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.