.
Chapter 6 -- Costs and Current Payment Mechanisms for AOD Detoxification. This chapter provides a strategy for estimating the costs of detoxification and summarizes information on public and private reimbursement for care.
Appendix A lists articles and other materials used in the development of this TIP as well as recent articles that cover particular aspects of detoxification treatment. Established and readily accessible knowledge in standard texts is not referenced.
Appendix B is a glossary of technical terms used in this TIP.
Appendix C provides information on private and public agencies and associations with resources that may be useful to staff members of AOD detoxification programs.
Appendix D is a list of acronyms that are commonly used in the AOD abuse treatment field.
Appendix E, written by an attorney, provides an overview of Federal confidentiality requirements and issues relating to recordkeeping and consent to treatment.
Appendix F lists the names of persons who attended the Federal resource panel in the early stages of development of the TIP.
Appendix G lists experts from across the country who participated in the field review of the TIP.
Treatment providers should discuss detoxification settings and patient matching within the context of two fundamental principles of high-quality patient care. The first is that the patient's needs should drive the selection of the most appropriate setting. The severity of the patient's withdrawal symptoms and the intensity of care required to ensure appropriate management of these symptoms are of primary importance.
Second, detoxification should be viewed as the gateway to ongoing treatment. As noted in Chapter 1 of this Treatment Improvement Protocol (TIP), providing a safe withdrawal is the first goal of detoxification, and another is to prepare the patient for appropriate followup treatment. Staff members in all detoxification settings, from the least restrictive to the most intensive, must facilitate this goal, as should policies governing reimbursement for services.
Insurance carriers' and managed health care organizations' goal of short-term cost savings is having a significant effect on the selection of the treatment settings. Insurance providers have developed and implemented stringent policies concerning reimbursement for alcohol and other drug (AOD) detoxification services. Such policies govern not only the setting in which the services are provided, but also the maximum number and length of detoxification episodes covered.
Insurance carriers' and managed health care organizations' goal of short-term cost savings is having a significant effect on the selection of treatment settings.
Insurers are increasingly reluctant to cover inpatient detoxification unless there is clear-cut medical or psychiatric evidence of the patient's need for this kind of care. They have established medical criteria, such as the severity of AOD dependence and the presence of concurrent medical complications, upon which to base the decision to provide coverage. Insurers may also tie reimbursement of detoxification programs to their structures. For example, services that are offered by social model programs may not be covered if the program has no formal affiliation with a physician.
Current policies concerning reimbursement for services may be problematic from a patient care perspective. They give insufficient weight to the variety of factors that affect the selection of a setting in which the patient has the greatest likelihood of achieving satisfactory detoxification. Some persons in need of detoxification, for example, may not be appropriate candidates for outpatient detoxification because their spouses or others in their household are AOD dependent. These individuals may be more appropriately treated if they undergo detoxification in a residential setting such as a recovery house or other AOD-free residential environment. Detoxification is ultimately cost effective only if it is appropriate to the needs of the individual patient.
Considerable variation exists in the levels of care provided by AOD abuse treatment programs. Inpatient programs generally have fairly extensive onsite capabilities for providing medical care to patients or are affiliated with a nearby medical center. Some residential treatment programs are loosely affiliated with a medical center. Intensive outpatient treatment programs may be located within or closely affiliated with a hospital or medical center. Therapeutic communities are residential and have minimal, if any, onsite medical capabilities. They tend to rely on outside sources of medical care. Detoxification services generally are available under a medical model or a social model.
Medical model programs are directed by a physician and staffed by other health care personnel. They range from hospital-based inpatient programs to free-standing medically based residential programs in hospitals or in community facilities that can draw on various medical resources.
Social model AOD abuse treatment programs concentrate on providing psychosocial services. Social workers and other clinicians provide services such as individual and family counseling and coordination of care. Patients who need a physician's care may be referred to a nearby emergency department, which is not a cost-effective source of detoxification services. Some programs that provide detoxification services have a physician on call who can prescribe detoxification medications.
Social model programs use a variety of approaches to detoxification, but the emphasis is most often on nonpharmacological management of withdrawal. Usually, counselors do not have prescribing privileges and cannot legally administer medications from stock bottles to patients. In some programs, counselors can assist patients in taking detoxification medications. The patient's medication supply must be in a container that is labeled with the patient's name and that includes instructions for taking the medication. Counselors observe the patient take the medication, and they maintain a log. Counselors can also monitor patients' symptoms and call physicians or nurse practitioners if patients become ill.
Social model programs should not provide detoxification for people who have severe dependence on alcohol or other sedative-hypnotics, as withdrawal can be life threatening in these cases. Patients must be properly medically evaluated when they enter a social model program.
Detoxification may occur either in an inpatient or an outpatient setting. Both types of settings initiate recovery programs that may include referrals for problems such as medical, legal, psychiatric, and family issues.
According to Alling(1992), inpatient detoxification has the following advantages:
Outpatient detoxification has the following advantages:
Medical model programs range from hospital-based inpatient programs to free-standing medically based residential programs in hospitals or in community facilities that can draw on various medical resources.
Inpatient detoxification is offered in medical hospitals, psychiatric hospitals, and medically managed residential treatment programs.
Many acute are hospitals formerly operated subacute-care units, or chemical dependency units, that served as sites for uncomplicated detoxification. These programs, known as Minnesota Model programs, generally involved a 28-day inpatient stay followed by varying lengths of outpatient therapy and participation in self-help groups. Most were based on the Alcoholics Anonymous (12-step) model of personal change and the belief that vulnerability to AOD dependence is permanent but controllable. The goals of these programs were abstinence from all AODs and lifestyle alteration. Because of decreasing insurance reimbursement for stays in such units, many have ceased operation. In an effort to maintain treatment for those who need this type of care, some of the hospitals that house these units have developed other addiction services, such as intensive outpatient treatment programs.
Many acute care hospitals that do not maintain chemical dependency units commonly use a "scatter bed" approach, placing a patient in any clinical area of the hospital in which a bed is available Alling(1992), inpatient detoxification has the following advantages:
Outpatient detoxification has the following advantages:
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. In areas where medical hospital detoxification programs are not available, patients with no psychiatric comorbid conditions may be admitted to a psychiatric unit for detoxification. The detoxification protocols used in psychiatric hospitals are the same as those used in medical acute and subacute settings.
Rather than acute care hospitals, medically managed residential treatment centers are AOD abuse medical care centers, where specialized services are provided by medical staff under the direction of a qualified physician with knowledge of and skills in addiction treatment. Psychosocial and behavioral services are usually provided as necessary components of successful treatment.
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.
Again, outpatient detoxification has three major advantages: It is less expensive; it is less disruptive; and it allows the patient to remain in the same setting where he or she will function when drug free. Outpatient detoxification usually is offered in community mental health centers, AOD abuse treatment clinics, and private clinics.
Emergency Departments. The emergency department (ED) often serves as a gateway to AOD detoxification services. AOD detoxification programs may rely on emergency department staff to assess and initiate treatment for patients with medical conditions or medical complications that occur during detoxification. For social model programs, EDs are often a safety net for patients who need medical treatment. For the AOD abuser who has overdosed or who is experiencing a medical complication of AOD abuse, the ED may be the initial point of contact with the health services system. It serves as a source of case identification and referral to AOD detoxification programs. Certain illnesses treated in emergency departments may mimic, mask, or resemble symptoms of withdrawal from AODs. Urine and blood toxicology testing may assist ED staff in making the correct diagnosis.
ED staff should refer patients who enter for detoxification to a more appropriate treatment site as soon as they have been assessed and stabilized. The ED of an acute care hospital is neither an appropriate setting for detoxification, nor is it a cost-effective one. However, because of the key role of the ED in the initial management and identification of persons in need of detoxification, ED staff should have both clinical expertise and familiarity with local AOD abuse treatment resources.
Intensive Outpatient Programs. Intensive outpatient programs offer a minimum of 9 hours a week of professionally directed evaluation and treatment in a structured environment. Examples include day or evening programs in which patients attend a full spectrum of treatment programming but live at home or in special residences. Some programs provide medical detoxification. Many programs have established linkages through which they may refer patients to behavioral and psychosocial treatment. One strength of these programs is the daily contact between patients and staff. Another TIP in this series, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, describes these programs in detail.
Nonintensive Outpatient Programs. In nonintensive outpatient programs, patients attend regularly scheduled sessions that usually total no more than 9 hours of professionally directed evaluation and treatment per week. These programs may provide detoxification services. Treatment approaches and philosophies in staffing of outpatient programs vary considerably. Some offer only assessments; in others, counseling may continue for a year or longer. A majority of programs provide one or two weekly patient visits and may deliver psychiatric or psychological counseling and other services, such as resource referral and management. Many combine counseling with 12-step recovery.
Methadone Maintenance (Maintenance Pharmacotherapy) Clinics. These clinics may provide medically supervised withdrawal for persons abusing heroin who do not want to enter a methadone maintenance program but instead want to use methadone for withdrawal only, as well as for people who want to withdraw from methadone maintenance. The clinics, which must be licensed by the Food and Drug Administration, the Drug Enforcement Administration, and State regulatory agencies, are the only programs in which methadone maintenance may be conducted for opiate addicts. They may be publicly funded and/or on a fee-for-service basis, but the distinction between public and private clinics is not clearcut; for example, many private clinics have contracts with the State or county to provide detoxification services.
Social model programs that provide detoxification should have reliable and routine access to medical services to manage medical and psychiatric complications of their patients' withdrawal. The access may be provided by a physician, nurse practitioner, or physician's assistant. The panel suggested calling social model programs that provide medical detoxification services under medical supervision a "modified medical model." The purpose of the new name is to assist such programs in obtaining reimbursement under State health care reform and through managed care and third-party payers. The suggested name "modified medical model" caused some controversy among the panelists and field reviewers. Nonmedical panelists noted that the new name could imply a "medical takeover" of social model programs. The panelists with medical backgrounds and orientations pointed out that the current state of the art of detoxification, particularly from alcohol and other sedative-hypnotics and opiates, requires medical assessment and prescription of medications. A closer alliance of the two models would provide better patient care and make some program services reimbursable by health care payers.
Advances in AOD abuse treatment over the past decade support this type of program, which may be described as a social model program backed up by all of the medical services needed to meet the physical needs of the patient undergoing detoxification. The essential characteristics of the ideal modified medical model are outlined under the following four headlines.
The "modified medical model" detoxification program is headed by a medical director who has knowledge of and skills in the treatment of addiction and who holds ultimate responsibility for patient care. The clinical responsibilities of the medical director include seeing patients when necessary and remaining on call for consultations. The director's primary administrative duties are supervising detoxification staff and establishing clinical protocols.
Triage and ongoing patient evaluation are essential components of the proposed "modified medical model." Staff regularly monitor each patient's vital signs, and the decision to medicate or not to medicate is made by a physician. Such a routine stands in sharp contrast to that of traditional social model programs. Frequently, in these settings, no one is available to monitor patients' vital signs. When crises occur, patients must be transported to a local emergency department. This practice is not cost-effective and does not ensure optimal patient care.
A nurse practitioner or a physician's assistant manages day-to-day program operations. If the staff of the modified medical detoxification unit does not include a nurse practitioner or physician's assistant, the medical director's time in the program is expanded.
The nurse's chief responsibilities are to monitor patients' vital signs and to perform other nursing services. When an individual needs medical attention, the nurses call on a member of the medical team, if one is available to the unit, rather than referring the patient to an emergency department. However, if a member of the medical team is not available, the patient should be seen in an emergency department. A registered nurse should remain on call, and nurse's aides (such as rehabilitation technicians or detoxification aides) should be on duty at all times. Appropriate support for the nurse's aides includes, at a minimum, a nurse and a backup physician.
Ideally, all staff working in the program, including nurses, nurse practitioners, nurse's aides, and physician's assistants, are trained in detoxification and in the treatment of chemical dependency. Taking and interpreting vital signs constitute a minimal standard of care, and some staff members, such as nurse's aides, might be trained to interpret signs relevant to AOD abuse issues, since such training is not provided in many standard curricula. Nurse's aides undoubtedly would also require additional training in AOD abuse issues in order to serve as effective members of the care team in a detoxification unit. Program administrators should establish minimum standards for licensure and accreditation of modified medical programs and staff.
The best detoxification setting for a given patient may be defined as the least restrictive, least expensive setting in which the goals of detoxification can be met. The ability to meet this standard assumes that treatment choices are always based primarily on a patient's clinical needs. The least expensive care may not necessarily be the best care for a given individual. Less expensive but clinically inappropriate care will not be cost effective. It is often difficult to know which patients will be able to reach their detoxification goals in a relatively unrestricted setting, such as an outpatient AOD clinic, and which patients will need closer medical supervision and more comprehensive care. Decisionmakers should rely on clinical experience, close collaboration on the part of the multidisciplinary team, and respect for the patient's wishes to make the appropriate decision.
A comprehensive evaluation of the patient often indicates what therapeutic goals might realistically be achieved during the time allotted for the detoxification process. Alling (1992) suggested that such goals might include "treating current medical problems discovered; helping the person arrange for further drug-free rehabilitation following discharge; and educating the person in the area of drug-related problems, such as relapse prevention, health-related issues, and attention to family, vocational, religious, and legal problems as may be required."
The best detoxification setting for a given patient may be defined as the least restrictive, least expensive setting in which the goals of detoxification can be met. The ability to meet this standard assumes that treatment choices are always based primarily on a patient's clinical needs.
For those who seek additional guidance in this area, a number of criteria sets have been developed to guide the process of matching patients to treatment settings. The Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (Hoffman, 1991), developed by the American Society of Addiction Medicine (ASAM) in 1991, are used by many programs. The ASAM criteria, which are intended for use as a clinical tool for matching patients to appropriate levels of care, reflect a clinical consensus of adult and adolescent treatment specialists and incorporate the results of a field review.
According to the ASAM Patient Placement Criteria, the three goals for management of detoxification are (1) avoidance of potential hazardous consequences of discontinuation of the drug of dependence; (2) facilitation of the patient's completion of detoxification and timely entry into continued treatment; and (3) promotion of patient dignity and easing of discomfort during the withdrawal process.
The ASAM criteria describe levels of treatment that are differentiated by the following three characteristics:
The ASAM levels of care range from outpatient treatment to medically managed intensive inpatient care. (The ASAM criteria do not provide for detoxification in social model programs.)
The ASAM criteria offer a variety of options, on the premise that each patient should be placed in a level of care that has the appropriate resources (staff, facilities, and services) to assess and treat the substance use disorder. While the criteria describe four levels of care, variations in staffing and support services may give some programs the capacity for more or less intense monitoring of detoxification than other programs at the same level of care.
The levels of care addressed by the ASAM Patient Placement Criteria are matched with the corresponding recommended detoxification settings described in Exhibit 2-1. The TIP titled The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (TIP 13; Center for Substance Abuse Treatment, 1995) provides a framework to help providers understand the issues surrounding patient placement criteria and offers potential strategies that can be useful in developing criteria. This TIP represents an initial effort to develop criteria that are more consistent with the overall needs of the treatment field.
It provides an analysis of several sets of public and private criteria, including the ASAM criteria and those used by the States of Minnesota, Massachusetts, and Iowa. The TIP provides recommendations for filling in the gaps in existing criteria sets, so uniform criteria can be developed that are acceptable to both treatment providers and payers.
A managed care bibliography that includes information on patient placement criteria is available from CSAT. This bibliography, titled Annotated Bibliography: Substance Abuse Treatment Services and Health Care Reform, can be obtained by contacting CSAT's Division of State and Community Assistance at (301) 443-8391.
In recent years, some States have begun to develop standards of care on the basis of models such as the ASAM Patient Placement Criteria. The move toward the development of standards of care and their subsequent application across a broad range of detoxification settings has advantages and disadvantages.
Properly developed and executed, such standards have the potential to ensure increased uniformity of treatment and improved appropriateness and cost-effective allocation of resources. A basic consideration is meeting these expectations while at the same time maintaining the focus on the patient's clinical needs as the primary concern. Patient placement criteria can provide a safety net that protects patients from falling to the lowest level of care as a consequence of economic considerations or a lack of treatment alternatives. A major risk in the use of placement standards, however, is that they may be taken too literally by those not directly involved in patient care. This could result in a patient's receiving an inappropriate level of care that does not meet his or her clinical needs.
Clinicians must exercise judgment in all cases. If a single approach to care is widely adopted and strictly adhered to as the "correct" approach, treatment innovation may be stifled. The chief value of any criteria set is the added power that it gives providers to identify specific patient needs by means of a consistent and detailed assessment process and to choose a level of care that will specifically address those needs.
Some detoxification procedures are specific to particular drugs of dependence; others are based on general principles of treatment and are not drug specific. In this chapter, the general principles are presented first, followed by specific treatment regimens for each category.
Principles of detoxification:
Most alcohol-dependent individuals can be detoxified in a modified medical setting, provided assessment is comprehensive, medical backup is available, and staff know when to obtain a medical consultation. As Gerstein and Harwood (1990) wrote:
Detoxification episodes are often hospital based and may begin with emergency treatment of an overdose. Much drug detoxification (an estimated 100,000 admissions annually) is now taking place in hospital beds. It is doubtful whether hospitalization (especially beyond a day or two) is necessary in most cases, except for the special problems of addicted neonates, severe sedative-hypnotic dependence, or concurrent medical or severe psychiatric problems. For clients with a documented history of complications or flight from detoxification, residential detoxification may be indicated. Detoxification may . . . be undertaken successfully in most cases on a nonhospital residential, partial day care, or ambulatory basis.
Patients who score higher than 20 on the Clinical Institute Withdrawal Assessment (CIWA-Ar) instrument should be admitted to a hospital. (A detailed description of the CIWA-Ar follows.)
Most patients can be detoxified from alcohol in 3 to 5 days. Providers should consider the withdrawal time frame in terms of when the patient will need the most support; for alcoholics, this occurs the second day after the last ingestion. Other factors that influence the length of the detoxification period include the severity of the dependency and the patient's overall health status. Patients who are medically debilitated should detoxify more slowly.
The signs and symptoms of acute alcohol abstinence syndrome generally begin 6 to 24 hours after the patient takes his or her last drink. The acute phase of alcohol abstinence syndrome may begin when the patient still has significant blood alcohol concentrations. Signs and symptoms may include
Symptoms do not always progress from mild to severe in a predictable fashion. In some patients, a grand mal seizure may be the first manifestation of acute alcohol abstinence syndrome.
Although many programs devise their own methods of monitoring patients' withdrawal signs and symptoms, there is considerable advantage to using a widely accepted validated instrument. The CIWA-Ar is commonly used in clinical and research settings for initial assessment and ongoing monitoring of alcohol withdrawal symptoms. It "takes 2 to 5 minutes to administer, helps make the decision to hospitalize the patient or to treat him or her as an outpatient, and is useful for monitoring and managing the patient during withdrawal" (Fuller and Gordis, 1994). It measures the severity of alcohol withdrawal by rating 10 signs and symptoms: nausea; tremor; autonomic hyperactivity; anxiety; agitation; tactile, visual, and auditory disturbances; headache; and disorientation. The maximum score is 67 (Saitz et al., 1994). The CIWA-Ar is not copyrighted, and the version in Exhibit 3-1 (Sullivan et al., 1989) may be used freely.
The CIWA-Ar should be repeated at regular intervals (initially every 1 or 2 hours) to monitor patients' progress (Sullivan et al., 1989). Increasing scores on the CIWA-Ar signify the need for additional medication or a higher level of treatment; decreasing scores suggest therapeutic response to medication or treatment milieu. Patients scoring less than 10 on the CIWA-Ar do not usually need additional medication for withdrawal (Saitz et al, 1994.; Sullivan et al., 1989).
Benzodiazepines, such as chlordiazepoxide (Librium), clonazepam (Klonopin), chlorazepate (Tranxene), and diazepam (Valium), are considered effective tools in ameliorating signs and symptoms of alcohol withdrawal because they decrease the likelihood and number of withdrawal seizures and episodes of delirium tremens. Chlordiazepoxide is "currently the most commonly administered medication for alcohol withdrawal in the United States" (Saitz et al., 1994). Oxazepam (Serax) or lorazepam (Ativan) are sometimes used with patients who have severe liver disease because neither is metabolized by the liver.
There are several acceptable medication regimens for treating alcohol withdrawal:
Signs and symptoms of the acute phase of alcohol abstinence syndrome may include:
Some patients can be withdrawn from alcohol without medication treatment; however, guidelines for identifying patients who can safely be treated without medication have not been validated in controlled clinical trials. Clinically, it is safer to provide treatment for patients who may not need it than to withhold medication until patients develop severe withdrawal signs and symptoms.
Symptom-triggered therapy is an approach that could individualize and improve the management of alcohol withdrawal.
Carbamazepine, a medication used for treatment of seizures, has been reported as effective in treatment of alcohol withdrawal. A controlled study comparing carbamazepine 800 mg/day to oxazepam 120 mg/day for treatment of alcohol withdrawal found that the two drugs precipitated equivalent scores on the CIWA-Ar. The study's authors concluded that "anticonvulsants with antikindling properties may be superior to traditional benzodiazepines in preventing alcohol withdrawal seizures and in potentially reducing long-term neurologic, behavioral, and psychiatric complications of alcoholism. To our knowledge, no double-blind, controlled studies have directly compared carbamazepine to a benzodiazepine in the treatment of alcohol withdrawal" (Malcolm et al., 1989).
Some of the autonomic nervous system hyperactivity of alcohol withdrawal (such as rapid heartbeat, elevation of blood pressure, sweating, and tremors) is ameliorated by medications, such as propranolol (Inderal) and atenolol (Tenormin), that block beta adrenergic receptors. Although effective in decreasing autonomic symptoms, beta-blockers do not prevent hallucinations and confusion or withdrawal seizures. Propranolol may increase the risk of delirium and hallucinations during alcohol withdrawal (Jacob et al., 1983).
Delirium tremens and seizures are two severe physiologic responses to withdrawal from sedative-hypnotics. Patients who develop delirium tremens with auditory, visual, or tactile hallucinations may need antipsychotic medications to ameliorate their hallucinations and to decrease agitation. Haloperidol, known by the trade name of Haldol, generally controls symptoms (0.5 to 2.0 mg every 4 hours by mouth or by intramuscular injection). Patients who are not vomiting may be given the medication by mouth; those who are severely agitated or vomiting may be administered Haldol intramuscularly. Patients should continue to receive benzodiazepines. Phenothiazines such as chlorpromazine (Thorazine) should not be used because of the increased risk of seizures.
A controlled study has shown that magnesium sulfate does not reduce seizure frequency, even in patients with low serum magnesium levels (Wilson and Vulcano, 1984). More recent studies have affirmed the use of benzodiazepines to treat delirium tremens and seizures (Gorelick, 1993).
The therapeutic or prophylactic value of a routine prescription of phenytoin to prevent alcohol withdrawal seizures is not established (American Society of Addiction Medicine, 1994b). The current consensus is that phenytoin or other anticonvulsant therapy appropriate for the seizure type should be used for patients with an established history of seizure disorder (seizures not caused solely by alcohol withdrawal). Expert opinion is mixed as to whether phenytoin (or other anticonvulsants) should be used in addition to adequate sedative-hypnotic medication in patients who are at an increased risk of alcohol withdrawal seizures because of previous withdrawal seizures, head injury, meningitis, encephalitis, or a family history of seizure disorder. Intravenous phenytoin is not beneficial for patients with isolated acute alcohol withdrawal seizures, but it may be indicated for patients who have multiple alcohol withdrawal seizures. Metabolism of phenytoin varies from patient to patient. It should be administered orally or intravenously because it is poorly absorbed when administered intramuscularly.
Phenobarbital can be used for alcohol detoxification when the patient is physically dependent on both sedative-hypnotics and alcohol.
Naltrexone has been approved by the Food and Drug Administration (FDA) as a treatment adjunct to reduce relapse to alcohol dependence among detoxified alcohol-dependent patients. Naltrexone, previously marketed under the trade name of Trexan, is now marketed under the trade name of ReVia. The name change was made to prevent possible confusion with the benzodiazepine Tranxene.
Naltrexone is an opioid antagonist that has previously been used primarily to block the effects of heroin and thereby reduce the likelihood of relapse. Its mechanism of action in reducing alcohol consumption is not understood; however, clinical trials support its efficacy when it is used in conjunction with training in coping skills and/or supportive therapy (O'Malley et al., 1992; Volpicelli et al., 1992). It appears to reduce alcohol craving and thus is associated with less frequent and shorter relapses.
The National Institute on Alcohol Abuse and Alcoholism cautions that naltrexone should be administered only by doctors with knowledge of addiction treatment and as part of a structured treatment program. Researchers are still determining which populations are likely to respond best to naltrexone, and possible long-term side effects are under investigation.
Alcohol-dependent patients may have vitamin deficiencies, particularly of thiamine. Patients should receive thiamine in addition to high-potency multivitamins.
Patients in alcohol withdrawal who are vomiting or who are in acute delirium may not be able to take oral medications. The absorption of diazepam or chlordiazepoxide after intramuscular administration is unpredictable. Intramuscular absorption of lorazepam (Ativan) is more reliable than that of diazepam or chlordiazepoxide. Lorazepam may be administered in doses of 2 mg every hour until signs and symptoms subside.
Increasingly, providers and patients are choosing the option of outpatient detoxification in part because of cost and in part because hospitalization (for other than serious sedative dependence) is considered unnecessary in most cases when there are no concurrent medical or severe psychiatric problems (Gerstein and Harwood, 1990). Providers must take into account some additional considerations when designing treatment plans for outpatients:
Patients may continue to use alcohol in addition to the prescribed detoxification medications. If they develop withdrawal symptoms, they may self-medicate with AODs.
Maintaining the patient's fluid and electrolyte balance is of key importance during detoxification. Most patents can be given fluids orally, beginning with juices and progressing to other liquids, such as soups. Solid foods should be added to the patient's diet only after he or she can tolerate liquids. Patients who are vomiting or having severe diarrhea should first be treated with sips of liquids that contain electrolytes. The amount can be increased to patient tolerance. Patients who become dehydrated should receive intravenous fluids containing electrolytes, dextrose, and thiamine (100 mg/bottle).
Patients withdrawing from alcohol are not always dehydrated; in fact, many are overhydrated. Parenteral fluid therapy may be harmful in these cases. During detoxification from alcohol, patients generally tolerate a mild degree of dehydration better than they do overhydration.
Hypoglycemia is a significant danger during detoxification. Oral fluids should contain carbohydrates; orange juice may be one option. Parenteral fluids should contain 5 percent dextrose.
Any elevation of temperature in an individual who is undergoing withdrawal should be investigated. If the elevated temperature is a result of withdrawal, there is a need for additional medication and reevaluation of the detoxification schedule. If a patient has no other signs or symptoms of withdrawal, the elevated temperature is probably caused by an infection, and early aggressive antibiotic therapy may be necessary.
While medical concerns must be addressed first via detoxification, any underlying psychiatric disorders must be dealt with as well. Failure to do so increases the risk of relapse. How to evaluate psychiatric conditions depends on the drug of abuse and the clinical situation. Because it is often difficult to differentiate between the symptoms of AOD abuse and those of various psychiatric conditions that may exist, it is preferable to do a thorough psychiatric work-up after a patient has withdrawn from the drug of abuse. This may not always be possible.
Suicidal patients can be detoxified, but they should be placed in an acute inpatient psychiatric setting rather than in an outpatient detoxification setting. These patients require close supervision by medical staff who understand both psychiatric and detoxification issues. The individual who takes the patient's history should include questions about suicidal feelings and previous suicide attempts.
More information on psychiatric comorbidity is included in the chapter on special populations (Chapter 4). Another Treatment Improvement Protocol (TIP) in this series, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (TIP 9; Center for Substance Abuse Treatment, 1994), provides practical information about the treatment of patients who have dual disorders.
Suicidal patients can be detoxified, but they should be placed in an acute inpatient psychiatric setting rather than in an outpatient detoxification setting.
Certain drugs of abuse and certain medications used in detoxification may interact with others. Thus, it is important to be aware of any other medications that the patient is taking and to consider potential drug interactions. Some examples of dangerous combinations include hypertensive medication and clonidine, phenytoin (Dilantin) and methadone, and rifampin and methadone.
Supportive and hygienic care must be provided. Staff should provide whatever assistance is necessary to help the patient get cleaned up as much as possible immediately after entering the facility and bathed thoroughly as soon as he or she has been medically stabilized. Dental and oral care should be made available. The staff should carefully assess the patient for trauma, including bruises and lacerations. Because of their decreased level of consciousness, severe alcoholics may not be aware of head injuries, lacerations, and the like. Staff should continue to observe patients for head injuries after admission, because some injuries, such as subdural hematomas, may not be immediately evident.
All opiates -- heroin, morphine, hydromorphone (Dilaudid), codeine, and methadone -- produce similar withdrawal signs and symptoms. However, the time of onset and the duration of the abstinence syndrome vary. The severity of the withdrawal syndrome depends on many factors, including the drug used, the total daily dose, the interval between doses, the duration of use, and the health and personality of the addict. The common signs and symptoms of opiate withdrawal are summarized in Exhibit 3-2.
Symptoms of withdrawal from opiates may be divided into four classes: (1) gastrointestinal distress, including diarrhea and, less frequently, nausea or vomiting; (2) pain, typically either arthralgias or myalgias or abdominal cramping; (3) anxiety; and (4) insomnia.
Signs and symptoms of withdrawal from heroin or morphine begin 8 to 12 hours following the patient's last dose. They subside over a period of 5 to 7 days.
Signs and symptoms of withdrawal from methadone begin 12 hours after the patient's last dose. The peak intensity occurs on the third day of abstinence or later. Symptoms gradually subside, but may continue for 3 weeks or longer. Methadone abstinence syndrome develops more slowly and is more prolonged but usually less intense than other opiate abstinence syndromes.
In July 1993, the FDA approved levo-alpha-acetylmethadol (LAAM) for use as a maintenance medication. It is a Schedule II controlled substance, which categorizes it as a medication with medical uses but also with a high potential for abuse. Few studies have addressed the medically supervised withdrawal of LAAM patients to a drug-free state. Withdrawal from LAAM produces similar symptoms to those produced by withdrawal from methadone.
Clonidine (Catapres), a medication marketed for the treatment of hypertension, has been used for treatment of the symptoms of opiate withdrawal since 1978 (Gold et al., 1978). Although clonidine has not yet been approved by the FDA for treatment of opiate withdrawal, its use has become standard clinical practice (Alling, 1992).
Clonidine has some practical advantages over methadone for treating narcotic withdrawal, particularly in drug-free programs (Clark and Longmuir, 1986). These advantages include the following:
Although clonidine alleviates some symptoms of opiate withdrawal, it is not effective for muscle aches, insomnia, or drug craving. These symptoms require additional medication.
An appropriate protocol for clonidine is 0.1 mg administered orally as a test dose (0.2 mg for patients weighing more than 200 pounds). If the patient's symptoms are acute, the sublingual route of administration may be used. Clinicians should check the patient's blood pressure after 45 minutes. If diastolic blood pressure is normal for the patient and the patient has no signs of orthostatic hypotension (a drop in systolic blood pressure of 10 mm hg upon standing), the patient may continue clonidine, 0.1 to 0.2 mg orally every 4 to 6 hours. Clonidine is most effective when used for detoxification in an inpatient setting, as side effects can be monitored more closely.
Clonidine transdermal patch. In 1986, a transdermal patch containing clonidine (Catapres-TTS) was approved for use in the United States for the treatment of hypertension. However, addiction specialists quickly grasped its potential for treatment of opiate withdrawal. Although the clonidine patch is commonly used for detoxification, several panelists and reviewers were concerned that the safety of the patch for treatment of opiate withdrawal has not been sufficiently studied in controlled clinical trials. If patients receive too much clonidine from the patch and become hypotensive, the effects are not rapidly reversed even when the patch is removed. Alling(1992) recommends the use of clonidine only if the patient's blood pressure is monitored regularly.
The clonidine patch is a 0.2 mm square that is applied in the same manner as a self-adhesive bandage. It is available in three sizes: 3.5, 7.0, and 10.5 cm2. In a 24-hour period, these patches deliver an amount of clonidine equivalent to twice-daily dosing with 0.1, 0.2, or 0.3 mg of oral clonidine, respectively. Once the patch is placed on the epidermal surface, clonidine enters the circulatory system through the skin. A rate-limiting membrane within the patch governs the maximum amount absorbed. The patch supplies clonidine for up to 7 days. One application of the patch is sufficient.
In a recovery-oriented treatment program, the transdermal patch offers some advantages over oral clonidine. First, it minimizes drug cravings. Nurses in chemical dependency units often interpret patient requests for medications differently than do nurses in a medical or surgical hospital. In a chemical dependency unit, nurses often perceive these requests as drug-seeking behavior, and the result may be a confrontation with the patient about whether or not the medication is needed. For this reason, the use of "as needed" medications should be minimized.
A second advantage of the transdermal patch is that it eliminates disruptions caused by administration of medication. Oral clonidine must be administered several times each day, and chemical dependency counselors often report that groups or counseling sessions are disrupted when patients leave to obtain their medication.
The patch overcomes the problem of missed doses. Asymptomatic patients may forget to go to nurses' stations at scheduled times or miss doses when they are attending outside activities.
The patch also prevents the buildup of withdrawal symptoms during the night. Patients who miss doses of oral clonidine during the night because the nurses are reluctant to wake them sometimes experience opiate withdrawal upon awakening. The patch continues to deliver clonidine throughout the night.
For reasons such as these, staff and patients often prefer the patch over oral clonidine. Patients treated with oral clonidine appear to have more withdrawal symptoms than those treated with transdermal patches. However, controlled studies have not yet confirmed these findings.
Methadone can be used for withdrawal from heroin, fentanyl, or any other opiate. For certain patient populations, including those with many treatment failures, methadone is the treatment of choice. Methadone generally is not used with adolescents because FDA regulations prohibit its use with this age group (except in rare exceptions). In this population, there are high risks of addiction and promotion of drug-seeking behavior.
This TIP focuses on the use of methadone for detoxification. For detailed information readers are referred to the TIPs State Methadone Treatment Guidelines and Matching Treatment to Patient Needs in Opioid Substitution Therapy (TIP 1; Center for Substance Abuse Treatment, 1993).
Opiate-dependent inpatients who are being treated for an acute medical illness can be administered methadone for prevention of opiate withdrawal if opiate withdrawal would complicate treatment of their medical conditions. The withdrawal protocols using methadone vary, depending on the setting.
Inpatient drug treatment program licensed for methadone detoxification. A starting dose of 30 to 40 mg per day of oral methadone is adequate to prevent severe withdrawal symptoms in most opiate-dependent patients. The methadone is administered four times daily, beginning with 10 mg doses, and the patient is observed for 2 hours following each dose. If the patient is sleepy, the next dose is decreased to 5 mg. If the patient shows objective signs of opiate withdrawal, the dose is increased to 15 mg. After 24 hours, the methadone is withdrawn by 5 mg per day; thus, most patients are withdrawn over 8 days.
Methadone can be administered for detoxification only in a hospital or in an outpatient program that is licensed for methadone detoxification. Opiate-dependent inpatients who are being treated for an acute medical illness can be administered methadone for prevention of opiate withdrawal if opiate withdrawal would complicate treatment of their medical conditions.
Outpatient methadone detoxification clinics. In an outpatient clinic, treatment staff usually administer medication no more than twice a day. Thus 20 mg of methadone, given orally twice daily, is a good starting point. To prevent an unacceptable level of withdrawal symptoms, some outpatients may need up to 60 mg of methadone per day administered in divided doses. After the second day, the methadone is tapered by 2.5 mg per day.
Federal regulations governing methadone detoxification. As of 1989, Federal regulations allow short-term methadone detoxification of 30 days and long-term detoxification of 180 days. As the State methadone licensing agencies develop regulations that parallel the Federal regulations, State-licensed methadone programs can implement long-term methadone detoxification.
Federal regulations allow physicians to administer (but not prescribe) narcotics for the purpose of relieving acute withdrawal symptoms while arrangements are being made for referral for treatment. Not more than 1 day's medication may be administered to the person or for the person's use at one time. Such emergency treatment may be carried out for not more than 3 days and may not be renewed or extended (21 C.F.R. Part 1306.07). Thus, under Drug Enforcement Administration (DEA) guidelines, in States that allow the prescription of narcotics, a physician may administer methadone for 3 days without a special license if the patient is experiencing acute withdrawal symptoms and cannot be immediately referred for treatment. This is considered an emergency situation.
Short-term detoxification. In a short-term detoxification regimen, patients are not allowed to take their methadone home. The initial treatment plan and periodic treatment plan evaluation required for maintenance patients are not necessary; however, the program must assign a primary counselor to monitor a patient's progress toward the goal of short-term detoxification and to provide a drug treatment referral.
A patient is required to wait at least 7 days between concluding a short-term detoxification treatment episode and beginning another. Before a short-term detoxification attempt is repeated, the program physician must document in the patient's record that the patient continues to be or is again physiologically dependent on narcotics. These requirements apply to both inpatient and outpatient short-term detoxification treatment.
Long-term detoxification. Federal methadone treatment guidelines define long-term detoxification treatment as longer than 30 days but not in excess of 180 days. For long-term detoxification, the opioid must be administered by the program physician or by an authorized agent who is supervised by and under the orders of the physician. The drug must be administered on a regimen designed to help the patient reach a drug-free state and to make progress in rehabilitation in 180 days or fewer. The following conditions apply:
These requirements apply to both inpatient and ambulatory long-term detoxification treatment.
In a critical study published in 1977, Senay and colleagues (Senay et al., 1977) suggested that "a slow rate of withdrawal, extending 6 or more months, may result in a greater percentage of patients reaching abstinence and maintaining a drug-free status." However, the 180-day detoxification protocol has not received adequate study. More research is needed to compare its effectiveness with that of shorter regimens. Also, the issue of appropriate dosage is still under investigation. A randomized, double-blind clinical trial comparing the effect of 80 mg to 40 mg doses of methadone in patients enrolled in a 180-day program did not show statistically significant differences in retention between the two dosage levels (Banys et al., 1994).
As mentioned previously, in July, 1993 the FDA approved LAAM for use as a maintenance medication. The trade name of LAAM is ORLAAM. A detailed discussion of the use of LAAM is presented in the TIP titled LAAM in the Treatment of Opiate Addiction (TIP 22; Center for Substance Abuse Treatment, 1995).
Until August, 1993, LAAM was a Schedule I controlled substance, which is defined as a drug with a high abuse potential but with no recognized medical use. In August, 1993 the DEA reclassified it as a Schedule II controlled substance, defined as a medication with medical uses as well as a high potential for abuse (21 C.F.R. Part 1308).
FDA methadone regulations have been revised (58 Fed. Reg. 38706 Part July 20, 1993) to allow use of LAAM (21 C.F.R. Part 291). The regulations for LAAM are similar to those for methadone, with two exceptions: Take-home doses of LAAM are not allowed, and LAAM cannot be administered to pregnant women. Patients who need take-home doses must be switched to methadone. Like methadone, LAAM may be dispensed only by licensed AOD abuse treatment clinics (21 C.F.R. '291.505).
LAAM is a prodrug with little opiate activity. This means that its opiate effects are produced by its long-acting metabolites, nor-LAAM and dinor-LAAM. Since LAAM itself is not a potent opiate, oral ingestion or intravenous injection of LAAM does not produce rapid onset of opiate effects as does the ingestion of methadone, heroin, morphine, and most other opiates.
Take-home doses of LAAM are not allowed, and LAAM cannot be administered to pregnant women. Patients who need take-home doses must be switched to methadone. Like methadone, LAAM may be dispensed only by licensed treatment clinics.
Take-home doses of LAAM are not allowed, and LAAM cannot be administered to pregnant women. Patients who need take-home doses must be switched to methadone. Like methadone, LAAM may be dispensed only by licensed treatment clinics.
Discontinuation from LAAM maintenance. The metabolites of LAAM are long-acting, and gradual discontinuation of LAAM will result in a slow decline in the plasma levels of nor-LAAM and dinor-LAAM and in the emergence of opiate withdrawal symptoms. Maintenance treatment with LAAM produces significant levels of dependence of the opiate type; therefore, discontinuation of LAAM requires management of opiate withdrawal. Few studies have addressed the medically supervised withdrawal of LAAM patients to a drug-free state. However, no evidence exists to suggest that withdrawal from LAAM is different than withdrawal from methadone or any other opioid. Because LAAM is longer acting than methadone, withdrawal will have a delayed onset and protracted course, although it may be less intense than withdrawal from methadone. Patients, however, tend to perceive a longer period as being "worse," whether the actual intensity of symptoms is greater or not. Special counseling may be needed to address this aspect of withdrawal from LAAM.
The LAAM dose can be reduced gradually at a rate determined by the patient's response. As an alternative, patients who want to withdraw from LAAM treatment can be converted to methadone (at 80 percent of their LAAM dose) with minimal difficulty (Ling et al., 1980). The key consideration may be the patient's support system; take-home methadone entails fewer clinic visits. Although patients can visit the clinic on nondose days for support services only, they are less likely to do so without the incentive of receiving medication. Another option is the use of clonidine in the dosage regimen described previously for treatment of heroin withdrawal, to assist in discontinuing use of LAAM. When involuntary withdrawal from medication is unavoidable, patients should switch to methadone before withdrawal begins.
Heroin detoxification with LAAM. Although there is substantial medical literature reporting clinical trials with LAAM in treatment of heroin withdrawal, the FDA has not approved LAAM for use in heroin detoxification. It should, therefore, be used for heroin detoxification only under an Investigational New Drug (IND) exemption. Because LAAM takes from 8 to 12 hours to produce significant opiate effects, it is not a good choice for treatment of acute heroin withdrawal symptoms. Addicts may become impatient while waiting for LAAM to relieve their opiate withdrawal symptoms and may self-medicate their withdrawal symptoms with heroin. As the opiate effects of LAAM develop, the combined effects of heroin and LAAM may result in a life-threatening overdose. Treatment providers may prefer to begin heroin detoxification by stabilizing the patient on methadone, then switch to LAAM for gradual discontinuation over 21 to 180 days. LAAM's long duration of effect makes it a logical option for this process. Additional research to determine how to optimally use LAAM for detoxification is necessary.
Although there is substantial medical literature reporting clinical trials with LAAM in the treatment of heroin withdrawal, the FDA has not approved LAAM for use in heroin detoxification.
The FDA has approved buprenorphine for the treatment of pain, and it is being investigated as a treatment for opiate dependence and detoxification. Buprenorphine is a potent analgesic that is available by prescription as a sublingual tablet in many parts of the world. In the United States, it is available by prescription as an analgesic in an injectable form (Buprenex). The doses of buprenorphine under investigation for maintenance treatment are considerably higher than those commonly prescribed for treatment of pain.
Buprenorphine has an unusual pharmacological profile that makes it attractive for the treatment of opiate dependence, and its potential was recognized as early as 1978 (Jasinski et al., 1978). The level of physical dependence produced by buprenorphine is not as great as that produced by methadone or heroin; therefore, most patients find buprenorphine easier to discontinue than methadone. Some patients can eventually be switched from buprenorphine maintenance to treatment with an opiate antagonist such as naltrexone.
Buprenorphine is safer than methadone or LAAM if an overdose is ingested. Its opiate effects appear to plateau at 16 mg (Walsh et al., 1994). Although it is used intravenously by heroin addicts in countries where the sublingual tablet is legally available as an analgesic (San et al., 1992), its abuse potential appears to be substantially less than that of methadone or heroin. And though it is currently an experimental drug with regard to its use in detoxification, buprenorphine may soon be approved by the FDA.
Discontinuation from buprenorphine maintenance. Buprenorphine produces physical dependence of the opiate type. The dosages of patients who have been maintained on buprenorphine for treatment of opiate dependence or chronic pain must be tapered. The onset of withdrawal symptoms is generally delayed for at least 24 hours, and peak intensity of withdrawal symptoms may not occur for 5 days or more. The intensity of withdrawal symptoms is generally less than that following methadone discontinuation. Buprenorphine can be discontinued by tapering the dosage to zero over 7 to 21 days. Symptoms also may be ameliorated with clonidine, particularly toward the end of the taper (Pickworth et al., 1993).
Buprenorphine for heroin detoxification. Buprenorphine has been used successfully to detoxify heroin addicts in a number of clinical trials (Bickel et al., 1988) and to assist with methadone discontinuation (Banys et al., 1994).
In 1985, buprenorphine was classified as a Schedule V narcotic (21 C.F.R. § 1308.15(b). A narcotic is defined by the Controlled Substance Act of 1984 as a class of drugs containing opiates and cocaine, 21 U.S.C. § 802(17). The narcotic classification is important because Federal law permits prescription of a narcotic to narcotic addicts only in specially licensed treatment programs (21 C.F.R. § 291.505). The sole exception is that when a patient is admitted to a hospital for treatment of an acute medical condition (not solely addiction to drugs) he or she may be administered narcotics to prevent opiate withdrawal.
Because buprenorphine has already been approved by the FDA for treatment of pain, physicians could use it in clinical practice, even for unapproved indications, if it were not classified as a narcotic. Until buprenorphine receives FDA approval for treatment of opiate dependence, it should be prescribed for opiate dependence only under an FDA-approved IND exemption. Physicians may be prosecuted for prescribing, dispensing, or administering buprenorphine for treatment of opiate dependence or withdrawal. State medical licensing boards also may discipline physicians for prescribing buprenorphine for treatment of opiate dependence, absent an IND.
Under investigation. Sublingual tablets containing naloxone and buprenorphine are under investigation for use as treatments for opiate dependency. Since the opiate antagonist naloxone would block the immediate effect of buprenorphine, the combination would be less subject to abuse than buprenorphine alone. If patients dissolve the sublingual tablets, mix them with naloxone, and inject them, they would get no immediate opiate effects. Some buprenorphine opiate effects would eventually occur, however, because naloxone is more rapidly metabolized than buprenorphine. If a dosage form can be developed that minimizes the potential for diversion, buprenorphine could become the first opiate maintenance medication that could be prescribed as part of general medical practice.
Because buprenorphine has already been approved by the FDA for treatment of pain, physicians could use it in clinical practice, even for unapproved indications, if it were not classified as a narcotic.
In the 1970s, dextropropoxyphene (Darvon) was among the medications used for opiate withdrawal. Because of abuse of dextropropoxyphene by addicts, the DEA reclassified it as a Schedule IV narcotic, narcotic, 21 C.F.R. Part 1308 (1980). The narcotic classification prohibits its use for treatment of opiate dependency in routine clinical practice.
Patients on opiate maintenance are sometimes discontinued from medication for disciplinary reasons. This situation is often awkward for both the program and the patient, particularly if the patient is abusive, threatening, and/or potentially violent.
The program manager should develop and post prominently on the program premises at least one copy of a written policy covering criteria for involuntary termination from treatment. This policy should describe patients' rights and responsibilities as well as those of program staff. At the time a patient enters treatment, a staff member designated by the program director should inform the patient about the policy and where it is posted. The staff person should inform patients of the conditions under which they might be involuntarily terminated from treatment and of their rights under the termination procedure.
The medication discontinuation should not occur so rapidly that the patient experiences severe opiate withdrawal symptoms. Treatment staff should taper the methadone dosage until the patient is receiving 30 to 40 mg a day. At this point, treatment with clonidine and other medications may begin.
Patients in methadone treatment, like others who are receiving daily medication on a long-term basis, should be evaluated periodically regarding the risks and benefits of their therapy. For some persons, eventual withdrawal from methadone maintenance is a realistic goal.
Research and clinical experience have not yet identified all the critical variables that determine when a patient can be withdrawn from methadone and remain drug-free. A decision to withdraw voluntarily from methadone maintenance must, therefore, be left to the patient and to the clinical judgment of the physician. Staff should encourage the patient to remain in the program for as long as necessary.
Patient care guidelines are similar to those for patients withdrawing from alcohol. Patient comfort is a primary consideration during detoxification, regardless of the detoxification agent. Medications recommended for symptomatic relief of opiate withdrawal are summarized in Exhibit 3-3.
A complete physical examination should be conducted. The patient should be checked for tuberculosis; symptoms of acquired immunodeficiency syndrome and opportunistic infections; hepatitis A, B, and C; and sexually transmitted diseases. Patients should be monitored for anxiety, sweating, chills, nutritional intake, diarrhea and gastrointestinal distress, sleep dysfunction, muscle cramps, aches, and bowel function.
Skin care is also important. Guidelines should be in place for management of conditions such as skin and subcutaneous abscesses due to needle use.
A few patients may remain in bed for several hours or for as long as a day during detoxification; however, most do not need to do so. Opiate addicts generally have less cognitive impairment than do alcoholics. During detoxification, they may view videotapes and participate in group activities.
If the patient might be pregnant, appropriate testing is essential. It is important to evaluate the safety of withdrawing a pregnant woman from opiates because of the potential effects on the fetus. Often it is best to put the pregnant patient on methadone maintenance. More on the treatment of pregnant women is found in Chapter 4 , Special Populations. Other TIPs in this series, State Methadone Treatment Guidelines (TIP 1; Center for Substance Abuse Treatment, 1993); Pregnant, Substance-Using Women (TIP 2; Center for Substance Abuse Treatment, 1993); and LAAM in the Treatment of Opiate Addiction (TIP 22; Center for Substance Abuse Treatment, 1995) include information on issues specific to pregnant women.
While some clinicians consider acupuncture an acceptable primary detoxification treatment for opiate abusers, there are few controlled studies that support this. Acupuncture can be a useful treatment adjunct to methadone or clonidine detoxification. One study found that "Increased use of acupuncture therapy not only may be an effective adjunct to therapy in current programs for patients with persistent craving for alcohol, but also may allow treatment to be extended to a large group of recidivist alcoholics for whom current therapies are not effective" (Bullock et al., 1989).
Auricular (ear) acupuncture has been used in treatment of opiate withdrawal since 1972, and it is done in clinics throughout the world. "The use of auricular acupuncture in treating acute drug withdrawal began in Hong Kong in 1972. It was used sporadically throughout the United States during the 1970s, and some experimentation with acupuncture was conducted at the Haight Asbury Free Clinic in San Francisco (Seymour and Smith, 1987). But it has been at Lincoln Hospital in New York, under the guidance of Michael O. Smith, M.D., director of the hospital's division of substance abuse, that the protocol has been refined and expanded and has taken its firmer root" (Brumbaugh, 1993). It is difficult to conduct rigorous double-blind controlled studies with acupuncture because the acupuncturist must insert the needles into very precise locations.
One study (Washburn et al., 1993) compared standard acupuncture with "sham" acupuncture (needles were inserted into points geographically close to standard points). Dropout rates were high in both groups; however, more subjects were retained in the standard than in the "sham" group. Subjects in the standard group also attended the clinic more frequently. According to Washburn and colleagues Of significance was the finding that lighter users attended the acupuncture clinic more days and over a longer period of time than those with heavier habits. Subjects who injected heroin at least three times a day apparently found that acupuncture did not help relieve withdrawal symptoms or reduce craving and, thus, terminated treatment early. That this was true for subjects in both the standard and sham groups suggests that the heroin users may have had little expectation that a drug-free treatment modality would help them. . . . indeed, we found that individuals who injected heroin at least three times a day were less likely to volunteer to participate in the study than were the lighter users. . . . Some of the clients receiving treatment beyond the detoxification episode were using acupuncture as an adjunct to methadone detoxification and maintenance; others seemed to seek additional treatment to detoxify after relapse to heroin use. (Washburn et al., 1993)
Until controlled clinical data indicate otherwise, acupuncture must be viewed as an adjunctive treatment to detoxification.
One study (Washburn et al., 1993) compared standard acupuncture with "sham" acupuncture. Dropout rates were high in both groups; however, more subjects were retained in the standard than in the "sham" group.
Although some studies have shown that neuroelectric therapy (NET) reduces chronic withdrawal period for some opiate abusers (Patterson, 1983), a recent study found that NET is no more effective than use of a placebo in opiate and cocaine detoxification (Gariti et al., 1992). NET is therefore not recommended.
For therapeutic use, barbiturates and the older sedative-hypnotics have been largely replaced by the benzodiazepines. The withdrawal syndromes from benzodiazepines and other sedative-hypnotics are similar, and the pharmacotherapy treatment strategies apply to both. This section focuses on the benzodiazepines and adds information about treatment of other types of sedative-hypnotic dependence when appropriate (Alling, 1992).
Dependence on benzodiazepines and other sedative-hypnotics usually develops in the context of medical treatment. Benzodiazepines have many therapeutic uses: As therapy for some conditions, such as panic disorder, long-term treatment is appropriate medical practice. Physical dependency is sometimes unavoidable. Benzodiazepine dependency that develops during pharmacotherapy is not necessarily a substance use disorder (Alling, 1992). When the dependency results from patients taking the prescribed doses as directed by a physician, the term "therapeutic discontinuation" is preferable to the term "detoxification."
Abusers of heroin and stimulants often misuse benzodiazepines and other sedative-hypnotics, sometimes to the extent that they develop a physical dependence. In such cases, it is appropriate to think of withdrawal from the sedative-hypnotic as detoxification.
Use of either benzodiazepines or sedative-hypnotics at doses above the therapeutic range for a month or more produces physical dependence. Without appropriate medical treatment, withdrawal from benzodiazepines or other sedative-hypnotics can be severe and life threatening. Withdrawal from benzodiazepines or other sedative hypnotics produces a similar withdrawal syndrome, described below under high-dose sedative-hypnotic withdrawal.
Some people will develop withdrawal symptoms after stopping therapeutic doses of benzodiazepines or other sedative-hypnotics after they have been used daily for 6 months or more. With "low-dose" withdrawal, the benzodiazepines and other sedative-hypnotics can produce qualitatively different withdrawal syndromes. These are described as high-dose sedative-hypnotic withdrawal syndrome and low-dose benzodiazepine withdrawal syndrome.
Signs and symptoms of high-dose sedative-hypnotic withdrawal include anxiety, tremors, nightmares, insomnia, anorexia, nausea, vomiting, orthostatic hypotension, seizures, delirium, and hyperpyrexia. The syndrome is qualitatively similar for all sedative-hypnotics; however, the time course of symptoms depends upon the particular drug. With short-acting sedative-hypnotics (e.g., pentobarbital [Nembutal], secobarbital [Seconal], meprobamate [Miltown, Equanil], and methaqualone) and short-acting benzodiazepines (e.g., oxazepam [Serax], alprazolam [Xanax], and triazolam [Halcion]), withdrawal symptoms typically begin 12 to 24 hours after the last dose and reach peak intensity between 24 and 72 hours after the last dose. Patients who have liver disease or who are elderly may develop symptoms more slowly because of decreased drug metabolism. With long-acting drugs (e.g., phenobarbital, diazepam [Valium], and chlordiazepoxide [Librium]), withdrawal symptoms peak on the fifth to eighth day after the last dose.
The withdrawal delirium may include confusion and visual and auditory hallucinations. The delirium generally follows a period of insomnia. Some patients may have only delirium, others only seizures; some may have both.
In the literature of addiction medicine, low-dose benzodiazepine withdrawal syndrome may be referred to as "therapeutic-dose withdrawal," "normal-dose withdrawal," or "benzodiazepine-discontinuation syndrome." Knowledge about low-dose dependency is based on clinical observations and is still sketchy and controversial. As a practical matter, often it is impossible to know with certainty whether symptoms are caused by withdrawal or whether they mark a return of symptoms that were ameliorated by the benzodiazepine. Patients who are treated with benzodiazepines may have had symptoms such as anxiety, insomnia, or muscle tension before taking the benzodiazepine. When they stop taking the benzodiazepine, these symptoms may reappear.
Some people who have taken benzodiazepines in therapeutic doses for months to years can abruptly discontinue the drug without developing symptoms. Others, taking similar amounts of a benzodiazepine, develop symptoms ranging from mild to severe when the benzodiazepine is stopped or the dosage is substantially reduced.
The risk factors associated with withdrawal are not completely understood. Patients who develop the severe form of low-dose benzodiazepine withdrawal syndrome include those with a family or personal history of alcoholism, those who use alcohol daily, or those who concomitantly use other sedatives. According to one study, "higher doses of benzodiazepine lead to increases of withdrawal severity." This study found that the short-acting, high-potency benzodiazepines appear to produce a more intense low-dose withdrawal syndrome than the long-acting, low-potency ones (Rickels et al., 1990).
During the 1980s, many clinical studies and case reports were published concerning withdrawals that were attributed to therapeutic dose discontinuation. Most patients experienced only a transient increase in symptoms for 1 to 2 weeks after termination of the benzodiazepine. This transient increase in symptoms is known as "symptom rebound" and is defined as an intensified return of the symptoms (e.g., insomnia or anxiety) for which the benzodiazepine was prescribed. According to the American Psychiatric Association (APA), "The most immediate discontinuance symptoms tend to be a rebound worsening of the original symptoms. A more severe withdrawal syndrome consists of the appearance of new symptoms, including perceptual hyperacusis, psychosis, cerebellar dysfunction, and seizures" (American Psychiatric Association, 1990). Original symptoms may reappear when the therapeutic medication is withdrawn, and it may be difficult to distinguish recurrence of original symptoms from rebound.
Most patients experienced only a transient increase in symptoms for 1 to 2 weeks after termination of the benzodiazepine. This transient increase is called "symptom rebound."
Because of psychiatrists' concerns about benzodiazepine dependency, the APA formed a task force to review these issues. The task force's conclusions (American Psychiatric Association, 1990) were unambiguous about therapeutic dose dependency: Physiological dependence on benzodiazepines, as indicated by the appearance of discontinuance symptoms, can develop with therapeutic doses. Duration of treatment determines the onset of dependence when typical therapeutic anxiolytic doses are used: Clinically significant dependence indicated by the appearance of discontinuance symptoms usually does not appear before four months of such daily dosing. Dependence may develop sooner when higher antipanic doses are taken daily.
A few patients experience a severe, long-lasting withdrawal syndrome, which includes symptoms such as paresthesia and psychoses, never experienced before the benzodiazepines were taken. It is this condition, which may be quite disabling and may last many months, that has generated much of the concern about the long-term safety of the benzodiazepines. However, many psychiatrists believe that the symptoms that occur after discontinuation of therapeutic doses of benzodiazepines are not a withdrawal syndrome but a reemergence or unmasking of the patient's psychopathology.
One additional form of withdrawal is sometimes attributed to the benzodiazepines and other sedative-hypnotics as well as to alcohol and opiates. This is a mild form of protracted withdrawal. Its symptoms include irritability, anxiety, insomnia, and mood instability. The symptoms may persist for months following the beginning of abstinence (Geller, 1991).
The physician's response during benzodiazepine withdrawal is critical to a successful outcome. Some physicians interpret patients' escalating symptoms as evidence of their need for additional benzodiazepine treatment. Consequently, they prescribe a benzodiazepine, often at higher doses, or switch the patient to another benzodiazepine. Reinstitution of any benzodiazepine agonist may not achieve satisfactory symptom control and may in fact prolong the recovery process.
Another common response is to declare patients addicted to benzodiazepines and refer them to primary chemical dependency treatment. Such a referral is not appropriate unless the patient has a substance use disorder.
Reinstitution of any benzodiazepine agonist may not achieve satisfactory symptom control and may in fact prolong the recovery process.
Selection of the withdrawal medication. Abrupt discontinuation of a sedative-hypnotic in patients who are severely physically dependent on it can result in serious medical complications and even death. For this reason, medical management is always needed, and treatment is best provided in a hospital. There are three general medication strategies for withdrawing patients from sedative-hypnotics, including benzodiazepines: (1) the use of decreasing doses of the agent of dependence; (2) the substitution of phenobarbital or another long-acting barbiturate for the addicting agent and the gradual withdrawal of the substitute medication (Smith and Wesson, 1970, 1983, 1985); and (3) the substitution of a long-acting benzodiazepine, such as chlordiazepoxide (Librium), which is tapered over 1 to 2 weeks. The method selected depends on the particular benzodiazepine, the involvement of other drugs of dependence, and the clinical setting in which detoxification takes place.
Discontinuation of the benzodiazepine of dependence occurs primarily in medical settings. The patient must be cooperative, be able to adhere to dosing regimens, and not be abusing AODs.
Stabilization. Substituting phenobarbital is the best choice for patients who have lost control of their benzodiazepine use or who are polydrug dependent. Phenobarbital substitution has the broadest use for all sedative-hypnotic drug dependencies and is widely used in drug treatment programs. For that reason, this approach will be described in detail. The patient's history of drug use during the month before treatment is used to compute the stabilization dose of phenobarbital. Although many patients exaggerate the number of pills they are taking, the patient's history is the best guide to initiating pharmacotherapy for withdrawal. Patients who have overstated the amount of drug they have taken will become intoxicated during the first day or two of treatment. The treatment provider can easily manage intoxication by omitting one or more doses of phenobarbital and recalculating the daily dose.
The patient's average daily sedative-hypnotic dose is converted to phenobarbital equivalents, and the daily amount is divided into three doses. (See Exhibits 3-4 and 3-5 for a list of benzodiazepines and other sedative hypnotics and their phenobarbital withdrawal equivalents.) The computed phenobarbital equivalence dosage is given in three or four doses daily. If the patient is using significant amounts of other sedative-hypnotics, including alcohol, the amounts of all the drugs are converted to phenobarbital equivalents and added (e.g., 30 cc of 100-proof alcohol are equated to 30 mg of phenobarbital for withdrawal purposes). Before receiving each dose of phenobarbital, the patient is checked for signs of phenobarbital toxicity (sustained nystagmus, slurred speech, or ataxia). Of these, sustained nystagmus is the most reliable. If nystagmus is present, the scheduled dose of phenobarbital is withheld. If all three signs are present, the next two doses of phenobarbital are withheld, and the daily dosage of phenobarbital for the following day is reduced by half.
If the patient is in acute withdrawal and has had or is in danger of having withdrawal seizures, the initial dose of phenobarbital is administered by intramuscular injection. If nystagmus and other signs of intoxication develop 1 to 2 hours following the intramuscular dosage, the patient is in no immediate danger from barbiturate withdrawal. Patients are maintained on the initial dosing schedule of phenobarbital for 2 days. If the patient displays neither signs of withdrawal nor of phenobarbital toxicity (slurred speech, nystagmus, unsteady gait), phenobarbital withdrawal is begun.
The patient's average daily sedative-hypnotic dose is converted to phenobarbital equivalents, and the daily amount is divided into three doses. The computed phenobarbital equivalent dosage is given in three or four doses daily. If the patient is using significant amounts of other sedative-hypnotics, including alcohol, the amounts of all the drugs are converted to phenobarbital equivalents and added.
Withdrawal. Unless the patient develops signs and symptoms of phenobarbital toxicity or sedative-hypnotic withdrawal, phenobarbital is decreased by 30 mg per day. Should signs of phenobarbital toxicity develop during withdrawal, the daily phenobarbital dose is decreased by 50 percent, and the 30 mg per day withdrawal is continued from the reduced phenobarbital dose. Should the patient have objective signs of sedative-hypnotic withdrawal, the daily dose is increased by 50 percent, and the patient is restabilized before continuing the withdrawal.
Clinicians should make decisions regarding the treatment of low-dose withdrawal based on the patient's symptoms. Withdrawal seizures are not usually expected. Patients with an underlying seizure disorder must be maintained on full doses of anticonvulsant medications, and medications that lower seizure threshold should be avoided. Patients may need much reassurance that the symptoms are transient and that with continued abstinence they will eventually subside.
Patients who have the severe form of withdrawal may need psychiatric hospitalization if symptoms become intolerable. Phenobarbital, in doses of 200 mg per day, generally provides considerable reduction in symptoms. Phenobarbital is slowly tapered over several months.
The two most commonly abused stimulants are cocaine and methamphetamine. Intermittent binge use of both agents is common. The withdrawal symptoms that occur after a 2- to 3-day binge are different than those that occur after chronic, high-dose use. The withdrawal syndromes are similar.
Following a 2- to 3-day binge, stimulant abusers are dysphoric, exhausted, and somnolent for 24 to 48 hours. Because cocaine abusers commonly take alcohol, marijuana, or even heroin with cocaine to reduce the irritability caused by high-dose stimulant abuse, the withdrawal may be in response to the combination of drugs. The patient also may have become dependent on more than one drug.
Following regular use, the withdrawal syndrome consists of dysphoria, irritability, difficulty sleeping, and intense dreaming. Often stimulant abusers experience signs and symptoms of the abuse of multiple drugs. The symptoms subside over 2 to 4 days of drug abstinence.
There is no specific treatment for stimulant withdrawal. Mild sedation with phenobarbital or chloral hydrate for sleep may ameliorate patients' distress.
In the medical literature, descriptions of cocaine withdrawal can be confusing because some authors define cocaine craving as a prominent withdrawal symptom. Scientists are not yet certain that craving is a withdrawal symptom. Cocaine craving usually rapidly diminishes in inpatient cocaine abusers when they are unable to get the drug and no longer come in contact with the environmental stimuli associated with cocaine use.
Although the mechanism of drug craving is not well understood, recent studies have demonstrated that environmental and other stimuli can trigger the physiological process of craving (O'Brien et al., 1991). Therefore, exposure to stimuli (which include other drugs) must be controlled.
There is no acute abstinence syndrome associated with withdrawal from marijuana. Some patients are irritable and have difficulty sleeping for a few days when they discontinue chronic use of marijuana. Persons withdrawing from marijuana, like those withdrawing from cocaine, benefit from a supportive environment during detoxification.
Two issues regarding tobacco smoking merit consideration by staff of AOD detoxification programs. The first is the program management's desire to establish a smoke-free treatment environment to comply with workplace ordinances and to safeguard the health and comfort of patients from exposure to second-hand smoke. The second issue is the patient's dependence on nicotine as a drug of abuse. Both issues are addressed in a theme issue of the Journal of Substance Abuse Treatment titled "Toward a Broader View of Recovery: Integrating Nicotine Addiction and Chemical Dependency Treatments" (Volume 10, Number 2, March/April 1993).
Many programs have implemented smoke-free environments. Some programs treat nicotine as a drug of abuse and require that patients stop smoking as part of their chemical dependency treatment. A growing number of researchers feel that "the acquisition, spread, and even severity of various drug dependencies may be related to prior or current tobacco use patterns" (Henningfield et al., 1990). Most programs provide education about nicotine and encourage patients to quit smoking. Some provide nicotine patches or other medication to manage physiological withdrawal symptoms.
Lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), psilocybin, mescaline, 3,4-methylenedioxy-amphetamine (MDA), and 3,4,-methylenedioxy-methamphetamine (MDMA, also called XTC or "ecstasy") do not produce physical dependence.
Treatment professionals have noted a recent resurgence in the use of hallucinogenic drugs such as LSD, phencyclidine (PCP), and MDMA. These drugs produce no acute withdrawal syndrome.
Chronic use of PCP can cause a toxic psychosis that takes days or weeks to clear; however, PCP does not have a withdrawal syndrome.
Individuals may become physically dependent on hydrocarbons, which include gasoline, glue, and aerosol sprays (including paint, waterproofing material, etc.) and paint thinner. There is clinical evidence that withdrawal from inhalant use is similar to that experienced by persons withdrawing from alcohol. Phenobarbital may be prescribed during detoxification.
Addicts rarely use just one drug. Typical combinations and the preferred modes of treatment are shown as follows:
Symptoms of withdrawal from opiates and barbiturates have some common features, making it difficult to assess the patient's clinical condition when both drugs are withdrawn at the same time. Many clinicians prefer to gradually withdraw the sedative-hypnotic first, while administering methadone to prevent opiate withdrawal. When the patient is barbiturate-free, the methadone is withdrawn at a level of 5 mg per day. If the sedative-hypnotic was a benzodiazepine (diazepam or chlordiazepoxide), some clinicians prefer to begin with a partial reduction of the sedative-hypnotic. While the patient is still receiving a partial dosage of the sedative, methadone is withdrawn. Finally, the sedative-hypnotic is totally withdrawn.
Persons in several groups need special consideration during detoxification because of the specific needs they present. Such persons include those who are incarcerated, women, adolescents, the elderly, those who are human immunodeficiency virus (HIV)-positive, or those who have other medical conditions.
Persons who are incarcerated or detained in holding cells or elsewhere should be assessed for physical dependence on alcohol, sedative-hypnotics, and/or heroin. Untreated withdrawal from alcohol or other sedative-hypnotics can be life threatening. Heroin withdrawal is not life threatening to an individual who is healthy; however, it may be difficult for the patient. Individuals who are on methadone maintenance may experience severe withdrawal symptoms if the medication is abruptly stopped.
Persons who have been on maintenance therapy before being incarcerated should continue to receive their usual dosage of medication if the expected period of incarceration is less than 2 weeks. If incarceration is longer, the maintenance therapy should be gradually discontinued.
The treatment protocols outlined in Chapter 3 are applicable for incarcerated persons who need detoxification. There may, however, be restrictions on the use of methadone or levo-alpha-acetylmethadol in a prison setting. In such cases, staff may need to create linkages with local methadone detoxification programs.
There is an underground market for psychoactive medications, drugs of abuse, or both, in most prisons. Patients may try to deceive staff about their dependence so that they can receive drugs that they then sell to other inmates. They may attempt to convince nurses that they have swallowed their medication when they have not. To ensure appropriate care of inmates, prison medical staff need special training in patient assessment and detoxification protocols.
Women who enter detoxification will benefit from a comprehensive physical examination, including a gynecological and obstetrical evaluation. Sensitivity to the wishes of the patient regarding examinations and tests is imperative, and the treatment staff must be careful to obtain consent. Unless they are pregnant or nursing, women can usually be treated under the detoxification protocols described in Chapter 3.
Special attention should be given to the detoxification setting. Establishing distance from the environment in which the alcohol and other drug (AOD) abuse has been taking place may be more critical for women than for men.
Special concerns surround detoxification during pregnancy. The Treatment Improvement Protocol (TIP) titled Pregnant, Substance-Using Women (TIP 2; Center for Substance Abuse Treatment, 1993) addresses the complex issues involved in treating this population. Conditions that ensure close observation and monitoring of maternal and fetal well-being are explored in depth. The TIP includes guidelines for withdrawal from alcohol, withdrawal from opiates, and the issues related to the use of methadone for stabilization, withdrawal from cocaine, and withdrawal from sedative-hypnotics.
Withdrawal from opiates can result in fetal distress, which can lead to miscarriage or premature labor. Opioid substitution therapy, coupled with good prenatal care, is generally associated with normal deliveries. Although these newborns tend to have a lower birth weight and smaller head circumference than drug-free newborns, no developmental differences at 6 months of age (Zweben and Payte, 1990) have been documented.
Treatment staff should not modify detoxification regimens for nursing women unless there is specific evidence that the pharmacologic product enters the milk in amounts that could be harmful to the infant. Women who are using benzodiazepines (e.g., Librium or Xanax) and antidepressant or antipsychotic agents should not breast feed.
All pregnant women and nursing mothers should be informed of the potential risks of drugs that are excreted in breast milk. For more information, see the TIP Improving Treatment for Drug-Exposed Infants (TIP 5; Center for Substance Abuse Treatment, 1993).
The availability of child care often influences a woman's ability to enter treatment. At a minimum, detoxification programs should have a linkage to child-care services; onsite services are preferable.
Adolescence is a period of rapid physical and psychosocial change. Issues facing adolescents in detoxification differ from those facing adults in several ways. Chief among these differences is that physical dependence is generally not as severe and response to detoxification is generally more rapid in adolescents than in adults. Adolescents are not as accustomed to pain as are adults; as a result, they may be more resistant to simple procedures, such as having blood drawn. Adolescents also are notorious for leaving treatment against medical advice.
Adolescents undergoing detoxification need nurturing, support, and structure. Treatment providers must be sensitive to their developmental stages. Adolescents should be housed separately from adults. Decisions about involving the family in treatment should be made on a case-by-case basis and based on an assessment of family functioning.
Federal regulations allow methadone detoxification of adolescents, but State regulations vary. Methadone detoxification is rare in this age group. For a complete discussion of this issue, see the TIP titled State Methadone Treatment Guidelines (TIP 1; Center for Substance Abuse Treatment, 1993).
Adolescents undergoing detoxification need nurturing, support, and structure. Treatment providers must be sensitive to their developmental stages. Adolescents should be housed separately from adults. Decisions about involving the family in treatment should be made on a case-by-case basis and based on an assessment of family functioning.
AOD-related disorders in elderly patients tend to be more severe than those in younger persons, and there is an increased likelihood of medical comorbidity in the elderly. For these reasons, detoxification in a medical setting is often required.
Age does not affect the choice of medication for detoxification; however, dosages may need to be reduced because of slowed metabolism. A complete assessment and careful monitoring of comorbid conditions (e.g., respiratory disease, heart disease, diabetes) is essential. Because many elderly patients are taking a number of prescription and over-the-counter medications, the possibility of drug interactions cannot be ignored.
AOD abuse and HIV infection often coexist in the same individual, who is usually also at risk of becoming infected with tuberculosis or sexually transmitted diseases. The capacity of AOD abuse treatment programs to address these multiple health problems has expanded greatly in recent years, but there remains a need for comprehensive guidelines for treatment of HIV-positive AOD patients. Collaborative, efficient approaches must be developed among AOD specialists, public health officials, mental health specialists, and primary health care providers in order to prevent further spread of disease and to assure delivery of high-quality care to infected individuals.
Those who treat patients with acquired immunodeficiency syndrome are naturally concerned about the risk of infection. Program staff may be concerned that they will be exposed to HIV when drawing blood, and they may have questions about the safety of collecting samples for urinalysis, about dispensing medications, and about simply being in proximity to HIV-infected patients. Programs can manage these concerns by developing guidelines and providing training. Treatment providers should apply clear infection control guidelines derived from hospital universal precautions for handling potentially infectious body fluids. Another TIP in this series, Screening for Infectious Diseases Among Substance Abusers (TIP 6; Center for Substance Abuse Treatment, 1993), provides a detailed discussion of the infectious diseases common to the AOD abuse treatment population and of the medical management of these diseases by program staff.
A diagnosis of HIV does not change the indications for medication used to treat AOD abuse. The most common medications used to treat substance abuse are methadone, disulfiram, and naltrexone. In addition, benzodiazepines, barbiturates, clonidine hydrochloride, and other medications are commonly used in detoxification. These medications can be used in HIV-infected AOD abuse patients in the same way they are used in uninfected patients. The detoxification process need not be altered by the presence of HIV. Another TIP in this series, Treatment for HIV-Infected Alcohol and Other Drug Users (TIP 15; Center for Substance Abuse, 1995), provides detailed protocols for those who are HIV-positive and need treatment for abuse of AODs.
For patients withdrawing from alcohol, a history of seizures during previous withdrawals strengthens the case for using an anticonvulsant (such as phenytoin [Dilantin], carbamazepine [Tegretol], or phenobarbital) during detoxification. A patient who is dependent on alcohol or sedative-hypnotic agents may have a withdrawal seizure even though he or she does not have a history of seizure disorders. An alcoholic who has a seizure while drinking has an underlying seizure disorder. Treatment staff must consider both possibilities when determining detoxification treatment.
Brain-injured patients are also at risk for seizures. If an AOD-abusing patient who has sustained trauma to the head becomes delirious, one must determine the exact cause of the delirium. Slower medication tapers should be used in patients with seizure disorders. Dosages of anticonvulsant medications should be stabilized before sedative-hypnotic withdrawal begins.
Patients with cardiac disease require close monitoring. Because a withdrawal seizure, or even the physiological stress of withdrawal, may complicate the patient's cardiac condition, it may be necessary to withdraw the drug at a lower-than-normal rate. Treatment providers should also be alert to the possibility of interactions between the cardiac medications and the agents used to manage detoxification.
Severe liver or kidney disease can slow the metabolism of both the drug of abuse and the medication. Use of slower-acting medications and a slower taper are appropriate for detoxification in these patients.
Because of these patients' increased risk of developing addictions, treatment providers should exercise caution when prescribing medication for chronic pain to patients with a history of AOD abuse. Opioid maintenance may, however, be necessary for patients with chronic, nonmalignant pain. Pain patients do not require detoxification from prescribed medications unless they meet the criteria for opiate abuse or dependence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). Nonsteroidal analgesic medications play a larger role in the management of pain in AOD-abusing patients than in other patients.
The term "dual diagnosis" or "dual disorder" is used in the addiction field to refer to patients who have both a substance use disorder and any psychiatric disorder, such as schizophrenia. Estimates of the incidence of psychiatric disorders among substance abusers vary widely. Another TIP in this series, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (TIP 9; Center for Substance Abuse, 1994), provides practical information about the treatment of patients with dual disorders.
As noted in Chapter 2 , it is difficult to accurately assess underlying psychopathology in a person undergoing detoxification. Drug toxicity, particularly with amphetamines and cocaine, hallucinogens, or phencyclidine, may mimic psychiatric disorders. For this reason, treatment providers should conduct a psychiatric evaluation after several weeks of abstinence.
Treatment providers should exercise caution when prescribing medication for chronic pain to patients with a history of AOD abuse. Pain patients do not require detoxification from prescribed medications unless they meet the criteria for opiate abuse or dependence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994).
At the time they are evaluated for detoxification, some patients with underlying psychiatric disorders are already taking antidepressants, neuroleptics, anxiolytics (benzodiazepines or other sedative-hypnotics), or lithium. Although staff may believe that these patients should immediately discontinue all mind-altering medication, such a course of action is not always in the best interest of the patient. Abrupt cessation of psychotherapeutic medications may cause withdrawal symptoms or reemergence of symptoms of the underlying psychopathology.
For the staff of a "drug-free" program, use of anxiolytics by a patient can pose a significant conflict with program ideology. If a patient who was abusing alcohol was also taking alprazolam (Xanax) for a panic disorder, for example, some programs would want the individual to discontinue the alprazolam. Indeed, unless the alprazolam was initiated during a period of extended alcohol abstinence, the diagnosis of panic disorder may not be correct. If panic attacks resume during alcohol detoxification because the alprazolam has been discontinued, however, the patient might leave therapy. As a general rule, therapeutic doses of medication should be continued during alcohol withdrawal if the patient has been taking it as prescribed, with respect to both amount and timing of dose. Decisions about discontinuing the medication should be temporarily deferred. If, however, the patient has been abusing the prescribed medication or the psychiatric condition was clearly caused by the alcohol abuse, the rationale for discontinuing the medication is more compelling.
During detoxification, some patients decompensate into psychosis, depression, or severe anxiety. In such cases, careful evaluation of the withdrawal medication regimen is of paramount importance. If the decompensation is a result of inadequate dosing with the withdrawal medication, the appropriate response is to increase that medication. If it appears that the withdrawal medication is adequate, other medications may be needed. Before choosing such an alternative, it is important to take into account additional considerations, such as the side effects of the added medication and the possibility of interaction with the withdrawal medication.
A patient who is psychotic may need to take neuroleptics. Medications that have a minimal effect on the seizure threshold are recommended, particularly if the patient is being withdrawn from alcohol or sedative-hypnotic medication. Small, frequent doses of haloperidol (Haldol), such as 1 mg every 2 hours, may be used until the patient's symptoms of psychosis dissipate. The case for the emergency use of antidepressants is less convincing because of the 2- to 3-week lag time between initiation of medication and therapeutic response.
After detoxification is complete, the patient's need for the medication should be reassessed. A trial period with no medications is sometimes the best way to assess the patient's need.
Detoxification protocols such as those described in Chapter 3 may be used effectively with persons of all races, cultures, and ethnic groups. However, treatment components and procedures should be reviewed to ensure that they are culturally sensitive and culturally relevant. Staff should be trained to avoid discriminatory language and behaviors.
The diversity of the counselors should reflect that of the surrounding community. Additionally, counselors must be specially trained and selected for cultural appropriateness. They must be aware, for example, that cultural attitudes toward communication styles vary with regard to preferred space (physical distance), appropriate physical contact, eye contact, and terminology. A treatment staff who are competent in the languages spoken by the clientele help the program retain more patients. Language competency entails not only the ability of a staff person to communicate with a patient but also familiarity with trends in street terminology.
Providers should evaluate written and visual materials provided to patients and families for readability as well as for cultural appropriateness. If the population is predominantly Spanish-speaking, materials, including intake and assessment forms and educational materials, should be printed in Spanish. At least some of the staff should speak Spanish.
An individual's response to authority differs from culture to culture. The counselor's sensitivity to such differences is essential in determining the patient's response to care and in engaging the patient in the detoxification process. Treatment providers should keep in mind that diversity exists within ethnic groups as well. For example, Spanish-speaking cultures are often thought of as one group (Hispanic) and assumed to be essentially identical. However, Hispanic cultures actually consist of a variety of different cultures such as Mexican, Puerto Rican, Cuban, and Central and South American, all of which differ significantly from one another. People of all ethnic groups vary by personality, geographic origin, socioeconomic class, religious upbringing, and other factors, all of which play a role in their individual "cultures." Treatment providers should assess each patient individually. Finally, the counselor should not presume the degree to which "cultural" factors are a determinant of current behavior.
Effective measurement of treatment outcomes has long been a critical issue in the development of the Nation's alcohol and other drug (AOD) abuse treatment system. Studies of methadone maintenance treatment programs indicate that variables such as adequacy of methadone dosing levels, staff turnover rates, and differences among counselors correlate significantly with patient performance. These factors are, nonetheless, rarely taken into account by standard measures of treatment effectiveness (Gerstein and Harwood, 1990).
This chapter provides general information on quality improvement and outcomes measurement. A more detailed discussion of these issues as they relate to AOD abuse treatment is found in another Treatment Improvement Protocol (TIP) in this series, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (TIP 14; Center for Substance Abuse Treatment, 1995). It is intended as an aid in developing, implementing, and managing outcome monitoring systems.
The move toward health care reform and the growing concern for financial accountability have made service providers increasingly aware of the need to ensure quality care. One potentially useful document, prepared by an organization with standing in the addictions field, is a 10-step quality assurance checklist issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (see Exhibit 5-1).
The specific indicators of quality shown in Exhibit 5-1 are of particular importance. Staff can perform chart reviews to verify the quality improvement indicators. Routine weekly reviews of charts of 25 percent of the patients seen, with followup of any problems discussed in weekly case conferences, is a standard recommended by JCAHO (Joint Commission on Accreditation of Healthcare Organizations, 1993). Treatment staff should complete and document each of the following steps in the patient's record. If a step has not been performed, a reason for the omission should be included.
The programs' internal management information system should include clinical reports, incident reports, followup reports from referral resources, insurance and accreditation reports, and public health and other Government inspection reports. In addition, any other quality-improvement reports that have been generated to analyze trend data drawn from patient charts should be included. Every treatment program should have such a system in place to capture and compile these data so that program administrators can take a step back from reviewing the charts of individual patients to look at the entire patient population. The following indicators should be documented:
The National Institute on Drug Abuse has published a technology transfer package to help program administrators and staff who have no previous experience or formal training in evaluation to plan and conduct evaluations of their programs. The package is titled How Good Is Your Drug Abuse Treatment Program? and includes an overview and case study manual, an evaluation guide, a resource manual, and looseleaf worksheets and agendas. The procedures and steps discussed in the guide conform to the standards of JCAHO. It is available free of charge from the National Clearinghouse for Alcohol and Drug Information at (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired) at (800) 487-4889.
A recent contribution to the literature on addiction treatment is the public policy statement on recommendations for design of treatment efficacy research with emphasis on outcome measures (American Society of Addiction Medicine, 1994a). These recommendations, developed from a consensus process involving more than 70 experts in the addictions field, begin by identifying the nine "essential elements" of studies that assess quality of treatment. They include
Within this framework, the American Society of Addiction Medicine recommends measurement of eight variables, as shown in Exhibit 5-2, but cautions that confirmation of patient self-reports of AOD use or nonuse is desirable, through either biochemical analysis or corroborative reports.
An appropriate system for measuring outcomes, no matter how simple or complex, must also take into account the goals of detoxification. Three desirable goals are to safely manage withdrawal; to engage the patient in treatment; and to provide withdrawal that is humane and respects the patient's dignity. The following list presents detoxification-specific outcomes indicators that are appropriate for these goals and may be used in conjunction with other measures.
In the United States, alcohol and other drug (AOD) detoxification services are provided in many different settings: general medical and psychiatric hospitals, inpatient AOD treatment programs, outpatient clinics, and social model detoxification programs. There is no one national reporting system that tallies the number of detoxification episodes each year in the United States. Discussions of the costs associated with detoxification must address the following considerations:
Given the uncertainties inherent in estimating the number of detoxification episodes and the settings in which they occur, the annual cost of detoxification services in the United States is unknown.
Current patterns of funding for AOD treatment are poorly coordinated and inflexible. The percentage of public funding earmarked for treatment has never been able to keep pace with demand. The following areas are of key concern:
The Substance Abuse and Mental Health Service Administration (SAMHSA), an agency of the Department of Health and Human Services (DHHS) , is the major source Federal support for treatment and related services for persons who are mentally ill or chemically dependent. SAMHSA is composed of three agencies: (1) the Center for Substance Abuse Treatment (CSAT), (2) the Center for Substance Abuse Prevention, and (3) the Center for Mental Health Services.
SAMHSA administers the DHHS AOD block grant program, which is the primary source of long-term Federal funding to the States for publicly supported AOD abuse treatment and prevention programs. In creating SAMHSA in 1992, Congress divided the block grant program into two parts: one for mental health and one for substance abuse prevention and treatment. The latter was authorized at $1.13 billion for fiscal year 1993, of which 35 percent was targeted to alcohol abuse services, 35 percent to drug abuse services, and 20 percent to prevention. Half of the remaining 10 percent was earmarked as a set-aside for special programs. Currently, this set-aside targets pregnant women and women with dependent children. According to the Center for Health Policy Research (CHPR), the remaining 5 percent was used by SAMHSA for technical assistance, data collection, program evaluation, and the creation of a national prevention database (Center for Health Policy Research, 1993).
Block grant funds are awarded to the single State agency in each State. The States distribute the funds according to their own priorities, within established Federal guidelines. Each State that receives block grant funds is required to submit a plan to the Federal Government. This plan must incorporate input from the public. Allocation procedures at the State level vary considerably. Each State, moreover, has a different format for reporting use of funds; consequently, tracking resource allocation and use of set-asides is difficult.
Categorical SAMHSA programs that may provide support for detoxification services include CSAT's Capacity Expansion Program, Cooperative Agreements for Drug Abuse Treatment Improvement -- Campus Treatment Program, and Cooperative Agreements for Drug Abuse Treatment Improvement in Crisis Areas (Target Cities) Program. CSAT's major demonstration program for Pregnant and Postpartum Women and Their Infants does not cover detoxification services. (For detailed information on CSAT programs, please contact the appropriate program division. See Appendix C for addresses and phone numbers.)
Categorical programs from other Federal Agencies may also provide services as part of a comprehensive health model. Information on these programs may be found in a report titled An Analysis of Resources to Aid Drug-Exposed Infants and Their Families (Center for Health Policy Research, 1993), as well as in directories of Federal grant and contract assistance programs.
Medicaid is a cooperative Federal and State program that is administered by the Health Care Financing Administration. Medicaid is an entitlement program and therefore is not subject to the congressional appropriations process. States receive Federal contributions based on per capita income; in poorer States, the Federal contribution may be as high as 83 percent -- in wealthier States, 50 percent. States may increase the Federal match by voluntarily raising their contribution to the program. The States participate in Medicaid voluntarily and administer the program within broad Federal guidelines. Eligibility requirements, covered benefits, and provider payment mechanisms vary enormously.
Although not designed to fund AOD abuse treatment services, Medicaid has become the most stable source of funding for such services. Medicaid reimbursement for AOD abuse treatment doubled between 1982 and 1987 (Center for Health Policy Research, 1993; Wilford, 1993). As with the overall program, there is little consistency from State to State with regard to individual coverage for AOD abuse treatment or the treatment settings for which services are reimbursed. Federal statutes stipulate that Medicaid is to cover "medical and remedial" services. It will cover most hospital-based services. In regard to AOD abuse treatment services, for example, a majority of States may cover a hospital stay for a 3- to 6-day inpatient detoxification and a limited number of visits for followup outpatient counseling (Center for Health Policy Research, 1993). To improve access to extended treatment, Gates, (1992) suggested that States reimburse for detoxification services contingent on coordination with long-term treatment placement or that they design specialized case-management services as part of the State plan.
Medicaid beneficiaries have few long-term options for coverage of AOD abuse treatment. This lack may contribute to the cycle of relapse and return to episodic hospital-based detoxification for some persons. Medicaid inpatient payment statistics reflect the unrealistic structure of the Medicaid reimbursement system. In fiscal 1994, the portion of Medicaid hospital costs attributable to AOD abuse treatment is expected to exceed $7.4 billion. Approximately 20 percent of annual Medicaid expenditures for hospital care are associated with substance abuse (Center on Addiction and Substance Abuse at Columbia University, 1993).
Many States are discouraged by the complex regulations that govern Medicaid. Some application procedures make it difficult for individuals to obtain benefits. Other States have responded creatively to the challenge (Center for Health Policy Research, 1993).
States also have demonstrated resourcefulness in developing ways to raise State revenue and thereby gain access to additional Medicaid funding (Gates, 1992). One technique is to transfer general State revenues intended for AOD services to the State Medicaid agency rather than to the State Division of Alcohol and Drug Abuse. The transferred funds become eligible for the Federal match. Some States apply revenues from alcohol excise taxes to their Medicaid match funds. Some States allow persons filing income tax returns to designate that a portion of their refunds be directed to AOD abuse treatment. Still others have enacted laws under which revenue generated by the sale of property confiscated during convictions for drug-related crimes are applied to the Medicaid match. And some practices are under close scrutiny by Federal agencies and may not have produced long-term solutions that are viable or cost effective.
Health care reform efforts, a matter of major debate at the Federal level at the time this consensus panel convened, are having a strong impact on clinical practice. Many States have already taken the lead in health care reform. Since the national health care reform act was not passed by Congress, States will continue to develop reform strategies consistent with a managed care environment. In all likelihood, the primary efforts for health care reform effort will proceed individually, State-by-State, rather than on a national basis.
Facing growing financial pressures to contain costs, many States have enacted comprehensive health care reform legislation. Coverage for addictive disorders has been the subject of extensive State house debate; "of more than 70 major reform bills considered in 45 States during 1993, two thirds contained some benefits for AOD abuse treatment" (Callahan, 1994).
Drawing on clinical experience, the continuum of care set forth in the CHPR Model, and an appreciation of fiscal realities, the panelists agreed that the following principles should govern the design and implementation of AOD detoxification services and benefits systems. Many of the recommendations concerning the number of treatment episodes and lengths of stay are based on the Legal Action Center's Model Legislation Mandating a National Health Insurance Benefit for Prevention and Treatment for Alcoholism and Drug Addiction (Legal Action Center, 1993).
Each client should be assessed before entering detoxification. The severity of predicted withdrawal symptoms, the intensity of care needed to ensure appropriate management, and identified psychosocial and family-support needs should determine the selection of treatment setting and the duration and type of services offered.
A majority of patients safely undergo detoxification without being admitted either to a hospital or to a residential setting. Nonetheless, patients' clinical and other needs, not the likelihood for reimbursement, should govern the choice of treatment setting. Inpatient detoxification should not be arbitrarily limited, for example, to patients with concurrent psychiatric problems.
The care system should be grounded in the understanding that individuals entering AOD detoxification programs have diverse and wide-ranging needs. While most patients will not require every available service, the system should be structured to meet each discrete need as well as any combination of needs. In most cases, development of such a structure will require the creation of a system of referral and interagency linkages. Timely and dependable communication among such agencies is essential. If, for example, a woman who has primary child care responsibilities enters a residential detoxification setting or is admitted to a hospital, appropriate child care services, possibly including room and board, should be available.
Ideally, there should be no caps on the number of covered inpatient detoxification episodes and no limits on length of stay. At a minimum, each participant in a health benefits plan should be eligible for 10 days of treatment in a hospital, nonhospital, or ambulatory detoxification program, as medically necessary, during any calendar year. If medical conditions require additional lengths of stay, benefits should be available.
Alcoholism is a chronic disease, and most alcoholics will experience at least one relapse. Some patients experience several detoxification episodes before they enter long-term treatment and achieve lasting abstinence. Given this reality, no arbitrary limits should be placed upon the number of detoxification episodes for which a patient will receive reimbursement or upon the length of these episodes.
One view holds that even a modest copayment may pose a burden to many clients and may discourage those initially seeking services as well as those patients remaining in aftercare. Others believe that revenue gained from such payments may be more than offset by the negative effect on patient retention rates and, in the long term, recidivism. However, some clinicians believe that even modest copayments reinforce the notion of commitment to treatment. Requiring patients to pay something may assign to treatment an importance equal to that of abusing AODs. Clinicians who hold this view do not necessarily recommend full copayments as an effort to raise revenue because they are aware that, especially in public sector programs, most clients lack the financial means to pay. They argue that
Some States, including Oregon and Massachusetts, have begun to develop patient placement criteria based on the American Society of Addiction Medicine model (Hoffman, 1991) and to tailor them to local needs. Properly used, such criteria ensure greater uniformity in care and more appropriate and cost-effective allocation of resources. They provide a safety net that protects the client from falling to an inappropriate level of care.
Patient placement criteria, however, may be subject to misinterpretation. For example, should a criteria set support a specific detoxification setting under well-specified conditions, benefits managers might seize on that recommendation to the exclusion of others and use it to justify expansion of lower cost and potentially inappropriate services. Individual clinical need as the primary concern in patient placement cannot be overemphasized.
Unregulated utilization review decisions by health professionals who are not experienced in AOD issues and treatment have led to the denial of needed AOD abuse treatment services and inappropriately restricted lengths of stay. Improperly performed and regulated, utilization review may be counterproductive and may ultimately increase the costs associated with AOD abuse.
Health care providers, administrators, benefits managers, and legislators should examine the merits of developing new configurations for the delivery of AOD detoxification services. New, intermediate-level service configurations are needed that will bridge service gaps and ensure cost-effective, high-quality delivery of care. Issues associated with the development of such settings, including allocation of staff, licensing requirements, prescribing authority, and interagency networking, should be explored.
The panel discussed various models available in the literature that service providers and administrators may use in developing cost estimates. One model they found particularly useful can be found in the book Treating Drug Problems (Gerstein and Harwood, 1990). The authors present and illustrate the use of a formula for estimating the cost of AOD abuse treatment.
The process begins with the acknowledgment that it is impossible to meet all needs. As treatment resources are limited, providers must establish priorities to ensure the optimum use of energy and financial resources. The authors developed an estimate for expansion of public coverage of certain AOD abuse treatment services nationwide and recommended consideration of the following four priorities as quoted below:
Next, the model suggests three strategic options for attaining service delivery goals:
Having established quantifiable targets (such as "Increase daily treatment enrollment by 66,000") and using documented sources to develop assumptions about variables such as capital costs, training needs, and the number of individuals who could be expected to enter treatment, the authors estimate the cost of services to meet the four goals under each of the three strategies (Gerstein and Harwood, 1990).
Field reviewers of the Treatment Improvement Protocol (TIP) were asked to provide specific cost data for a model detoxification program, a social model detoxification program, and an intensive outpatient program. Some general information on medical model and social model detoxification programs is included in this TIP in 6-2, and 6-3. Data on intensive outpatient costs are not included as there is a comprehensive section on costing for this type of treatment program in the TIP titled Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (TIP 8; Center for Substance Abuse, 1994).
The cost data presented here are based on information provided from field reviewers in six different regions of the country and include both private and public programs. The types of the represented localities are rural, suburban, and urban. Because of regional and programmatic differences, it is not possible to ascertain definitive costs for the delivery of detoxification services. The actual costs vary considerably depending on the size of the program, the rent or purchase price of treatment facilities, and varying labor costs from one region of the country to another. Costs are examples only but may provide useful estimates of these models of detoxification services. It is important to emphasize that the cost data that appear in 6-2, and 6-3 were not gathered in a controlled study. The following marks indicate characteristics of the programs represented by the exhibits:
*Described by program director as modified medical model, not necessarily consistent with the modified medical model discussed in the TIP. (Costs are estimates for 20 beds based on actual experience with a six-bed program. Estimates and costs reflect a 90 percent utilization rate.)
**Represents the number of clients/patients that can be treated at one time.
***Includes admissions not over 24 hours. ---------
