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Detoxification - and - Substance - Abuse - Treat PDF
Detoxification - and - Substance - Abuse - Treat PDF
A Treatment
Improvement
Protocol
TIP
45
A Treatment
Improvement
Protocol
TIP
45
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
ii Acknowledgments
Contents
What Is a TIP?........................................................................................................vii
Consensus Panel ......................................................................................................ix
KAP Expert Panel and Federal Government Participants ................................................xi
Foreword ..............................................................................................................xiii
Executive Summary .................................................................................................xv
Chapter 1—Overview, Essential Concepts, and Definitions in Detoxification........................1
Purpose of the TIP .....................................................................................................1
Audience ..................................................................................................................2
Scope ......................................................................................................................2
History of Detoxification Services...................................................................................2
Definitions................................................................................................................3
Guiding Principles in Detoxification and Substance Abuse Treatment .....................................7
Challenges to Providing Effective Detoxification ................................................................8
Chapter 2—Settings, Levels of Care, and Patient Placement ...........................................11
Role of Various Settings in the Delivery of Services ...........................................................11
Other Concerns Regarding Levels of Care and Placement ...................................................20
Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification .......23
Evaluating and Addressing Psychosocial and Biomedical Issues ...........................................24
Strategies for Engaging and Retaining Patients in Detoxification ..........................................33
Referrals and Linkages ..............................................................................................38
Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .......47
Psychosocial and Biomedical Screening and Assessment .....................................................47
Alcohol Intoxication and Withdrawal.............................................................................52
Opioids ..................................................................................................................66
Benzodiazepines and Other Sedative-Hypnotics ...............................................................74
Stimulants...............................................................................................................76
Inhalants/Solvents.....................................................................................................82
Nicotine..................................................................................................................84
Marijuana and Other Drugs Containing THC ..................................................................95
Anabolic Steroids......................................................................................................96
Club Drugs..............................................................................................................97
Management of Polydrug Abuse: An Integrated Approach.................................................101
Alternative Approaches ............................................................................................103
Considerations for Specific Populations ........................................................................105
iii
Chapter 5—Co-Occurring Medical and Psychiatric Conditions.......................................121
General Principles of Care for Patients With Co-Occurring Medical Conditions .....................122
Treatment of Co-Occurring Psychiatric Conditions..........................................................136
Standard of Care for Co-Occurring Psychiatric Conditions ...............................................138
Chapter 6—Financing and Organizational Issues .........................................................145
Preparing and Developing a Program...........................................................................145
Working in Today’s Managed Care Environment.............................................................157
Preparing for the Future...........................................................................................168
Appendix A—Bibliography ......................................................................................169
Appendix B—Common Drug Intoxication Signs and Withdrawal Symptoms .....................223
Appendix C—Screening and Assessment Instruments ...................................................225
Section I: Screening and Assessment for Alcohol Abuse ....................................................225
Section II: Screening and Assessment for Alcohol and Other Drug Abuse ..............................228
Appendix D—Resource Panel..................................................................................231
Appendix E—Field Reviewers..................................................................................233
Index ..................................................................................................................237
CSAT TIPs and Publications....................................................................................243
Figures
Figure 1-1 DSM-IV-TR Definitions of Terms .....................................................................6
Figure 1-2 Guiding Principles Recognized by the Consensus Panel .........................................7
Figure 2-1 Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred .......................................................................................21
Figure 3-1 Initial Biomedical and Psychosocial Evaluation Domains......................................25
Figure 3-2 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26
Figure 3-3 Strategies for De-escalating Aggressive Behaviors ...............................................28
Figure 3-4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural
Framework ...........................................................................................................32
Figure 3-5 The Transtheoretical Model (Stages of Change) ..................................................36
Figure 3-6 Clinician’s Characteristics Most Important to the Therapeutic Alliance....................38
Figure 3-7 Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans...............................................................................................40
Figure 3-8 Strategies To Promote Initiation of Treatment and Maintenance Activities ................42
Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and
Specific Illicit Drugs................................................................................................49
Figure 4-2 Symptoms of Alcohol Intoxication ...................................................................53
Figure 4-3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61
Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67
Figure 4-5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77
iv Contents
Figure 4-6 Other Sedative-Hypnotics and Their Phenobarbital Withdrawal Equivalents ............78
Figure 4-7 Stimulant Withdrawal Symptoms....................................................................79
Figure 4-8 Commonly Abused Inhalants/Solvents..............................................................83
Figure 4-9 DSM-IV-TR on Nicotine Withdrawal ...............................................................86
Figure 4-10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87
Figure 4-11 The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) ........................88
Figure 4-12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With
Other Psychiatric Conditions ....................................................................................89
Figure 4-13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90
Figure 4-14 The “5 A’s” for Brief Intervention .................................................................91
Figure 4-15 Some Definitions Regarding Disabilities ........................................................111
Figure 4-16 Impairment and Disability Chart .................................................................112
Figure 4-17 Locating Expert Assistance.........................................................................114
Figure 6-1 Financial Arrangements for Providers............................................................162
Contents v
What Is a TIP?
After selecting a topic, CSAT invites staff from pertinent Federal agencies
and national organizations to be members of a resource panel that recom-
mends specific areas of focus as well as resources that should be consid-
ered in developing the content for the TIP. Then recommendations are
communicated to a consensus panel composed of experts on the topic who
have been nominated by their peers. This consensus panel participates in
a series of discussions. The information and recommendations on which
they reach consensus form the foundation of the TIP. The members of
each consensus panel represent substance abuse treatment programs, hos-
pitals, community health centers, counseling programs, criminal justice
and child welfare agencies, and private practitioners. A panel chair (or
co-chairs) ensures that the guidelines mirror the results of the group’s
collaboration.
vii
A large and diverse group of experts closely “front-line” information quickly but responsi-
reviews the draft document. Once the changes bly. For this reason, recommendations prof-
recommended by these field reviewers have fered in the TIP are attributed to either pan-
been incorporated, the TIP is prepared for elists’ clinical experience or the literature. If
publication, in print and online. The TIPs research supports a particular approach, cita-
can be accessed via the Internet at tions are provided.
www.kap.samhsa.gov. The online TIPs are
consistently updated and provide the field This TIP, Detoxification and Substance
with state-of-the-art information. Abuse Treatment, revises TIP 19,
Detoxification From Alcohol and Other
While each TIP strives to include an evidence Drugs. The revised TIP provides the clinical
base for the practices it recommends, CSAT evidence-based guidelines, tools, and
recognizes that the field of substance abuse resources necessary to help substance abuse
treatment is evolving, and research frequently counselors and clinicians treat clients who are
lags behind the innovations pioneered in the dependent on substances of abuse.
field. A major goal of each TIP is to convey
ix
Charles A. Dackis, M.D. Hendree E. Jones, M.A., Ph.D.
Assistant Professor Assistant Professor
Department of Psychiatry CAP Research Director
University of Pennsylvania School of Medicine Department of Psychiatry and Behavioral
Philadelphia, Pennsylvania Sciences
Johns Hopkins University Center
Sylvia J. Dennison, M.D. Baltimore, Maryland
Chief/Medical Director
Division of Addiction Services Frances J. Joy, R.N., CD, CASAC
Department of Psychiatry Manager
University of Illinois Alcohol and Drug Abuse Unit
Chicago, Illinois State of Missouri Department of Mental Health
Fulton State Hospital
Patricia L. Mabry, Ph.D. Fulton, Missouri
Health Scientist Administrator/Behavioral
Scientist
Office of Behavioral and Social Sciences
Research
Office of the Director
National Institutes of Health
Bethesda, Maryland
x Consensus Panel
KAP Expert Panel and Federal
Government Participants
Barry S. Brown, Ph.D. Michael Galer, D.B.A., M.B.A., M.F.A.
Adjunct Professor Independent Consultant
University of North Carolina at Wilmington Westminster, Massachusetts
Carolina Beach, North Carolina
Renata J. Henry, M.Ed.
Jacqueline Butler, M.S.W., LISW, LPCC, Director
CCDC III, CJS Division of Substance Abuse and
Professor of Clinical Psychiatry Mental Health
College of Medicine Delaware Health and Social Services
University of Cincinnati New Castle, Delaware
Cincinnati, Ohio
Joel Hochberg, M.A.
Deion Cash President
Executive Director Asher & Partners
Community Treatment & Correction Los Angeles, California
Center, Inc.
Canton, Ohio Jack Hollis, Ph.D.
Associate Director
Debra A. Claymore, M.Ed.Adm. Center for Health Research
Owner/Chief Executive Officer Kaiser Permanente
WC Consulting, LLC Portland, Oregon
Loveland, Colorado
Mary Beth Johnson, M.S.W.
Carlo C. DiClemente, Ph.D. Director
Chair Addiction Technology Transfer Center
Department of Psychology National Office
University of Maryland Baltimore County University of Missouri—Kansas City
Baltimore, Maryland Kansas City, Missouri
xi
Diane Miller Nedra Klein Weinreich, M.S.
Chief President
Scientific Communications Branch Weinreich Communications
National Institute on Alcohol Abuse Canoga Park, California
and Alcoholism
Kensington, Maryland Clarissa Wittenberg
Director
Harry B. Montoya, M.A. Office of Communications and Public Liaison
President/Chief Executive Officer National Institute of Mental Health
Hands Across Cultures Kensington, Maryland
Espanola, New Mexico
The talent, dedication, and hard work that TIPs panelists and reviewers
bring to this highly participatory process have helped to bridge the gap
between the promise of research and the needs of practicing clinicians and
administrators to serve, in the most scientifically sound and effective ways,
people who abuse substances. We are grateful to all who have joined with
us to contribute to advances in the substance abuse treatment field.
xiii
Executive Summary
xv
traditional settings—emergency rooms, medi- 5. Level IV-D: Medically Managed Intensive
cal and surgical wards in hospitals, acute care Inpatient Detoxification
clinics, and others—to be prepared to partici-
pate in the process of getting the patient who ASAM criteria are being adopted extensively
is in need of detoxification services into treat- on the basis of their face validity, though
ment as quickly as possible. Furthermore, it their outcome validity has yet to be clinically
promotes the latest strategies for retaining proven. The ASAM guidelines are to be
individuals in detoxification while also regarded as a work in progress, as their
encouraging the development of the therapeu- authors readily admit. They are an important
tic alliance to promote the patient’s entrance set of guidelines that are of great help to clini-
into substance abuse treatment. The TIP also cians. For administrators, the standards pub-
includes suggestions on addressing psychoso- lished by such groups as the Joint
cial issues that may impact detoxification Commission on Accreditation of Healthcare
treatment, such as providing culturally Organizations and the Commission on
appropriate services to the patient popula- Accreditation of Rehabilitation Facilities pro-
tion. vide guidance for overall program operations.
Matching patients to appropriate care repre- Placement will depend in part on the sub-
sents a challenge to detoxification programs. stance of abuse. The consensus panel suggests
Given the wide variety of settings and the that for alcohol, sedative-hypnotic, and opi-
unique needs of the individual patient, estab- oid withdrawal syndromes, hospitalization (or
lishing criteria that take into account all the some form of 24-hour medical care) is often
possible needs of patients receiving detoxifica- the preferred setting for detoxification, based
tion and treatment services is an extraordi- on principles of safety and humanitarian con-
narily complex task. Addiction medicine has cerns. When hospitalization cannot be pro-
sought to develop an efficient system of care vided, then a setting that provides a high level
that matches patients’ clinical needs with the of nursing and medical backup 24 hours a
appropriate care setting in the least restric- day, 7 days a week is desirable.
tive and most cost-effective manner. Patient A further challenge for detoxification pro-
placement criteria, such as those published grams is to provide effective linkages to sub-
by the American Society of Addiction stance abuse treatment services. Patients
Medicine (ASAM) in the Patient Placement often leave detoxification without followup to
Criteria, Second Edition, Revised, represent the treatment needed to achieve long-term
an effort to define how care settings may be abstinence. Each year at least 300,000
matched to patient needs and special charac- patients with substance use disorders or acute
teristics. These criteria—the five “Adult intoxication obtain inpatient detoxification in
Detoxification” placement levels—define the general hospitals, while additional numbers
most broadly accepted standard of care for obtain detoxification in other settings. Only
detoxification services. The five levels of care 20 percent of people discharged from acute
are care hospitals receive substance abuse treat-
1. Level I-D: Ambulatory Detoxification ment during that hospitalization. Only 15
Without Extended Onsite Monitoring percent of people who are admitted to a
detoxification program through an emergency
2. Level II-D: Ambulatory Detoxification With room and then discharged go on to receive
Extended Onsite Monitoring treatment.
3. Level II.2-D: Clinically Managed Residential
Detoxification The consensus panel recognizes that medical-
ly assisted withdrawal is not always necessary
4. Level III.7-D: Medically Monitored
or desirable. A nonmedical approach can be
Inpatient Detoxification
highly cost-effective and provide inexpensive
A major clinical question for detoxification is This TIP also provides medical information
the appropriateness of the use of medication on detoxification protocols for specific sub-
in the management of an individual in with- stances as well as considerations for individu-
drawal. This can be a difficult matter because als with co-occurring medical conditions
protocols have not been firmly established including mental disorders. While the TIP is
through scientific studies or evidence-based not intended to take the place of medical
methods. Furthermore, the course of with- texts, it provides the practitioner with an
drawal is unpredictable and currently avail- overview of common medical complications
able techniques of screening and assessment seen in individuals who use substances.
do not predict who will experience life-threat- Disorders of several systems are discussed in
ening complications. some detail: gastrointestinal (including the
gastrointestinal tract, liver, and pancreas),
Although it is the philosophy of some treat- cardiovascular system, hematologic (blood)
ment facilities to discontinue all medications, abnormalities, pulmonary (lung) diseases, dis-
this course of action is not always in the best eases of the central and peripheral nervous
interest of the patient. Abrupt cessation of system, infectious diseases, and special mis-
psychotherapeutic medications may cause cellaneous disorders. The TIP presents a cur-
severe withdrawal symptoms or the re-emer- sory overview of special conditions, modifica-
gence of a psychiatric disorder. As a general tions in protocols, and the use of detoxifica-
rule, therapeutic doses of medication should tion medications in patients with co-occurring
be continued through any withdrawal if the medical conditions or mental disorders.
patient has been taking the medication as pre- Overall treatment of specific conditions is not
scribed. Decisions about discontinuing the addressed unless modification of such treat-
medication should be deferred until after the ment is needed.
individual has completed detoxification. If,
however, the patient has been abusing the
Audience
1
This TIP provides clinicians with up-to-date provide detoxification services—to be pre-
information in these areas. It also expands on pared to participate in the process of getting
the administrative, legal, and ethical issues the patient who is in need of detoxification
commonly encountered in the delivery of into a program as quickly as possible to
detoxification services and suggests perfor- potentially avoid the myriad possible negative
mance measures for detoxification programs. consequences associated with substance abuse
Like its predecessor, this TIP was created by (e.g., physiological and psychological distur-
a panel of experts with diverse experience in bances/disorders, criminal involvement,
detoxification services—physicians, psycholo- unemployment, etc.). Furthermore, it pro-
gists, counselors, nurses, and social workers, motes the latest strategies for retaining indi-
all with particular expertise to share. viduals in detoxification while also encourag-
ing the development of the therapeutic
alliance to promote the patient’s entrance into
Audience substance abuse treatment. This includes sug-
The primary audiences for this TIP include gestions on addressing psychosocial issues
substance abuse treatment counselors; adminis- that may affect detoxification services.
trators of detoxification programs; Single State This TIP provides medical information on
Agency directors; psychiatrists and other detoxification protocols for specific sub-
physicians working in the field; primary care stances, as well as considerations for individ-
providers such as physicians, nurse practition- uals with co-occurring medical conditions
ers, physician assistants, nurses, psychologists, including mental disorders. While the TIP is
and other clinical staff members; staff of man- not intended to take the place of medical
aged care and insurance carriers; policymak- texts, it provides the practitioner with an
ers; and others involved in planning, evaluat- overview of medical considerations.
ing, and delivering services for detoxifying
patients from substances of abuse. Secondary This TIP will also bring clinicians and adminis-
audiences include public safety/police and trators up-to-date on important aspects of
criminal justice personnel, educational institu- detoxification, including how the services are to
tions, those involved with assisting workers be paid for. It is unusual in a clinical treatment
(e.g., Employee Assistance Programs), shel- improvement protocol to discuss issues related
ters/feeding programs, and managed care orga- to how clinical services are reimbursed.
nizations. The TIP also should prove useful to However, in the field of substance abuse and
providers of other services in comprehensive detoxification services, reimbursement issues
systems of care (vocational counseling, occupa- have become so intertwined with the delivery of
tional therapy, and public housing/assisted liv- services that the consensus panel deemed it
ing), administrators, and payors (public, pri- necessary to address the conflicts and misun-
vate, and managed care). derstandings that sometimes arise between the
care systems and the reimbursement systems.
Scope
Among other issues covered in this TIP is the History of
importance of detoxification as one compo- Detoxification Services
nent in the continuum of healthcare services
for substance-related disorders. The TIP Prior to the 1970s, public intoxication was
reinforces the urgent need for nontraditional treated as a criminal offense. People arrested
settings—such as emergency rooms, medical for it were held in the “drunk tanks” of local
and surgical wards in hospitals, acute care jails where they underwent withdrawal with
clinics, and others that do not traditionally little or no medical intervention (Abbott et al.
2 Chapter 1
1995; Sadd and Young 1987). Shifts in the Just as the treatment and the conceptualiza-
medical field, in perceptions of addiction, and tion of addiction have changed, so too have
in social policy changed the way that people the patterns of substance use and the accom-
with dependency on drugs, including alcohol, panying detoxification needs. The popularity
were viewed and treated. Two notable events of cocaine, heroin, and other substances has
were particularly instrumental in changing led to the need for different kinds of detoxifi-
attitudes. In 1958, the American Medical cation services. At
Association (AMA) took the official position the same time, public
that alcoholism is a disease. This declaration health officials have
suggested that alcoholism was a medical prob- increased invest- The AMA’s
lem requiring medical intervention. In 1971, ments in detoxifica-
the National Conference of Commissioners on tion services and position is that sub-
Uniform State Laws adopted the Uniform substance abuse
Alcoholism and Intoxication Treatment Act, treatment, especially stance dependence
which recommended that “alcoholics not be after 1985, as a
subjected to criminal prosecution because of means to inhibit the is a disease, and it
their consumption of alcoholic beverages but spread of HIV infec-
rather should be afforded a continuum of tion and AIDS encourages physi-
treatment in order that they may lead normal among people who
lives as productive members of society” inject drugs. More
(Keller and Rosenberg 1973, p. 2). While this recently, people with
cians and other
recommendation did not carry the weight of substance use disor-
law, it made a major change in the legal impli- ders are more likely clinicians, health
cations of addiction. With these changes came to abuse more than
more humane treatment of people with addic- one drug simultane- organizations, and
tions. ously (i.e., polydrug
abuse) (Office of policymakers to
Several methods of detoxification have evolved Applied Studies
that reflect a more humanitarian view of people 2005). base all their activi-
with substance use disorders. In the “medical
model,” detoxification is characterized by the The AMA continues
use of physician and nursing staff and the to maintain its posi- ties on this premise.
administration of medication to assist people tion that substance
through withdrawal safely (Sadd and Young dependence is a dis-
1987). The “social model” rejects the use of ease, and it encour-
medication and the need for routine medical ages physicians and other clinicians, health
care, relying instead on a supportive nonhospi- organizations, and policymakers to base all
tal environment to ease the passage through their activities on this premise (AMA 2002).
withdrawal (Sadd and Young 1987). Today, it is As treatment regimens have become more
rare to find a “pure” detoxification model. For sophisticated and polydrug abuse more com-
example, some social model programs use medi- mon, detoxification has evolved into a com-
cation to ease withdrawal but generally employ passionate science.
nonmedical staff to monitor withdrawal and
conduct triage (i.e., sorting patients according
to the severity of their disorders). Likewise, Definitions
medical programs generally have some compo- Few clear definitions of detoxification and
nents to address social/personal aspects of related concepts are in general use at this
addiction. time. Criminal justice, health care, substance
abuse, mental health, and many other sys-
4 Chapter 1
other significant people when appropriate stance-induced disorders. According to the
and with release of confidentiality. DSM-IV-TR, substance use disorders include
• Fostering the patient’s entry into treatment both “substance dependence” and “substance
involves preparing the patient for entry into abuse.” Substance dependence refers to “a
substance abuse treatment by stressing the cluster of cognitive, behavioral, and physio-
importance of following through with the logical symptoms indicating that the individu-
complete substance abuse treatment contin- al continues use of the substance despite sig-
uum of care. For patients who have demon- nificant substance-related problems. There is
strated a pattern of completing detoxifica- a pattern of repeated self-administration that
tion services and then failing to engage in can result in tolerance, withdrawal, and com-
substance abuse treatment, a written treat- pulsive drug-taking behavior” (APA 2000, p.
ment contract may encourage entrance into 192). Substance abuse refers to “a maladap-
a continuum of substance abuse treatment tive pattern of substance use manifested by
and care. This contract, which is not legally recurrent and significant adverse conse-
binding, is voluntarily signed by patients quences related to the repeated use of sub-
when they are stable enough to do so at the stances” (APA 2000, p. 198). It should be
beginning of treatment. In it, the patient noted that for purposes of this TIP, the term
agrees to participate in a continuing care “substance abuse” is sometimes used to
plan, with details and contacts established denote both substance abuse and substance
prior to the completion of detoxification. dependence as they are defined by the DSM-
IV-TR.
All three components (evaluation, stabiliza-
tion, and fostering a patient’s entry into This TIP also uses the DSM-IV-TR definitions
treatment) involve treating the patient with for substance intoxication and substance
compassion and understanding. Patients withdrawal. Substance intoxication is “the
undergoing detoxification need to know that development of a reversible substance-specific
someone cares about them, respects them as syndrome due to the recent ingestion of (or
individuals, and has hope for their future. exposure to) a substance” whereas substance
Actions taken during detoxification will withdrawal is “the development of a sub-
demonstrate to the patient that the provider’s stance-specific maladaptive behavioral
recommendations can be trusted and fol- change, with physiological and cognitive con-
lowed. comitants, that is due to the cessation of, or
reduction in, heavy and prolonged substance
use” (APA 2000, pp. 199, 201). Figure 1-1
Other Relevant Terms (p. 6) defines these and other relevant terms.
As defined by the Diagnostic and Statistical Treatment/rehabilitation includes an ongoing,
Manual of Mental Disorders, 4th edition, continual assessment of the patient’s physical,
Text Revision (DSM-IV-TR) (American psychological, and social status, as well as an
Psychiatric Association [APA] 2000), a sub- analysis of environmental risk factors that
stance-related disorder is a “disorder related may be contributing to substance use and the
to the taking of a drug of abuse (including identification of immediate relapse triggers as
alcohol), to the side effects of a medication, well as prevention strategies for coping with
and to toxin exposure” (APA 2000, p. 191). them. It also includes the delivery of primary
The term substance “can refer to a drug of medical care and psychiatric care, if neces-
abuse, a medication, or a toxin” (APA 2000, sary, to help the patient abstain from sub-
p. 191). In this TIP, the term substance refers stance use and minimize the physical harm
to alcohol as well as other drugs of abuse. caused by it. Ultimately, the goal of treat-
Substance-related disorders are divided into ment/rehabilitation is to attain a higher level
two groups: substance use disorders and sub- of social functioning by reducing risk factors,
Term Definition
Substance abuse (in this TIP, also A maladaptive (i.e., harmful to a person’s life) pattern of sub-
sometimes used to denote “substance stance use marked by recurrent and significant negative conse-
dependence”) quences related to the repeated use of substances.
Substance dependence (in this TIP, A cluster of cognitive, behavioral, and physiological symptoms
“substance abuse” is sometimes used indicating that the individual is continuing use of the substance
to include “dependence”) despite significant substance-related problems. A person experi-
encing substance dependence shows a pattern of repeated self-
administration that usually results in tolerance, withdrawal, and
compulsive drug-taking behavior.
enhancing protective factors, and thus patients to emphasize that these persons are
decreasing the possibility of relapse. coming into contact with physicians, nurses,
physician assistants, and medical social work-
Maintenance includes the continuation of ers in a medical setting in which the patient
counseling and support specified in the treat- often is physically ill from the effects of with-
ment plan, refinement and strengthening of drawal from specific substances. In some
strategies to avoid relapse, and engagement in social setting detoxification programs, the
ongoing relapse prevention, aftercare, and/or terms “client” or “consumer” may be used in
domiciliary care (Lehman et al. 2000). place of “patient.”
As a final note, in this TIP persons in need of
detoxification services and subsequent sub-
stance abuse treatment are referred to as
6 Chapter 1
Guiding Principles in empirically measurable and agreed upon by all
parties. The consensus panel developed guide-
Detoxification and lines (listed in Figure 1-2) that serve as the
foundation for the TIP.
Substance Abuse
Treatment
The consensus panel recognizes that the suc-
cessful delivery of detoxification services is
dependent on standards that are to some extent
Figure 1-2
Guiding Principles Recognized by the Consensus Panel
1. Detoxification does not constitute substance abuse treatment but is one part of a continuum of care for
substance-related disorders.
2. The detoxification process consists of the following three sequential and essential components:
•Evaluation
•Stabilization
•Fostering patient readiness for and entry into treatment
A detoxification process that does not incorporate all three critical components is considered incomplete
and inadequate by the consensus panel.
3. Detoxification can take place in a wide variety of settings and at a number of levels of intensity within
these settings. Placement should be appropriate to the patient’s needs.
4. Persons seeking detoxification should have access to the components of the detoxification process
described above, no matter what the setting or the level of treatment intensity.
5. All persons requiring treatment for substance use disorders should receive treatment of the same
quality and appropriate thoroughness and should be put into contact with a substance abuse treat-
ment program after detoxification, if they are not going to be engaged in a treatment service provided
by the same program that provided them with detoxification services. There can be “no wrong door
to treatment” for substance use disorders (CSAT 2000a).
6. Ultimately, insurance coverage for the full range of detoxification services is cost-effective. If reim-
bursement systems do not provide payment for the complete detoxification process, patients may be
released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical com-
plications ultimately drive up the overall cost of health care.
7. Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as
unique health needs and life situations. Organizations that provide detoxification services need to
ensure that they have standard practices in place to address cultural diversity. It also is essential that
care providers possess the special clinical skills necessary to provide culturally competent compre-
hensive assessments. Detoxification program administrators have a duty to ensure that appropriate
training is available to staff. (For more information on cultural competency training and specific
competencies that clinicians need to be “culturally competent” see the forthcoming TIP Improving
Cultural Competence in Substance Abuse Treatment [CSAT in development a]).
8. A successful detoxification process can be measured, in part, by whether an individual who is sub-
stance dependent enters, remains in, and is compliant with the treatment protocol of a substance
abuse treatment/rehabilitation program after detoxification.
8 Chapter 1
insurers try to reach agreements on the level for resolving conflicts as well as clearly defin-
of treatment required by a given patient, as ing terms used in patient placement and treat-
well as the medically appropriate setting in ment settings as a step toward clearer under-
which the treatment services are to be deliv- standing among interested parties.
ered. Accordingly, the TIP offers suggestions
11
Least Restrictive Care
Least restrictive refers to patients’ civil rights and their right to choice of care. There are four spe-
cific themes of historical and clinical importance:
1. Patients should be treated in those settings that least interfere with their civil rights and freedom to
participate in society.
2. Patients should be able to disagree with clinician recommendations for care. While this includes the
right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as
long as considerations of dangerousness and mental competency are satisfied). It implies a patient’s
right to seek a higher or different level of care than that which the clinician has planned.
3. Patients should be informed participants in defining their care plan. Such planning should be done
in collaboration with their healthcare providers.
4. Careful consideration of State laws and agency policies is required for patients who are unable to
act in their own self-interests. Because the legal complexities of this issue will vary from State to
State the TIP cannot provide definitive guidance here, but providers need to consider whether or
not the person is “gravely” incapacitated, suicidal, or homicidal; likely to commit grave bodily
injury; or, in some States, likely to cause injury to property. In such cases, State law and/or case
law may hold providers responsible if they do not commit the patient to care, but in other cases
programs may be open to lawsuits for forcibly holding a patient.
In spite of the impediments, some progress has 2. Biomedical Conditions and Complications
been made in developing comprehensive 3. Emotional, Behavioral, or Cognitive
patient placement criteria. Because the choice Conditions and Complications
of a treatment setting and intensity of treat-
4. Readiness to Change
ment (level of care) are so important, the
American Society of Addiction Medicine 5. Relapse, Continued Use, or Continued
(ASAM) created the Patient Placement Problem Potential
Criteria, Second Edition, Revised (PPC-2R) a 6. Recovery/Living Environment
consensus-based clinical tool for matching
patients to the appropriate setting and level of The ASAM PPC-2R describes both the settings
care. The ASAM PPC-2R represents an effort in which services may take place and the inten-
to define how care settings may be matched to sity of services (i.e., level of care) that patients
patient needs and special characteristics. These may receive in particular settings. It is impor-
criteria currently define the most broadly tant to reiterate, however, that the ASAM
accepted standard of care for the treatment of PPC-2R criteria do not characterize all the
substance use disorders. ASAM criteria are details that may be essential to the success of
intended to provide flexible clinical guidelines; treatment (Gastfriend et al. 2000). Moreover,
these criteria may not be appropriate for par- traditional assumptions that certain treatment
ticular patients or specific care settings. can be delivered only in a particular setting
may not be applicable or valuable to patients.
The PPC-2R identifies six “assessment dimen- Clinical judgment and consideration of the
sions to be evaluated in making placement patient’s particular situation are required for
decisions” (ASAM 2001, p. 4). They are as appropriate detoxification and treatment.
follows:
In addition to the general placement criteria
1. Acute Intoxication and/or Withdrawal
for treatment for substance-related disorders,
Potential
ASAM also has developed a second set of place-
12 Chapter 2
ment criteria, which are more important for should increase the patient’s readiness for
the purposes of this TIP—the five “Adult and commitment to substance abuse treat-
Detoxification” placement levels of care within ment and foster a solid therapeutic alliance
Dimension 1 (ASAM 2001). These “Adult between the patient and care provider.
Detoxification” levels of care are
It is important to note that ASAM PPC-2R
1. Level I-D: Ambulatory Detoxification criteria are only guidelines, and that there
Without Extended Onsite Monitoring (e.g., are no uniform protocols for determining
physician’s office, home health care agen- which patients are placed in which level of
cy). This level of care is an organized out- care. For further information on patient
patient service monitored at predeter- placement, readers are advised to consult
mined intervals. TIP 13, The Role and Current Status of
2. Level II-D: Ambulatory Detoxification Patient Placement Criteria in the Treatment
With Extended Onsite Monitoring (e.g., of Substance Use Disorders (Center for
day hospital service). This level of care is Substance Abuse Treatment [CSAT] 1995h).
monitored by appropriately credentialed Because this TIP is geared to audiences that
and licensed nurses. may or may not be familiar with the ASAM
3. Level III.2-D: Clinically Managed PPC-2R levels of care, this section discusses
Residential Detoxification (e.g., nonmedi- the services and staffing specific to the care
cal or social detoxification setting). This settings that are familiar to a broad audience.
level emphasizes peer and social support
and is intended for patients whose intoxi-
cation and/or withdrawal is sufficient to Physician’s Office
warrant 24-hour support. It has been estimated that nearly one half of
4. Level III.7-D: Medically Monitored the patients who visit a primary care provider
Inpatient Detoxification (e.g., freestanding have some type of problem related to sub-
detoxification center). Unlike Level stance use (Miller and Gold 1998). Indeed,
III.2.D, this level provides 24-hour medi- because the physician may be the first point
cally supervised detoxification services. of contact for these people, initiation of treat-
5. Level IV-D: Medically Managed Intensive ment often begins in the family physician’s
Inpatient Detoxification (e.g., psychiatric office (Prater et al. 1999). Physicians should
hospital inpatient center). This level pro- use prudence in determining which patients
vides 24-hour care in an acute care inpa- may undergo detoxification safely on an out-
tient settings. patient basis. As a general rule, outpatient
treatment is just as effective as inpatient
As described by the ASAM PPC-2R, the treatment for patients with mild to moderate
domain of detoxification refers not only to the withdrawal symptoms (Hayashida 1998).
reduction of the physiological and psychologi-
cal features of withdrawal syndromes, but For physicians treating patients with sub-
also to the process of interrupting the momen- stance use disorders, preparing the patient to
tum of compulsive use in persons diagnosed enter treatment and developing a therapeutic
with substance dependence (ASAM 2001). alliance between patient and clinician should
Because of the force of this momentum and begin as soon as possible. This includes pro-
the inherent difficulties in overcoming it even viding the patient and his family with infor-
when there is no clear withdrawal syndrome, mation on the detoxification process and sub-
this phase of treatment frequently requires a sequent substance abuse treatment, in addi-
greater intensity of services initially to estab- tion to providing medical care or referrals if
lish participation in treatment activities and necessary. Staffing should include certified
patient role induction. That is, this phase interpreters for the deaf and other language
14 Chapter 2
designated counselors, psychologists, social only when there are serious concerns about a
workers, and acupuncturists who are avail- patient’s safety.
able either onsite or through the healthcare
system (ASAM 2001). A timely and accurate assessment in an emer-
gency department is of the highest impor-
tance. This will permit the rapid transfer of
Freestanding Urgent Care the patient to a setting where complete care
Center or Emergency can be provided.
Ideally, personnel in
Department the emergency Although they
There are several distinctions between urgent department will have
care facilities and emergency rooms (ERs). at least a small
Urgent care often is used by patients who amount of experi-
need not be
cannot or do not want to wait until they see ence and expertise in
their doctor in his or her office, whereas identifying critically present in the
emergency rooms are utilized more often by ill substance-using
patients who perceive themselves to be in a patients who may be treatment setting
crisis situation. Unlike emergency depart- about to experience
ments, which are required to operate 24 or are already expe- at all times,
hours a day, freestanding urgent care centers riencing withdrawal
usually have specific hours of operation. symptoms. Three physicians and
Staffing for urgent care centers generally is essential rules apply
more limited than for an ER. Standard to emergency depart- nurses are
staffing includes only a physician, an RN, a ments and their han-
technician, and a secretary. Despite these dis- dling of intoxicated
essential to
tinctions, in actual practice there is consider- patients and patients
able overlap between the two—the ER will see who have begun to
medical problems that could be handled by experience with- office-based
visits to offices, and urgent care facilities will drawal:
handle some cases of emergency medicine. detoxification.
• Emergency depart-
A freestanding urgent care center or emergen- ments and their
cy department reasonably can be expected to clinicians should
provide assessment and acute biomedical never simply
(including psychiatric) care. However, these administer medications to intoxicated persons
settings often are unable to provide satisfacto- and then send them home.
ry psychosocial stabilization or complete • No intoxicated patient should ever be allowed
biomedical stabilization (which includes both to leave a hospital setting. All such persons
the initiation and taper of medications used in should be referred to the appropriate detoxi-
the treatment of substance withdrawal syn- fication setting if possible, although there are
dromes). Appropriate triage and successful legal restrictions that forbid holding persons
linkage to ongoing detoxification services is against their will under certain conditions
essential. The ongoing detoxification services (Armenian et al. 1999).
may be provided in an inpatient, residential, • A clear distinction must be made between
or outpatient setting. Patients with more than acute intoxication on the one hand and with-
moderate biomedical or psychosocial compli- drawal on the other. Acute intoxication, it
cations are more likely to require treatment must be remembered, creates special issues
in an inpatient setting. Care in these settings and challenges that need to be addressed.
can be quite costly and should be accessed The risk of suicidality in patients who pre-
sent in a state of intoxication needs to be
16 Chapter 2
indispensable to identifying the least restric- Clinically Managed Residential
tive and most cost-effective treatment option Detoxification
that may be available. Concern for safety is Residential settings vary greatly in the level of
of primary importance, and the final decision care that they provide. Those with intensive
regarding placement always rests with the medical supervision involving physicians, nurse
treating physician. practitioners, physician assistants, and nurses
can handle all but the most demanding compli-
Level of care cations of intoxication and withdrawal. On the
other hand, some residential settings have min-
Medically Monitored Inpatient imally intensive medical oversight. Residential
Detoxification detoxification in settings with limited medical
Inpatient detoxification provides 24-hour oversight often is referred to as “social detoxifi-
supervision, observation, and support for cation.” (Though the “social detoxification”
patients who are intoxicated or experiencing model is not limited to residential facilities.)
withdrawal. Since this level of care is relatively Facilities with lower levels of care should have
more restrictive and more costly than a resi- clear procedures in place for implementing and
dential treatment option, the treatment mission pursuing appropriate medical referral and
in this setting should be clearly focused and linkage, especially in the case of emergencies.
limited in scope. Primary emphasis should be For example, a patient who is in danger of
placed on ensuring that the patient is medically seizures or delirium tremens needs to be
stable (including the initiation and tapering of referred to the appropriate medical facility for
medications used for the treatment of sub- acute care of presenting symptoms, possibly
stance use withdrawal); assessing for adequate medicated, and then returned to a social detox-
biopsychosocial stability, quickly intervening to ification setting for continuing monitoring and
establish this adequately; and facilitating effec- observation. The establishment of this kind of
tive linkage to and engagement in other appro- collaborative relationship between institutions
priate inpatient and outpatient services. provides a good example of a cost-effective way
to provide adequate care to patients.
Inpatient settings provide medically managed
intensive inpatient detoxification. At this level Residential detoxification programs provide
of care, physicians are available 24 hours per 24-hour supervision, observation, and sup-
day by telephone. A physician should be port for patients who are intoxicated or expe-
available to assess the patient within 24 hours riencing withdrawal. They are characterized
of admission (or sooner, if medically neces- by an emphasis on peer and social support
sary) and should be available to provide (ASAM 2001). Standards published by such
onsite monitoring of care and further evalua- groups as the Joint Commission on
tion on a daily basis. An RN or other quali- Accreditation of Healthcare Organizations
fied nursing specialist should be present to (JCAHO) and the Commission on
administer an initial assessment. A nurse will Accreditation of Rehabilitation Facilities
be responsible for overseeing the monitoring (CARF) provide further information on quali-
of the patient’s progress and medication ty measures for residential detoxification.
administration on an hourly basis, if needed. Additional information is available on the
Appropriately licensed and credentialed staff JCAHO Web site (www.jcaho.org) and the
should be available to administer medications CARF Web site (www.carf.org).
in accordance with physician orders.
18 Chapter 2
tate the patient’s engagement in ongoing treat- as an interdisciplinary team to assess and
ment and recovery (ASAM 2001). care for the patient with a substance-related
disorder, as well as patients with both a sub-
A partial hospitalization program may occupy stance use disorder and a co-occurring
the same setting (i.e., physical space) as an biomedical, emotional, or behavioral condi-
acute care inpatient treatment program. tion. Successful linkage to treatment for the
Although occupying the same space, the levels substance use disorder (in addition to
of care provided by these two programs are biomedical stabilization) is central to the mis-
distinct yet complementary. Acute care inpa- sion of an intensive
tient programs provide detoxification services outpatient or partial
to patients in danger of severe withdrawal hospitalization pro-
and who therefore need the highest level of gram (ASAM 2001). Successful linkage
medically managed intensive care, including For more informa-
access to life support equipment and 24-hour tion, see the TIP to treatment for
medical support. In contrast, partial hospital- Substance Abuse:
ization programs provide services to patients Clinical Issues in the substance use
with mild to moderate symptoms of withdraw- Intensive Outpatient
al that are not likely to be severe or life- Treatment [CSAT in
threatening and that do not require 24-hour disorder (in
development d].
medical support. The transition from an
acute care inpatient program to either a par- addition to
tial hospitalization or intensive outpatient Acute Care
program sometimes is referred to as a “step- Inpatient biomedical
down.” Typically, whether these programs
share space and staff with an acute care inpa- Settings stabilization) is
tient program or are physically distinct from There are several
a hospital structure, they have close clinical types of acute care central to the
and/or administrative ties to hospital centers. inpatient settings.
Collaborative working relationships are indis- They include mission of an
pensable in pursuing the goal of providing • Acute care general
patients with the most appropriate level of hospitals
care in the most cost-effective setting.
intensive out-
• Acute care addic-
tion treatment units patient or partial
Staffing in acute care gener-
al hospitals hospitalization
IOPs and PHPs should be staffed by physi-
cians who are available daily as active mem- • Acute care psychi-
bers of an interdisciplinary team of appropri- atric hospitals program.
ately trained professionals and who medically • Other appropriately
manage the care of the patient. An RN or licensed chemical
other licensed and credentialed nurse should dependency special-
be available for primary nursing care and ty hospitals
observation during the treatment day.
Addiction counselors or licensed or registered These settings share the ready availability of
addiction clinicians should be available to acute care medical and nursing staff, life sup-
administer planned interventions according to port equipment, and ready access to the full
the assessed needs of the patient. The multi- resources of an acute care general hospital or
disciplinary professionals (such as physicians, its psychiatric unit. This level of care provides
nurses, counselors, social workers, psycholo- medically managed intensive inpatient detoxifi-
gists, and acupuncturists) should be available cation (ASAM 2001).
20 Chapter 2
Figure 2-1
Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred
Considerations Indications
Supportive person to assist Not essential but advisable for outpatient detoxifi-
cation
This chapter addresses the psychosocial and biomedical issues that may
affect detoxification and ensuing treatment. It highlights evaluation pro-
cedures for patients undergoing detoxification, discusses strategies for
engaging and retaining patients in detoxification and preparing them for
treatment, and presents an overview for providing linkages to other
services.
23
Overarching Principles for Care During
Detoxification Services
• Detoxification services do not offer a “cure” for substance use disorders. They often are a first step
toward recovery and the “first door” through which patients pass to treatment.
• Substance use disorders are treatable, and there is hope for recovery.
• Substance use disorders are brain disorders and not evidence of moral weaknesses.
• Patients are treated with respect and dignity at all times.
• Patients are treated in a nonjudgmental and supportive manner.
• Services planning is completed in partnership with the patient and his or her social support network,
including such persons as family, significant others, or employers.
• All health professionals involved in the care of the patient will maximize opportunities to promote rehabili-
tation and maintenance activities and to link her or him to appropriate substance abuse treatment imme-
diately after the detoxification phase.
• Active involvement of the family and other support systems while respecting the patient’s rights to privacy
and confidentiality is encouraged.
• Patients are treated with due consideration for individual background, culture, preferences, sexual orien-
tation, disability status, vulnerabilities, and strengths.
24 Chapter 3
Figure 3-1
Initial Biomedical and Psychosocial Evaluation Domains
Biomedical Domains
• General health history—What is the patient’s medical and surgical history? Are there any psychi-
atric or medical conditions? Are there known medication allergies? Is there a history of seizures?
• Mental status—Is the patient oriented, alert, cooperative? Are thoughts coherent? Are there signs of
psychosis or destructive thoughts?
• General physical assessment with neurological exam—This will ascertain the patient’s general health
and identify any medical or psychiatric disorders of immediate concern.
• Temperature, pulse, blood pressure—These are important indicators and should be monitored
throughout detoxification.
• Patterns of substance abuse—When did the patient last use? What were the substances of abuse?
How much of these substances was used and how frequently?
• Urine toxicology screen for commonly abused substances.
• Past substance abuse treatments or detoxification—This should include the course and number of
previous withdrawals, as well as any complications that may have occurred.
Psychosocial Domains
• Demographic features—Gather information on gender, age, ethnicity, culture, language, and educa-
tional level.
• Living conditions—Is the patient homeless or living in a shelter? What is the living situation? Are sig-
nificant others in the home (and, if so, can they safely supervise)?
• Violence, suicide risk—Is the patient aggressive, depressed, or hopeless? Is there a history of vio-
lence?
• Transportation—Does the patient have adequate means to get to appointments? Do other arrange-
ments need to be made?
• Financial situation—Is the patient able to purchase medications and food? Does the patient have
adequate employment and income?
• Dependent children—Is the patient able to care for children, provide adequate child care, and
ensure the safety of children?
• Legal status—Is the patient a legal resident? Are there pending legal matters? Is treatment court
ordered?
• Physical, sensory, or cognitive disabilities—Does the client have disabilities that require considera-
tion?
a list of signs and symptoms of conditions that Seizures are of special concern. Practitioners
require immediate medical attention. All staff should interview the patient and family about
members who work with patients should be seizure disorders and seizure history. In addi-
aware of these and seek medical consultation tion, nonmedical staff should be aware of signs
for the patients as necessary. of impending seizures such as tremors,
increased blood pressure, overactive reflexes, HIV, viral hepatitis, abscesses, and sepsis (the
and high temperature and pulse. It is essential spreading of infection from its original site in
that nonmedical staff be trained in protocols to the body). Intrapulmonary (within the lungs)
prevent injury in the event of a seizure. administration can cause lung disorders
Competence in carrying out these protocols (Dackis and Gold 1991). Nonmedical detoxifi-
should be evaluated by a physician or nurse cation staff also should be aware of the medi-
clinician. For more information on seizures, cations used in detoxification, medications for
see chapter 4. common medical and psychiatric disorders,
and signs of common medication reactions
All staff working with patients should be and interactions.
familiar with medical disorders that are asso-
ciated with various addictive substances or
routes of administration. Alcoholism has mul- Infectious disease
tiple organ effects involving the liver, pan- Standard precautions should be used with all
creas, central nervous system, cardiovascular patients to protect the staff and patients against
system, and endocrine system. Cocaine pro- the transmission of infectious diseases, includ-
duces many of its medical complications ing HIV and hepatitis A, B, and C. All open
through vasoconstriction (i.e., narrowing of wounds should be cultured and treated to pre-
the blood vessels), including myocardial vent the spread of infections. Providers should
infarction (heart attack), stroke, renal dis- use HIV/blood and respiratory infection pre-
ease, spontaneous abortion, and even bowel cautions until HIV and respiratory infectious
infarction (death of tissue). Cocaine also can status are known. Patients with respiratory
cause seizures and cardiac arrhythmia (irreg- infections should be carefully evaluated. The
ular heartbeat). A heroin overdose can lead panel suggests that tuberculin testing be per-
to a fatal respiratory depression. Intravenous formed or recent test results obtained on all
drug use is particularly likely to increase the patients to screen for active tuberculosis. A
risk of infectious complications, including chest x-ray is recommended if indicated by the
26 Chapter 3
patient’s history and physical assessments. risk for suicide, staff should avoid harsh con-
Nonmedical detoxification staff should be frontation and judgment and instead focus on
trained to watch for the signs of common infec- the treatable nature of substance use disor-
tious diseases passed through casual contact, ders and the rehabilitation options available.
including infestation with scabies and lice. These interactions offer an opportunity to
start a dialog with the patient regarding the
impact of substance use on mental illness and
General Guidelines for vice versa.
Addressing Immediate Mental
Health Needs Anger and aggression
The following section provides general guide- Alcohol, cocaine, amphetamine, and hallu-
lines for treating patients who have immediate cinogen intoxication may be associated with
mental health needs. For more detailed infor- increased risk of violence. Symptoms associ-
mation on the treatment of patients with co- ated with this increased risk for violence
occurring psychiatric conditions see TIP 42, include hallucinations, paranoia, anxiety, and
Substance Abuse Treatment for Persons With depression. As a precaution, all patients who
Co-Occurring Disorders (Center for are intoxicated should be considered poten-
Substance Abuse Treatment [CSAT] 2005c). tially violent (Miller et al. 1994). Programs
should have in place well-developed plans to
Suicide promote staff and patient safety, including
protocols for response by local law enforce-
Those who are users of multiple illicit sub- ment agencies or security contractors. Staff
stance are more likely to experience psychiatric working in detoxification programs should be
disorders, and the risk is highest among those trained in techniques to de-escalate anger and
who use both opiates and benzodiazepines aggression. In many cases, aggressive behav-
and/or alcohol (Marsden et al. 2000). iors can be defused through verbal and envi-
Depression is more common among those who ronmental means (Reilly and Shopshire
abuse a combination of these substances, and 2002). For the protection of the staff and the
women are at higher risk than men. Among patient, physical restraint should be used as a
those patients who are positive for depression, last resort and programs should be aware of
the risk of suicide is high. Marsden and col- local laws and regulations pertaining to physi-
leagues’ 2000 study of 1,075 clients entering cal restraint. Figure 3-3 (p. 28) lists some use-
treatment showed that 29 percent reported sui- ful ways of managing patients who are angry
cidal ideation in the past 3 months. and aggressive. Readers may refer to the
During acute intoxication and withdrawal, it standards published by such groups as the
is important to provide an environment that Joint Commission on Accreditation of
minimizes the opportunities for suicide Healthcare Organizations (JCAHO) and the
attempts. As a precaution, locations not Commission on Accreditation of
clearly visible to staff should be free of items Rehabilitation Facilities (CARF) for further
that might be used for suicide attempts. guidance. Additional information is available
Frequent safety checks should be implement- on the JCAHO Web site (www.jcaho.org) and
ed; the frequency of these checks should be the CARF Web site (www.carf.org). The
increased when signs of depression, shame, Substance Abuse and Mental Health Services
guilt, helplessness, worthlessness, and hope- Administration (SAMHSA) also has published
lessness are present. When feasible, patients guidelines on the use of seclusion and
at risk for suicide should be placed in areas restraint, which call for the reduction and
that are easily monitored by staff. Most possible elimination of their use (SAMHSA
important, when interacting with patients at 2002).
28 Chapter 3
The nutritional evaluation should consist of with a substance use disorder may lead to dras-
laboratory and anthropometric indices, a tic mood changes. When blood glucose levels
detailed nutritional history, and nutrition drop below a certain threshold, these patients
counseling (Simko et al. 1995). The interven- usually feel depressed, anxious, or moody and
tion begins in the initial acute phase of with- may experience cravings for their drug of
drawal and continues through detoxification choice.
and subsequent substance abuse treatment. If
the patient consents, family members or signifi-
cant others may be included in the nutritional Nutritional deficits
evaluation and counseling. associated with specific
Weight is an important consideration in deter- substances
mining the nutritional status of the person with As noted, the abuse of drugs can interfere with
a substance use disorder. Substance abuse may nutrient utilization and storage. Detoxification
result in a reduction in food intake and disrup- personnel should be familiar with the nutrition-
tion in the patient’s metabolism that may in al deficits associated with specific substances.
turn have caused an eating disorder, weight Opioids are known to decrease calcium absorp-
loss, and malnutrition. Conversely, weight gain tion and to increase cholesterol and body
may be related to inactivity and an excessive potassium levels. Magnesium deficiency often is
intake of highly refined carbohydrates (Zador seen in chronic alcohol dependence. Other
et al. 1996). Patients should be asked whether nutrient deficiencies seen in alcohol abuse
there have been any recent changes in their include protein, fat, zinc, calcium, iron, vita-
weight. While a patient may appear to be ade- mins A and E, and the water-soluble vitamins
quately nourished, a skinfold caliper (an pyridoxine, thiamine, folate, and vitamin B12
instrument that measures the thickness of a (Nazrul Islam et al. 2001). Alcohol also con-
fold of skin with its underlying layer of fat) can tains calories (7 kcal/gm) that when consumed
determine body density (the relationship of the in excessive amounts may displace nutrient-
body’s mass to its volume), though the body dense foods. Cocaine is an appetite suppressant
mass index may be a better indicator of nutri- and may interfere with the absorption of calci-
tional status (Simko et al. 1995). um and vitamin D. Laboratory tests for pro-
tein, vitamins, and iron and the other elec-
Other questions to ask during the initial evalu- trolytes are recommended to determine the
ation concern appetite, eating patterns, food extent of liver function as well as supplementa-
preferences, snacking habits, food allergies, tion (Fontaine et al. 2001). Caution should be
food intolerance, special diets, and foods to be exercised when using supplements because of
avoided because of cultural or religious beliefs. their potential interactions with other drugs
A food frequency questionnaire, food diary, or and treatments.
24-hour food recall may be of use.
30 Chapter 3
appropriate. In milder cases, observation in a Considerations for Victims of
quiet, secure room with compassionate reas-
surance may be sufficient. Additionally, ado-
Domestic Violence
lescents served in adult settings should be While both men and women are victims of
separated from the adult population and domestic abuse, women’s substance use is asso-
observed closely to ensure that they are not ciated with increased risk of intimate partner
victimized (i.e., verbally, physically, or sexu- violence (Cunradi et al. 2002). Staff should
ally) by adult clients. Finally, adolescents in know the signs of domestic violence and be pre-
detoxification settings should always be pared to follow proce-
screened carefully for suicide potential and dures to ensure the
co-occurring psychiatric problems. safety of the patient.
Figure 3-4
Questions To Guide Practitioners To Better Understand the Patient’s
Cultural Framework
Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.
32 Chapter 3
vides clinicians with some helpful questions to Educate the Patient on the
guide their discussions.
Withdrawal Process
During intoxication and withdrawal, it is useful
Considerations for Chronic to provide information on the typical with-
Relapsers drawal process based on the particular drug of
abuse. Usually withdrawal includes symptoms
A patient who recently relapsed after a period
that are the opposite of the effects of the partic-
of extended abstinence may feel especially
ular drug. This rebound effect can cause anxi-
hopeless and vulnerable (an abstinence viola-
ety and concern for patients. Providing infor-
tion effect). In this situation, clinicians can
mation about the common withdrawal symp-
acknowledge progress that had been made
toms of the specific drugs of abuse may reduce
prior to relapse and reassure the patient that
discomfort and the likelihood that the individu-
the internal gains from past recovery work
al will leave detoxification services prematurely
have not all been lost (despite the feeling at the
(for a list of withdrawal symptoms, see chapter
moment that they have), perhaps reframing the
4). Settings that routinely encounter individu-
severity of emotional pain as an indicator of
als in withdrawal should have written materials
how important recovery is to the patient.
available on drug effects and withdrawal from
specific drugs, and have staff who are well
Strategies for versed in the signs and symptoms of withdraw-
al. An additional consideration is providing
Engaging and such information to non–English-speaking
Retaining Patients in patients and their families.
34 Chapter 3
assist the patient in preparing for change in a transtheoretical model, also known as the
nonthreatening, nonconfrontational manner. stages of change model (DiClemente and
The consensus panel does not recommend Prochaska 1998). The interventions to
that clinicians use direct confrontation in increase patient motivation for substance
helping a person with a substance use disor- abuse treatment described in TIP 35,
der begin the process of detoxification and Enhancing Motivation for Change in
subsequent substance abuse treatment. Substance Abuse
Techniques that involve purposefully con- Treatment (CSAT
fronting patients about their substance use 1999c) are based on
behavior, such as the Johnson Intervention, this model.
where significant others are taught to con-
front the individuals using substances According to the
Clinicians,
(Liepman 1993), have been shown to be high- model, a client is
ly effective when significant others implement considered to be at
one of five stages of groups, and
them. However, subsequent studies of clini-
cians, groups, and programs that rely on con- readiness to change
his substance-abus- programs that
frontational techniques have yielded poor
outcomes (Miller et al. 1995). Moreover, the ing behavior, each
vast majority of significant others do not wish stage being progres- rely on
to use these techniques, and for that reason sively closer to sus-
these techniques are not recommended (Miller tained recovery. confrontational
et al. 1999). Those stages are pre-
contemplation, con- techniques have
Care should be taken to ensure that any sig- templation, prepara-
nificant other who is involved in motivating tion, action, and yielded poor
the patient for therapy is appropriate for this maintenance. The
task. Only significant others who have been model assumes that
appropriately introduced to the intervention individuals may
outcomes.
by a clinician should participate. The pres- move back and forth
ence of a trained facilitator is recommended, between different
either for coaching or for facilitating the stages over time. A
intervention. It also is important to have the corollary to this
recommended treatment option readily avail- assumption is that an
able so if the patient agrees, admission can be individual’s level of motivation is definitely
swift and seamless. Those individuals selected not a permanent characteristic. Rather, moti-
to intervene should support the patient’s vation to change can be influenced by others,
abstinence from substances of abuse. including detoxification treatment staff.
Furthermore, if the patient places consider-
able value on her or his relationships with In general, the basic concept is to try to move
these significant others, success is more likely patients to the next stage of change. The clini-
(Longabaugh et al. 1993). cian needs to identify any potential obstacles
that might hinder the patient’s progress
through the stages of change. The transtheo-
Tailoring Motivational retical model is illustrated in Figure 3-5
Intervention to Stage of (p. 36) and the details of each stage are
described in the text below.
Change
Perhaps the most well-known and empirically
validated model of “readiness to change” that
has been applied to substance abuse is the
In the precontemplation stage, the individual expressed by the patient toward substance-
is not considering any change in substance- related behaviors. Such ambivalence may be
using behavior in the foreseeable future. more likely to emerge during initial detoxifi-
Typically, a patient in this stage either is cation, before the patient has returned to a
unaware that his substance use is a problem relative zone of comfort and greater denial.
or is unwilling or too discouraged to make a For patients who are determined to remain in
change. Often, a person in the precontempla- the precontemplation stage, the main goal is
tion stage has not experienced serious conse- to get the patient to begin to consider chang-
quences from substance use. During the pre- ing. To accomplish this, the clinician might
contemplation stage, the clinician should be express concern, listen to the patient’s per-
attentive for and seize upon any ambivalence
36 Chapter 3
spective, and keep the door open for further cal that the clinician respond quickly to any
communication regarding treatment options. requests for treatment to capitalize on this
motivation before it wanes. One of the most
In the contemplation stage, the individual has critically important roles the clinician can
some awareness that substance use presents a play in this stage is to assist the patient in
problem. In this stage, the patient may developing a plan of action or a behavioral
express a desire or willingness to change, but contract, taking into account the individual
has no definite plans to do so in the near needs of the patient. As part of this process
future, which generally is considered to be the clinician should help the patient enlist
the next 2 to 6 months. Whether it is explicit- social support. Exploring the patient’s expec-
ly stated or not, it is thought that most indi- tations regarding treatment and her role in it
viduals in this stage are ambivalent about is important. Finally, because of the common-
changing. That is, side-by-side with any ly experienced difficulty in accessing treat-
desire to change is a desire to continue the ment, the clinician should discuss with the
current behavior. For patients in the contem- patient ways of maintaining motivation for
plation stage, clinicians are advised to use change during a possible wait for entry into a
“decisional balancing strategies” to help the treatment program, should the patient be
patient move to the action stage (Carey et al. placed, for example, on a waiting list.
1999). In this approach, the clinician helps
the patient to consider the positive and nega- In the action stage, the patient is taking
tive aspects of her substance abuse and has active steps to change substance use behav-
the patient weigh them against each other iors. This includes making modifications to
with the expectation that the scale of balance his habits and environment, such as not
tips in favor of adopting new behavior. spending time in places or with people associ-
Psychoeducation on the interaction of sub- ated with drug taking behavior. These
stance abuse with other problems, including changes may even continue to be made 3 to 6
health, legal, employment, parenting, and months after substance abuse has ceased.
mental illness, can be part of this procedure.
Helping the patient understand that ambiva- In the maintenance stage, the patient is work-
lent feelings about changing substance use ing to maintain the changes initiated in the
behaviors are normal and expected can be action phase.
particularly useful at this stage.
Figure 3-6
Clinician’s Characteristics Most Important to the Therapeutic Alliance
38 Chapter 3
Ensuring that patients with substance use dis- 5. Relapse, Continued Use, or Continued
orders enter substance abuse treatment fol- Problem Potential
lowing detoxification often is difficult. Many 6. Recovery/Living Environment
patients believe that once they have eliminat-
ed the substance or substances of abuse from Due to the limited time patients stay in detoxifi-
their bodies, they have achieved abstinence. cation settings, it is challenging for programs to
Moreover, some insurance policies may not conduct a complete assessment of the rehabili-
cover treatment, or only offer partial cover- tation needs of the individual. With this in
age. The patient may have to go through cum- mind, detoxification programs should focus on
bersome channels to determine if treatment is those areas that are essential to make an
covered, and if so, how much. appropriate linkage to substance abuse treat-
ment services. The assessment of the psychoso-
Preparation should focus on eliminating cial needs affecting the rehabilitation process
administrative barriers to entering substance itself may have to be left to the professionals
abuse treatment prior to discussing treatment providing substance abuse treatment. Other
options with the patient. Discussions with the assessment considerations include
patient should be consistent with the patient’s
• Special needs, such as co-occurring psychi-
improving ability to process and assess infor-
atric and medical conditions that may com-
mation in such a way that the patient appears
plicate treatment or limit access to available
to be acting with his or her own interests in
rehabilitation services
mind.
• Pregnancy, physical limitations, and cogni-
tive impairments that limit the settings suit-
Evaluation of the Patient’s able for the individual
Rehabilitation Needs • Support system issues such as family sup-
To make appropriate recommendations for port, domestic violence, and isolation that
ongoing treatment and recovery activities, influence recommendations about residen-
detoxification staff need to determine the tial versus outpatient settings
individual characteristics of clients and their • The needs of dependent children
environments that are likely to influence the • The need for gender-specific treatment (for
level of care, setting, and specialized services more information see the forthcoming TIPs
needed for recovery. ASAM’s Patient Substance Abuse Treatment: Addressing
Placement Criteria, Second Edition, Revised the Specific Needs of Women [CSAT in
(PPC-2R) (ASAM 2001) provides one widely development e] and Substance Abuse
used model for determining the level of ser- Treatment: Men’s Issues [CSAT in develop-
vices needed to address substance-related dis- ment g]).
orders. The levels of treatment services range
from community-based early intervention Figure 3-7 (p. 40) outlines the areas the consen-
groups to medically managed intensive inpa- sus panel recommends for assessment to deter-
tient services. As noted in chapter 2, mine the most appropriate rehabilitation plan.
providers need to make a placement decision
based on six dimensions: Appendix C lists a variety of instruments use-
ful in characterizing the addiction and related
1. Acute Intoxication and/or Withdrawal disorders (for example, the Addiction
Potential Severity Index [ASI]), measuring motivation-
2. Biomedical Conditions and Complications al willingness to change (Stages of Change
3. Emotional, Behavioral, or Cognitive Readiness and Treatment Eagerness Scale
Conditions or Complications [SOCRATES] and University of Rhode Island
4. Readiness to Change Change Assessment [URICA]), and evaluating
co-occurring psychiatric conditions and social
Medical Conditions and Infectious illnesses, chronic illnesses requiring intensive or specialized treat-
Complications ment, pregnancy, and chronic pain
Motivation/Readiness to Degree to which the client acknowledges that substance use behaviors are a
Change problem and is willing to confront them honestly
Physical, Sensory, or Physical conditions that may require specially designed facilities or staffing
Mobility Limitations
Relapse History and Historical relapse patterns, periods of abstinence, and predictors of absti-
Potential nence; client awareness of relapse triggers and craving
Developmental and Ability to participate in confrontational treatment settings, and benefit from
Cognitive Issues cognitive interventions and group therapy
Family and Social Degree of support from family and significant others, substance-free friends,
Support involvement in support groups
Co-Occurring Psychiatric Other psychiatric symptoms that are likely to complicate the treatment of the
Disorders substance use disorder and require treatment themselves, concerns about
safety in certain settings (note that assessment for co-occurring disorders
should include a determination of any psychiatric medications that the patient
may be taking for the condition)
Dependent Children Custody of dependent children or caring for noncustodial children and
options for care of these children during rehabilitation
Trauma and Violence Current domestic violence that affects the safety of the living environment, co-
occurring posttraumatic stress disorder or trauma history that might compli-
cate rehabilitation
Treatment History Prior successful and unsuccessful rehabilitation experiences that might influ-
ence decision about type of setting indicated
Cultural Background Cultural identity, issues, and strengths that might influence the decision to
seek culturally specific rehabilitation programs, culturally driven strengths or
obstacles that might dictate level of care or setting
Strengths and Resources Unique strengths and resources of the client and his or her environment
40 Chapter 3
and family factors. Administering these highly intensive substance abuse counseling
instruments requires varying degrees of and clients may participate in the upkeep of
sophistication on the part of the clinician. All facilities. Peer support is critical to the
instruments should be considered for their treatment delivered. As a general rule,
cultural, linguistic, level of cognitive compre- patients will stay at a residential treatment
hension, and developmental appropriateness facility for 7 to 30 days.
for each patient. For further information on • Therapeutic communities (TCs) usually
patient placement see TIP 13, The Role and have 24-hour supervision by nonmedical
Current Status of Patient Placement Criteria staff or clients who have sustained recov-
in the Treatment of Substance Use Disorders ery. They tend to provide highly intensive
(CSAT 1995h). counseling services and rely on peer sup-
port and confrontation to shape behaviors
Settings for Treatment of clients. The TC is based on concepts of
self-help. Residence in a TC is longer than a
Just as with settings for detoxification, set- patient’s stay in a residential program—
tings where substance abuse treatment is pro- patients usually stay for a period of at least
vided often are confused with the level of 30 days and often 6 months to a year. In
intensity of the services. It is increasingly some special situations, such as a criminal
clear that although level of intensity of ser- justice setting, TC residence can last 2
vices and setting are both critical to success- years or more.
ful recovery, they are two separate dimen-
• Transitional residential programs and
sions to be considered when linking clients to
halfway houses ordinarily have 24-hour
treatment. This process has been called “de-
supervision from nonmedical staff or clients
linking” or “unbundling” and generally
who have sustained recovery. Patients in
involves determining the need for social ser-
these programs often are working and par-
vices independently from the clinical intensity
ticipate in counseling and peer support dur-
(Gastfriend and McLellan 1997; McGee and
ing the evening and weekend hours.
Mee-Lee 1997).
• Partial hospitalization and day treatment
Treatment and maintenance activities are programs use a combination of medical and
offered in a variety of settings. These include nonmedical staff to deliver a high intensity
settings specifically designed to deliver sub- of counseling services during daytime
stance abuse treatment, such as freestanding hours. Patients return home in the
substance abuse treatment centers, as well as evenings.
settings operating for other purposes, includ- • Intensive outpatient programs usually are
ing mental health centers, jails and prisons, delivered by nonmedical staff in a clinic
and community corrections facilities. location. Patients receive 6 to 9 hours of
Descriptions of these settings appear below: counseling services each week in two or
• Inpatient programs for treatment of sub- three contacts.
stance abuse generally are delivered in hos- • Traditional outpatient services typically are
pitals and freestanding clinics and provide delivered by counselors in a clinic or office
24-hour nursing care in addition to inten- setting and provide fewer hours of services
sive treatment for substance-related prob- than the “intensive outpatient” programs.
lems.
• Recovery maintenance activities are not
• Residential treatment programs normally treatment but are highly valuable for ongo-
provide 24-hour supervision by nonmedical ing sobriety maintenance. They include 12-
staff and the availability of medical staff Step and other support groups aimed at
may be limited. These programs deliver maintaining the gains accomplished in treat-
Figure 3-8
Strategies To Promote Initiation of Treatment and
Maintenance Activities
42 Chapter 3
will be addressed, including those needs typi- these programs includes more than a phone
cally addressed by wraparound services (e.g., number; detoxification staff should assist
housing, vocational assistance, childcare, patients in scheduling initial appointments
transportation) (Fiorentine et al. 1999). and arranging for transportation.
Moreover, patients receiving needed
wraparound services remain in substance Linkage to primary health and prenatal care
abuse treatment longer and improve more than as well as to community resources is essential
people who do not receive such services (Hser for individuals with substance use disorders.
et al. 1999). Linkages can be an effective mechanism to
assist the patient in accessing these services if
As the individual passes through acute intoxi- they are not available as a part of the detoxi-
cation and withdrawal, it is important to fication program. Formalized referral
ensure that the basic needs of the patient are arrangements through contracts or memoran-
met after discharge. These needs include da of understanding can be useful to specify
access to a safe, stable, and drug-free living organizational obligations (D’Aunno 1997).
environment if possible; physical safety; food
and clothing; ongoing health and prenatal
care; financial assistance; and childcare. Minimize Access Barriers
Ensuring access to these basic needs may be An integral part of the process of linking an
problematic, and staff must be flexible and individual with rehabilitation and treatment
creative in finding the means to meet the resources is to address access barriers.
basic needs of the patient. Transportation, child care during treatment,
the potential for relapse between detoxification
Clearly, services planning should extend discharge and treatment admission, housing
beyond the issues of substance dependence to needs, and safety issues such as possible
other areas that may affect compliance with domestic violence should be addressed through
rehabilitation. Detoxification providers an individualized plan prior to discharge.
should be familiar with available resources
for legal assistance, dental care, support The problem of a patient’s placement on a
groups, interpreters, housing assistance, waiting list presents a special barrier to treat-
trauma treatment, recovery-sensitive parent- ment. The solution lies in developing strate-
ing groups, spiritual and cultural support, gies to maintain motivation for treatment dur-
employment assistance, and other assistance ing the waiting period.
programs for basic needs. Family and other
support systems also can be helpful to the For pregnant women and patients with depen-
patient in accessing services and should take dent children, the threat of Child Protective
part in the services planning as often as possi- Services removing their children for abuse
ble, always with the patient’s consent. and neglect due to drug use can be a barrier
to entering a treatment program.
To address the needs of homeless and indigent
patients, detoxification providers should be Additionally, interacting with hostile or
familiar with emergency shelters, cash assis- unfriendly practitioners and encountering
tance, and food programs in their communi- resistance from family, partners, or friends
ties and should have established referral rela- can be barriers to treatment entry.
tionships. Assessing women, teenagers, older
Detoxification staff should be knowledgeable
adults, and other vulnerable individuals for
about State laws regarding drug use during
victimization by another member of the
pregnancy and definitions of child abuse and
household also is important. Patients should
neglect in order to be able to reassure and
be linked with prenatal and primary health
encourage women to enter treatment.
care for domestic violence. Ideally, linkage to
44 Chapter 3
mental health providers are implementing approaches may not be effective. In some
models using clinicians trained to deliver both cases, addressing other needs may provide an
substance abuse and mental health treatment avenue to engage the individual with chronic
concurrently (Drake and Mueser 2000). For substance dependence in treatment. Case
more information, see TIP 42, Substance management approaches can be successful at
Abuse Treatment for Persons With Co- addressing the need for housing, health care,
Occurring Disorders (CSAT 2005c). and basic needs even though the individual is
not yet willing to confront the issue of drink-
ing or other drug use (Cox et al. 1998). TIP
Linkage to Followup 27, Comprehensive Case Management for
Medical Care Substance Abuse Treatment (CSAT 1998a),
The patient’s consent should be sought to provides additional information about deliv-
involve her or his primary healthcare provider ery of case management services to homeless
in the coordination of care. Patients with individuals with substance use disorders and
chronic medical conditions and those in need of those with other complex problems.
followup care should have an appointment Documentation of repetitive inappropriate
made for followup medical care before leaving use of voluntary detoxification services may
the detoxification setting (Luborsky et al. help pave the way for civil commitment to
1997). involuntary treatment where this is an option,
and, where detoxification resources are limit-
ed, treatment systems need to be creative in
Considerations for Individuals designing care plans for patients seeking fre-
With Chronic Substance quent detoxification without evidence of any
therapeutic benefit.
Dependence
For individuals with substance abuse prob-
lems who detoxify regularly but have limited
periods of abstinence, traditional treatment
47
Case Study
A 44-year-old Caucasian male with a fifth-grade education presented to an emergency clinic in mild alcohol
withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia;
blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical
Institute Withdrawal Assessment for Alcohol (CIWA-Ar) (see below) score = 12, indicating mild withdrawal.
A treatment plan was recommended that called for an outpatient 3-day fixed-dose taper of lorazepam (a
benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return
daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that
there was no reliable transportation to the clinic, there had been domestic violence on the parts of both
spouses, and the patient’s ability to carry out routine medical instructions was questionable.
aspects of the patient’s health and psychosocial rehabilitation, and treatment are being
status that should be covered in screening and promoted.
assessment, see Figure 3-1, p. 25.
Clinicians also can use the presentation of
Figure 4-1 lists several instruments useful in information from biochemical markers to
characterizing the intensity of specific with- patients as an effective tool in motivational
drawal states (see appendix C for more infor- enhancement. For example, information
mation on these instruments and how to obtain regarding liver transaminases (specific kinds
them). of enzymes that perform chemical reactions
within the liver) helps provide the patient
with objective information on the level of
Biochemical Markers and recent alcohol use and potential acute hepatic
Their Use damage. This may help the patient move from
This section focuses on biochemical laborato- contemplating treatment to actually beginning
ry tests that detect the presence or absence of treatment. For a more detailed discussion of
alcohol or another substance of abuse, may biological markers in substance abuse, see
be able to quantify the level of present use, or Javors and colleagues (1997).
may be able to quantify cumulative use over
the past few weeks. Tests in all of these areas Blood alcohol content
are reasonably well developed and validated
for alcohol. This is not the case for most Blood alcohol content (BAC) can be determined
other substances of abuse. Biochemical mark- by highly sensitive laboratory procedures that
ers are not adequate screening or assessment generally are available in most emergency
instruments alone, but rather are used to departments, hospitals, and clinical chemistry
support a more comprehensive clinical assess- laboratories. Alcohol elimination undergoes,
ment. Common uses of these biochemical for the most part, zero-order kinetics (decreas-
markers are: ing a set amount per unit of time rather than a
set percentage), so the concept of half-life is not
1. In the initial screening setting to support really accurate. However, first-order kinetics
or refute other information that leads to and half-life do occur when BAC is low (i.e.,
proper diagnosis, assessment, and manage- below 10mg percent), and the half-life is on the
ment. order of about 15 minutes at that point.
2. For forensic purposes (e.g., evaluating a Though disappearance rates of 15mg percent
driver after an automobile accident). per hour are probably average for moderate
3. In detecting occult (secretive or hidden) drinkers, higher values were seen in a group of
use of alcohol and other substances in Swedish drivers apprehended for driving while
therapeutic settings where abstinence, intoxicated (19mg/dL/hr) (Jones and Andersson
48 Chapter 4
Figure 4-1
Assessment Instruments for Dependence and Withdrawal From Alcohol
and Specific Illicit Drugs
1996). The rate of metabolism of alcohol range (about 15 or higher), the clinician can
increases with dependence—some alcoholics reasonably predict that the withdrawal will be
can metabolize 20–25mg/dL/hr (Jones and relatively severe. As noted, however, the rate
Andersson 1996), and Jones and Sternebring of metabolism of alcohol increases with
(1992) have found that alcohol-dependent dependence. The diagnosis of alcohol intoxi-
patients may metabolize 22mg/dL/hr during cation is a clinical diagnosis and not based
detoxification. simply on a BAC. A person with a BAC of
200mg percent could be in withdrawal, intoxi-
When knowledge of BAC is combined with cated (showing related signs and symptoms),
clinical information, the healthcare provider or showing no signs and symptoms of either
can make some predictions regarding the intoxication or withdrawal. A BAC above
acuteness of withdrawal. For example, in an 100mg percent does not necessarily indicate
individual whose blood alcohol level is 200mg clinical intoxication. Like all laboratory pro-
percent but who is already showing tremu- cedures, the blood alcohol levels test has limi-
lousness (shakiness of the hands), brisk tations. Usually, patient permission must be
reflexes, tachycardia (rapid heart rate), obtained prior to testing, the testing itself can
diaphoresis (excessive sweating), and perhaps be expensive, and forensic testing may be
a CIWA-Ar score in the moderate or high subject to specific legal procedures.
50 Chapter 4
It also should be noted that current testing for insults to the liver from toxins (such as chemi-
opioids primarily refers to “organic” drugs that cals, alcohol, prescribed or over-the-counter
are derived from opium (i.e., heroin, codeine, medications). In any form of hepatitis, GGT
and morphine). Synthetic opioids like may be elevated, indicating damage to liver
hydrocodone and methadone are not detected cells. Therefore, GGT elevation does not
by the usual tests; this is true of oxycodone as automatically mean liver damage from alcohol
well. If the use of these drugs is suspected, spe- use, although this is certainly one of the most
cial tests can be ordered. Most important, each common reasons for elevated GGT levels in
program should tailor its urine screening tests patients hospitalized in North America. The
to reflect the substance use patterns prevalent use of GGT levels along with carbohydrate-
in the community. deficient transferrin (CDT) levels is a rela-
tively sensitive and specific indicator of alco-
hol use. The CDT test is discussed below.
Gamma-glutamyltransferase
(GGT)
Carbohydrate-deficient
GGT has been measured in serum (the portion
of the blood that has neither red nor white transferrin
blood cells) for many years as a marker for CDT has been developed over the past 20 years
liver damage. More recently, GGT has been as a marker of cumulative alcohol consumption
advocated as a measure of cumulative alcohol but is just now becoming widely available as a
use (Dackis 2001). Sensitivity of the test is in clinical tool. Sensitivities appear to be in the 70
the 60 to 70 percent range and specificity (its to 80 percent range, and specificities of greater
ability not to misidentify or confuse alcohol use than 90 percent have been found. Sensitivity
with other disorders) is in the 40 to 50 percent and specificity are somewhat lower among
range. In general, both sensitivity and specifici- females than males. Most therapeutic drugs or
ty are lower in females than males. GGT does drugs of abuse do not appear to affect CDT
correlate with alcohol intake but often requires levels. When CDT and GGT levels are com-
heavy drinking (more than six drinks per day) bined, sensitivity and specificity rise to more
to elevate it, and only about half of individuals than 90 percent (Anton 2001). CDT testing is
will show elevations. The half-life of elevated limited by its relatively high cost, lack of clini-
serum GGT after the onset of abstinence is said cal availability in some laboratories, and false-
to be 2 to 3 weeks with alcoholic liver disease. positive results in abstaining individuals who
Chlorpromazine, phenobarbital, and have endstage liver disease from causes other
acetaminophen can all raise serum GGT levels. than alcohol use (DiMartini et al. 2001).
52 Chapter 4
Figure 4-2
Symptoms of Alcohol Intoxication*
Blood Alcohol Level Clinical Picture
301–400mg percent •Worsening of above symptoms with reduction of body temperature and blood
pressure
•Excessive sleepiness
•Amnesia
*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood
alcohol level).
sleep, awakening later with some mild to even the heading Management of Delirium and
severe confusion, generally occurs) Seizures (p. 63).
• Hyperthermia (high fever) Mild alcohol withdrawal generally consists of
• Delirium with disorientation with regard to anxiety, irritability, difficulty sleeping, and
time, place, person, and situation; fluctua- decreased appetite. Severe alcohol withdrawal
tion in level of consciousness usually is characterized by obvious trembling
of the hands and arms, sweating, elevation of
For a discussion of seizures and delirium,
pulse (above 100) and blood pressure (greater
including delirium tremens, see below under
54 Chapter 4
Management of Withdrawal withdrawal. The consensus panel has found
that in actual practice, social detoxification
Without Medication programs vary greatly in their approach and
The management of an individual in alcohol scope. Some programs offer some medical and
withdrawal without medication is a difficult nursing onsite supervision, while others pro-
matter because the indications for this have not vide access to medical
been established firmly through scientific stud- and nursing evalua-
ies or any evidence-based methods. tion through clinics, For alcohol,
Furthermore, the course of alcohol withdrawal urgent care pro-
is unpredictable and currently available tech- grams, and emergen- sedative-hypnotic,
niques of screening and assessment do not cy departments.
allow us to predict with confidence who will or Some social detoxifi-
will not experience life-threatening complica-
and opioid with-
cation programs only
tions. Severe alcohol withdrawal may be associ- offer basic room and
ated with seizures due to relative impairment of board for a “cold drawal syndromes,
gamma-aminobutyric acid (GABA) and relative turkey” detoxifica-
over-activity of N-methyl-D-aspartate systems tion, while other pro- hospitalization (or
(a subtype of the excitatory glutamate receptor grams offer super-
system) (Moak and Anton 1996). The failure to vised use of medica- some form of
treat incipient convulsions is a deviation from tions. Sometimes
the established general standard of care. medications are pre- 24-hour medical
scribed at the onset of
Positive aspects of the nonmedication withdrawal by health-
approach are that it is highly cost-effective care) is generally the
care professionals in
and provides inexpensive access to detoxifica- an outpatient setting,
tion for individuals seeking aid. Observation preferred setting for
while the staff in the
is generally better than no treatment, but social detoxification
people in moderate to severe withdrawal will program supervises
detoxification, based
be best served at a higher level of care. Young the administration of
individuals in good health, with no history of these medications. on principles of
previous withdrawal reactions, may be well Whatever the partic-
served by management of withdrawal without ular situation might safety and humani-
medication. However, personnel supervising be, there should
in this setting should possess assessment abili- always be medical tarian concerns.
ties and be able to summon help through the surveillance, includ-
emergency medical system. Methods of with- ing monitoring of
drawal management without medication vital signs, as part of every social detoxification
include frequent interpersonal support, pro- program.
vision of adequate fluids and food, attention
to hygiene, adequate sleep, and the mainte- The consensus panel agrees that for alcohol,
nance of a no-alcohol/no-drug environment. sedative-hypnotic, and opioid withdrawal syn-
dromes, hospitalization (or some form of 24-
hour medical care) is generally the preferred
Social Detoxification setting for detoxification, based on principles of
Social detoxification programs are defined as safety and humanitarian concerns. When hos-
short-term, nonmedical treatment services for pitalization cannot be provided, a setting that
individuals with substance use disorders. A provides a high level of nursing and medical
social detoxification program offers room, backup 24 hours a day, 7 days a week is desir-
board, and interpersonal support to intoxicat- able. The panel readily acknowledges that
ed individuals and individuals in substance use social detoxification programs are, for some
56 Chapter 4
tremens, or seizures are not good candidates sion, been abstinent for a few hours and have
for social detoxification programs. not developed signs or symptoms of withdraw-
• All social detoxification programs should al. A decision regarding medication for this
have an alcohol- and drug-free environment, group should be in part based on age, num-
have personnel who are familiar with the fea- ber of years of alcohol dependence, and the
tures of substance use withdrawal syn- number of previously treated or untreated
dromes, have training in basic life support, severe withdrawals (three or four appears to
and have access to an emergency medical sys- be a significant threshold in predicting future
tem that can provide transportation to emer- serious withdrawal) (Shaw 1995). If there is
gency departments and other sites of clinical an opportunity to observe the patient in the
care. emergency department of the clinic or similar
setting over the next 6 to 8 hours, then it is
possible to delay a decision regarding treat-
Management of Withdrawal ment and periodically reevaluate a client of
With Medications this category. If this is not possible, then the
Over the last 15 years several reviews and posi- return of the patient to a setting in which
tion papers (Fuller and Gordis 1994; Lejoyeux there is some supervision by family, signifi-
et al. 1998; Mayo-Smith 1997; Nutt et al. 1989; cant others, or in a social detoxification pro-
Shaw 1995) have asserted that only a minority gram is desirable.
of patients with alcoholism will in fact go into
The decision as to whether to give the patient
significant alcohol withdrawal requiring medi-
a single medication dose prior to discharge
cations. Identifying that significant minority
and perhaps provide one or two additional
sometimes is problematic, but there are signs
medication doses to be administered in the
and symptoms of impending problems that can
referral setting rests on adequacy of supervi-
alert the caretaker to seek medical attention.
sion, the probability of whether the patient
Deciding on whether to use medical manage- will drink while undergoing treatment, and
ment for the treatment of alcohol withdrawal whether the patient can or will return for
requires that patients be separated into three assessments the following day. In some cir-
groups. The first and most obvious group cumstances, no treatment may be safer than
comprises those clients who have had a previ- treatment with medication. Mayo-Smith
ous history of the most extreme forms of with- (1997) has shown that benzodiazepines confer
drawal, that of seizures and/or delirium. This protection against alcohol withdrawal seizures
group is discussed in more detail below, but and thus patients with previous seizures
in general, the medication treatment of this should be treated early. The same applies to
group in early abstinence, whether or not delirium. Both of these topics will be explored
they have had the initiation of withdrawal in greater detail in the next section.
symptoms, should proceed as quickly as pos- Extremely heavy drinking in the weeks prior
sible. to complete cessation also predicts more
severe withdrawal (Lejoyeux et al. 1998), but
The second group of patients requiring imme- confirming such a history often is difficult.
diate medication treatment includes those
patients who are already in withdrawal and A less accepted and more controversial posi-
demonstrating moderate symptoms of with- tion on the indications for medication treat-
drawal. ment for alcohol withdrawal springs from
studies that attempt to measure oxidative
The third group of patients includes those stress, which is the formation of oxidative
who may still be intoxicated and therefore free radicals (chemicals that damage pro-
have not had time to develop withdrawal teins), and stress hormones during alcohol
symptoms or who have, at the time of admis- withdrawal (Dupont et al. 2000; Tsai et al.
58 Chapter 4
The training of staff in a standardized proce- drug response) according to severity of symp-
dure of administering rating scales is impor- toms. An alternative regimen might be the
tant and periodic retraining to ensure contin- administration of 1 to 2mg lorazepam two or
ued reliability among raters is essential. A three times a day the first day, followed by
typical routine of administration of symptom- gradual reduction over the next 3 to 5 days.
triggered therapy is as follows: Administer The general approach to tapering is to estab-
50mg of chlordiazepoxide (Librium) for lish an acute dose in the first 24 hours, then
CIWA-Ar > 9 and reassess in 1 hour. to reduce it over the next three days: for
Continue administering 50mg chlordiazepox- example, 400 chlordiazepoxide total on day 1,
ide every hour until CIWA-Ar is < 10. Dosage then 300, 200, 100,
amount and frequency can be modified and off on day 5.
depending on the individual clinical situation This has to be
as determined by the medical provider. extended if
Patients with a history of withdrawal seizures lorazepam is used.
should receive scheduled doses of a long-act- Doses of withdrawal Benzodiazepines
ing benzodiazepine (e.g., diazepam [Valium], medication are omit-
20mg every 6 hours for 3 days) regardless of ted if the patient is remain the
CIWA-Ar score, and should receive addition- sleeping soundly,
al doses if indicated by elevated CIWA-Ar showing signs of medication class
score. It must be noted here that symptom- oversedation, or
triggered therapy is not recommended for exhibiting marked
of choice for
outpatient detoxification. Symptom-triggered ataxia.
therapy requires monitoring and decision-
making by a healthcare professional. The use of gradual, treating alcohol
tapering doses is
Gradual, tapering doses appealing in settings withdrawal.
Before beginning any tapering regimen, the where trained nurs-
patient must be fully stabilized; that is, all signs ing or medical
and symptoms of withdrawal must be observations cannot
improved. Without proper stabilization, no be made frequently;
tapering scheme will succeed. Once the patient however, this in
has been stabilized, oral benzodiazepines can itself is a pitfall.
be administered on a predetermined dosing Under- or overmedication with this regimen
schedule for several days and gradually can occur depending on benzodiazepine toler-
tapered over time. This is a commonly used ance; the presence of chronic cigarette smok-
regimen. ing, which induces benzodiazepine
metabolism; liver function; age; and the pres-
Dosing protocols vary widely among treat- ence of co-occurring medical or psychiatric
ment facilities based on the needs of the conditions. The use of this regimen may be
patient population. One example is that problematic in the outpatient settings in
patients might receive 50mg of chlordiazepox- which it frequently is applied. Supplying the
ide or 10mg of diazepam every 6 hours during patient with 4 to 5 days of a benzodiazepine
the first day of treatment and 25mg of chlor- and facing the probability that the patient
diazepoxide or 5mg of diazepam every 6 may drink and take the benzodiazepine is a
hours on the second and third days. This hazard. It is important to enforce strict limi-
approach to dosing, that is, every 6 hours, is tations on driving automobiles, climbing, or
not as accurate in tailoring medications to operating hazardous machinery.
counter symptoms; a more precise dosing reg-
imen is titrating (adjusting dosage in light of
60 Chapter 4
ordination (leading to falls and automobile the majority of these studies, patients were
accidents), and abuse of the medications. treated with benzodiazepines, although in a
Abuse usually is in the context of the concur- few, phenobarbital was used.
rent use of alcohol, opioids, or stimulants.
A second, and at present more hypothetical,
There are two other limitations of benzodi- concern about benzodiazepine use to treat out-
azepines that may be relevant in some clinical patients in alcohol withdrawal is that they may
settings for some patients. First, although ben- “prime” or reinstate alcohol use during their
zodiazepines have been studied for more than administration. Two preclinical studies support
30 years and are effective for suppressing alco- this premise (Deutsch and Walton 1977;
hol withdrawal symptoms at any one episode, Hedlund and Wahlstrom 1998). A recent ran-
their ability to halt the progressive worsening domized, blinded, clinical trial comparing car-
of each successive alcohol withdrawal reaction bamazepine to lorazepam for the outpatient
is in question. There are now at least nine stud- treatment of alcohol withdrawal found that the
ies that have found that an ever-increasing outpatients on lorazepam were three times as
number of previous alcohol withdrawals likely to drink as those on carbamazepine. The
increases the severity of withdrawal, particu- lorazepam group drank about twice as much
larly seizures and delirium tremens, and alcohol in the immediate post-detoxification
decreases responsiveness to benzodiazepines period than the carbamazepine group (Malcolm
(Ballenger and Post 1978; Booth and Blow et al. 2002).
1993; Brown et al. 1988; Gross et al. 1972;
Lechtenberg and Worner 1990, 1992; Malcolm For a list of potential contraindications to using
et al. 2000; Shaw et al. 1998; Worner 1996). A benzodiazepines to treat alcohol withdrawal in
tenth study (Wojnar et al. 1999) found that certain patients, see Figure 4-3.
increasing severity of alcohol withdrawal symp-
toms was observed only in a minority (22 per- Other medications
cent) of 418 repeatedly treated clients.
However, within this group of one in five indi- Barbiturates
viduals, seizures were three times more com- Barbiturates have been used for nearly a cen-
mon than in the larger, nonprogressive group tury for the treatment of alcohol withdrawal.
and premature age of death was 7 years Most barbiturates, other than phenobarbital,
younger than for the nonprogressive group. In have fallen into disfavor because of severe
Figure 4-3
Potential Contraindications To Using Benzodiazepines To Treat
Alcohol Withdrawal
64 Chapter 4
What To Do in the Event of a Seizure
• At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel.
• Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for
the clinic or hospital unit.
• While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt
to prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s head
and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen
by anyone.
• In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from
extreme head-banging by placing a soft object under the head and neck. Sometimes placing one’s hand or
shoe under the head is adequate.
• No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades).
Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially
swallowed and obstruct the airway.
• Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach
contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a
severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia.
• Even if the individual appears to become fully awake, alert, and oriented without any harm following a
seizure, it is strongly recommended that he be referred for medical evaluation.
• Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages
to reorient them as to what happened and where they are.
• Having drunk for more than two decades preferably with IV administration. The study
• Having poor general medical health and poor by D’Onofrio and colleagues (1999) indicated
nutritional status that a single dose of 1mg of IV lorazepam
reduced recurrent seizure risk, reduced rates
• Having had previous head injuries
of return to emergency departments, and low-
• Having had disturbances of serum calcium, ered hospitalization rates. Despite this
sodium, potassium, or magnesium report, the consensus panel agrees that hospi-
talization for further detoxification treatment
Patients having a witnessed seizure can be
is strongly advised to monitor and ameliorate
treated with IV diazepam or lorazepam and
other withdrawal symptoms, reduce suffering,
ACLS protocol procedures. This reduces but
and stabilize the patient for rehabilitation
does not completely prevent the likelihood of a
treatment.
second seizure (D’Onofrio et al. 1999). In the
rare patient with recurrent multiple seizures or The addition of anti-epileptic drugs (AEDs)
status epilepticus (continuous seizures of sever- has not been established as effective (Chance
al minutes) an anesthesiology consultation may 1991; Hillbom and Hjelm-Jager 1984; Rathlev
be required for general anesthesia. Evaluation et al. 1994). This is primarily based on evalu-
of electrolyte disturbances, central nervous sys- ations of phenytoin (Dilantin and others).
tem (CNS) trauma, and consideration of seda- Newer AEDs have not been studied extensive-
tive-hypnotic withdrawal should be reviewed. ly for preventing alcohol withdrawal seizures.
The consensus panel suggests that AED thera-
Patients who have had a single witnessed or
py should be considered in alcohol withdraw-
suspected alcohol withdrawal seizure should
al patients with multiple past seizures (of any
be immediately given a benzodiazepine,
cause), a history of recent head injury, past
66 Chapter 4
after about 3 days, and gradually subsides over the opioid withdrawal syndrome, after which
a period of 3 weeks or longer. Physiological, dose reductions can be made gradually.
genetic, and psychological factors can signifi-
cantly affect intoxication and withdrawal sever- Medical complications associated with opioid
ity. Figure 4-4 summarizes many of the com- withdrawal can develop and should be quick-
mon signs and symptoms of opioid intoxication ly identified and treated. Unlike alcohol and
and withdrawal. sedative withdrawal, uncomplicated opioid
withdrawal is not life-threatening. Rarely,
The clinician uses intoxication and withdraw- severe gastrointestinal symptoms produced by
al measures as guides to avoid under- or over- opioid withdrawal, such as vomiting or diar-
medicating patients during medically super- rhea, can lead to dehydration or electrolyte
vised detoxification; the number and intensity imbalance. Most individuals can be treated
of signs determine the severity of opioid with- with oral fluids, especially fluids containing
drawal. It is important to appreciate that electrolytes, and some might require intra-
untreated opioid withdrawal gradually builds venous therapies. In addition, underlying
in severity of signs and symptoms and then cardiac illness could be made worse in the
diminishes in a self-limited manner. Repeated presence of the autonomic arousal (increased
assessments should be made during detoxifi- blood pressure, increased pulse, sweating)
cation to determine whether symptoms are that is characteristic of opioid withdrawal.
improving or worsening. Repeated assess- Fever may be present during opioid with-
ments also should address the effectiveness of drawal and typically will respond to detoxifi-
pharmacological interventions. Detoxification cation. Other causes of fever should be evalu-
strategies should aim to establish control over ated, particularly with intravenous users,
Figure 4-4
Signs and Symptoms of Opioid Intoxication and Withdrawal
Opioid Intoxication Opioid Withdrawal
Signs Signs
Bradycardia (slow pulse) Tachycardia (fast pulse)
Hypotension (low blood pressure) Hypertension (high blood pressure)
Hypothermia (low body temperature) Hyperthermia (high body temperature)
Sedation Insomnia
Meiosis (pinpoint pupils) Mydriasis (enlarged pupils)
Hypokinesis (slowed movement) Hyperreflexia (abnormally heightened reflexes)
Slurred speech Diaphoresis (sweating)
Head nodding Piloerection (gooseflesh)
Increased respiratory rate
Symptoms Lacrimation (tearing), yawning
Euphoria Rhinorrhea (runny nose)
Analgesia (pain-killing effects) Muscle spasms
Calmness
Symptoms
Abdominal cramps, nausea, vomiting, diarrhea
Bone and muscle pain
Anxiety
68 Chapter 4
seeking substance abuse treatment. Such and endocrinologic defects caused by long-term
patients also can be maintained on methadone heroin addiction. This is one of many impor-
during the course of hospitalization for any tant reasons to consider conversion to mainte-
condition other than opioid addiction. The nance during most methadone detoxification
hospital does not have to be a registered opi- admissions.
oid treatment program, as long as the patient
was admitted for a detoxification treatment Once the dose requirement for methadone has
for some substance other than opioids. On been established, methadone can be given
the other hand, some persons may not have once daily and generally tapered over 3 to 5
used sufficient amounts of opioids to develop days in 5 to 10mg daily reductions. The initial
withdrawal symptoms, and for others suffi- dose requirement is determined by estimating
cient time may have elapsed since their last the amount of opioid use and gauging the
dose to extinguish withdrawal and eliminate patient’s response to administered
the need for detoxification. methadone. Clinicians should take care not to
underdose patients with methadone; adequate
dosage is vitally important. Patients some-
Methadone times exaggerate their daily consumption to
This section discusses methadone as an agent receive greater dosages of methadone. For
for detoxification. For detailed information this reason, history is no substitute for a
on methadone maintenance, readers are physical examination that screens for signs of
referred to TIP 43 Medication-Assisted opioid withdrawal. Treating clinicians should
Treatment for Opioid Addiction in Opioid not only be familiar with the intoxication and
Treatment Programs (CSAT 2005d). While withdrawal signs that are set forth in Figure
methadone is one of the more common medi- 4-4 (p. 67), but also should be skilled in dis-
cations for opioid detoxification, its use is cerning these features of opioid withdrawal.
highly regulated and it can only be prescribed Avoidance of overmedicating is crucial during
for withdrawal by a doctor at a Substance methadone detoxification because excessive
Abuse and Mental Health Services doses of this agent can produce overdose,
Administration (SAMHSA)-certified whereas opioid withdrawal does not constitute
methadone clinic or if the patient is being a medical danger in otherwise healthy adults.
hospitalized for another medical condition. For more information on methadone and
(Detoxification programs may become certi- other medications used to treat opioid addic-
fied to prescribe methadone by undergoing tion, see TIP 43, Medication-Assisted
the process described in TIP 43.) Federal reg- Treatment for Opioid Addiction in Opioid
ulations allow for the use of methadone in Treatment Programs (CSAT 2005d).
both a short-term detoxification treatment of Patients with significant opioid dependence
less than 30 days and a long-term treatment may require a starting dose of 30 to 40mg per
of 30 to 180 days. The regulations also specify day; this dose range should be adequate for
that if a patient has failed two detoxification even the most severe withdrawal. If the
attempts in a 12-month period he or she must degree of dependence is unclear, withdrawal
be evaluated for a different course of treat- signs and symptoms can be reassessed 1 to 2
ment (e.g., ongoing opioid substitution hours after giving a dose of 10mg of
therapy). methadone. The practice of giving a dose of
Methadone is a long-acting agonist at the :-opi- methadone and later assessing its effect (also
oid receptor site that, in effect, displaces hero- termed a challenge dose) is an important
in (or other abused opioids) and restabilizes the intervention of detoxification. Sedation or
site, thereby reversing opioid withdrawal symp- intoxication signs after a methadone challenge
toms. If maintained for long enough, this stabi- dose indicate a lower starting dose. Similarly,
lizing effect can even reverse the immunologic intoxication at any point of the detoxification
70 Chapter 4
1986 for the treatment of hypertension (high Buprenorphine is available in oral form as
blood pressure), also is used in opioid detoxi- Subutex, which contains only buprenorphine,
fication. However, the safety of the patch for and is meant for patients who are starting
treatment of opioid withdrawal has not been treatment for drug dependence. Another
sufficiently studied in controlled clinical tri- form, Suboxone, contains buprenorphine and
als. The transdermal route of administration naloxone and is intended for persons depen-
has the disadvantage of continued clonidine dent on opioids who have already started and
action even after the patch has been removed. are continuing medication therapy.
Blood pressure effects of clonidine can there- Buprenorphine has great affinity for the
fore be prolonged, leading to undesirable and :-opioid receptor, in
persistent reductions of blood pressure. For spite of being only a
this reason, it has been recommended that the partial agonist, and
patch be used only if the patient’s blood pres- can displace other One advantage of
sure is monitored regularly (Alling 1992). opioids such as hero-
in. This feature gives buprenorphine is
The clonidine patch is available in three buprenorphine the
sizes that deliver a total daily oral equivalent ability to precipitate
clonidine dose of 0.2mg (3.5 cm2), 0.4mg (7.0 that it can be
opioid withdrawal
cm2), or 0.6mg (10.5 cm2). The patch supplies when administered to
clonidine for up to 7 days and one patch patients who have
dispensed at a
application usually is sufficient. The conve- recently used heroin
nience of one application allows the clinician (Kosten and physician’s office,
to avoid the disruption that multiple dosing McCance-Katz 1995).
might have during rehabilitative program- unlike methadone,
ming. In particular, patients can focus on An advantage to
rehabilitative treatment without being dis- buprenorphine is its which can be
tracted by the need to ask repeatedly for oral safety. Because of
clonidine doses. Vital signs should be moni- the partial agonist
dispensed only at
tored at least four times daily to assess persis- action, buprenor-
tent signs and symptoms of withdrawal or phine has a “ceiling
undesirable effects of clonidine on blood pres- effect” with regard to designated treat-
sure. overdose potential
(Walsh et al. 1994). ment centers.
That is, unlike
Buprenorphine methadone, which
Buprenorphine, a partial α-opioid agonist that produces increasing
is FDA approved in an injectable form respiratory suppression with increasing dose,
(Buprenex) for the treatment of pain, has respiratory effects of buprenorphine tend to
recently been approved as a detoxification level off due to its partial agonist action.
agent and for opioid maintenance treatment as Another advantage of buprenorphine is that
an alternative to methadone maintenance. A it can be dispensed at a physician’s office,
number of clinical trials have reported it to be unlike methadone, which can be dispensed
effective for heroin detoxification (Becker et al. only at designated treatment centers. This
2001; Bickel et al. 1988; Diamant et al. 1998), makes access to this medication for opioid
and the medication should play an important dependence much more convenient for both
role in gradually removing patients from patient and clinician. See TIP 40, Clinical
methadone maintenance (Amass et al. 2004; Guidelines for the Use of Buprenorphine in
Banys et al. 1994; Johnson et al. 2000). the Treatment of Opioid Addiction (CSAT
2004a).
72 Chapter 4
Inpatient treatment, if available, can provide and shortened during the 1980s (Charney et
additional support, medical supervision, and al. 1982, 1986; Kleber et al. 1987; Riordan
rehabilitative treatment that serve as disin- and Kleber 1980; Vining et al. 1988) so that a
centives to relapse. blocking dose of naltrexone—at least 25mg—
usually was used by the second or third day
of treatment. The rate-limiting factor of this
Rapid and Ultrarapid rapid clonidine-naltrexone method is its
Detoxification capacity to adequately relieve the precipitat-
Although there are few data showing that the ed withdrawal symptoms in the conscious
rapid or ultrarapid methods of opioid detoxifi- patient. Golden and Sakhrani (2004) found
cation show a positive correlation with the like- that 25 percent of the 20 patients they studied
lihood of a patient’s being abstinent a few who were undergoing rapid detoxification
months later, efforts persist to make the detoxi- using clonidine and naltrexone developed
fication process shorter and easier. This stems delirium and had to discontinue the proce-
in part from the desire of the person addicted dure after the first day, and another patient
to opioids for a rapid, painless procedure, and dropped out before completion.
in part from an attempt to coax more such per- The 1990s witnessed a variety of attempts to
sons into treatment (fewer than one in five peo- overcome this barrier by using general anes-
ple with substance use disorders in the United thesia or heavy sedation. Although the ultra-
States are in treatment at any time) (Office of rapid procedure under anesthesia has
National Drug Control Policy 2002). Another received wide publicity, controlled studies
contributing factor is the American culture’s that would make it possible to evaluate the
search for rapidity in most endeavors. Finally, risk/benefit ratio are absent. The procedure
the desire for rapid opioid detoxification is a is still unproven and controversial. For a
remnant of the belief system of a century ago, brief review of studies done in this area, see
when detoxification often was erroneously Stine and colleagues (2003).
equated with cure.
74 Chapter 4
and delirium. So patients who are comatose diazepine are at risk for falls and myocardial
from benzodiazepines and are benzodiazepine infarctions. Delirium without marked auto-
dependent may move quickly from coma to nomic hyperactivity (no elevations of pulse,
acute benzodiazepine withdrawal symptoms blood pressure, or temperature) also may be
when flumazenil is administered. seen in the elderly. The management of benzo-
diazepine withdrawal is not recommended
Assessing the potential or actual severity of a without medical supervision. All benzodi-
benzodiazepine and other sedative-hypnotic azepines should be tapered rather than stopped
abstinence syndrome is based primarily on abruptly, regardless of dose or duration of
clinical information obtained from the patient, use—unless it is a
significant others, and physical assessment. matter of use for only
Confirmation of length of benzodiazepine treat- a few days (Ashton
ment with significant others, local pharmacies, 2002). Patients
and treating physicians is useful. Specific name
of medication, dose, and duration of therapy
are vital. The presence or absence of alcohol Management intoxicated with
use is also important to know, as with the use of of
other sedative-hypnotics, such as medications sedative-hypnotics
for sleep. The existence of co-occurring psychi- Withdrawal
atric disorders such as panic disorder also are With appear similar to
important factors and should be investigated. Medications
Cigarette smoking tends to induce the individuals
metabolism of some benzodiazepines and this There are a limited
can be a factor in scheduling a taper. Physical number of controlled
trials that can pro-
intoxicated with
assessment, with particular attention to mental
status, and neurologic exams are important. vide guidance regard-
ing the management alcohol. Slurred
Determination of vital signs also provides guid-
ance. A urine drug screen may confirm the of benzodiazepine
and other sedative- speech, ataxia,
presence of benzodiazepines but otherwise will
not be particularly helpful. Although sedative- hypnotic withdrawal.
hypnotic withdrawal scales have been used in For reviews, see and poor physical
research studies, they are not widely available Rickels and col-
for clinical practice. leagues (1999) and coordination are
Eickelberg and Mayo-
Medical complications of withdrawal from ben- Smith (1998). One prominent.
zodiazepines include problems similar to those strategy that is appro-
seen in alcohol withdrawal. Seizures are partic- priate is to begin with
ularly worrisome and may occur without being a slow taper of the
preceded by other evidence of withdrawal. As benzodiazepine that the patient already is tak-
in alcohol withdrawal, seizures and delirium ing. This taper may be conducted over several
represent the most extreme pathology seen. weeks or perhaps even months. This may be
Anecdotal reports appearing in the literature effective in cases of long-acting benzodiazepines
also have described distortions in taste, smell, but often is not effective in detoxification from
and other perceptions. Since many individuals short half-life benzodiazepines. Sometimes
who take benzodiazepines have underlying switching to another benzodiazepine in a
anxiety disorders, it often is difficult during patient who has had serious loss of control and
periods of withdrawal to determine whether abuse problems with his primary agent is ther-
symptomatology is related to withdrawal or the apeutic. Another strategy is to switch the
emergence of panic attack symptoms. Elderly patient to another benzodiazepine with a long
patients who are being withdrawn from benzo- half-life. Frequently chlorodiazepoxide and
76 Chapter 4
Figure 4-5
Benzodiazepines and Their Phenobarbital Withdrawal Equivalents
Generic name Trade name Therapeutic dose Dose equal to Phenobarbital
range (mg/day) 30mg of pheno- conversion
barbital for with- constant
drawal (mg)**
Benzodiazepines
Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.
Barbiturates
Others
78 Chapter 4
drawal or after these symptoms have largely or amphetamine withdrawal and, in part, a
disappeared. While the processes that govern reaction to individuals’ acute realization of the
addiction to cocaine and amphetamines are devastating psychosocial consequences after a
believed to be similar, recent animal research binge ends. While both cocaine and
suggests that there are also subtle differences in amphetamine users may experience depression
the ways in which these two types of drugs cre- during withdrawal, the period of depression
ate sensitization (and perhaps addiction) in reg- experienced by amphetamine users is more
ular users (Li et al. 2005). prolonged and may be more intense.
Amphetamine users, in particular, should be
monitored closely during detoxification for
Stimulant Withdrawal signs of suicidality and treated for depression if
Symptoms appropriate.
Stimulants are associated with withdrawal Although the literature on cocaine withdrawal
symptoms that differ markedly from those seen is controversial, reasonable consensus supports
with opioid, alcohol, and sedative dependence the constellation of symptoms depicted in
(see Figure 4-7). While most clinicians believe Figure 4-7 (Coffey et al. 2000; Cottler et al.
that alcohol and heroin withdrawal should be 1993). These symptoms often disappear after
treated aggressively with detoxification, there several days of stimulant abstinence but can
has been little emphasis on treating symptoms persist for 3 to 4 weeks (Coffey et al. 2000). In
of stimulant withdrawal. Consequently, no addition, since individuals addicted to stimu-
medications have been developed for this pur- lants often fail to achieve abstinence, withdraw-
pose. This situation is understandable because al symptoms can be a persistent component of
stimulant withdrawal usually does not involve active addiction. In addition, individuals
medical danger or intense patient discomfort. addicted to stimulants may experience impair-
However, if stimulant withdrawal predicts poor ment in hedonic function (ability to experience
outcome, it may be a reasonable target for clin- pleasure) that has been ascribed to stimulant-
ical interventions. induced disruptions of endogenous reward cen-
An often overlooked but potentially lethal ters (Dackis and O’Brien 2002). Research on
“medical danger” during stimulant withdrawal animals has found that exposure to high doses
is the risk of a profound dysphoria (depres- of methamphetamine results in changes to both
sion, negative thoughts and feelings) that may the dopaminergic and serotonergic systems of
include suicidal ideas or attempts. This may the brain (Nordahl et al. 2005) and dopamine
be, in part, a physiological response to cocaine abnormalities among animals and humans who
had been ingesting cocaine (Schuckit 2000).
Figure 4-7
Stimulant Withdrawal Symptoms
80 Chapter 4
Management of Withdrawal or hydroxyzine (Vistaril) 25 to 50mg at bed-
time. Benzodiazepines should be avoided unless
With Medications required for concomitant alcohol or sedative
There are no medications with proven efficacy detoxification. As stimulant withdrawal symp-
to treat stimulant withdrawal. However, toms wane, patients are best treated with an
researchers have investigated some medications active rehabilitative approach that combines
for cocaine detoxification. Amantadine may entry into substance abuse treatment with sup-
help reduce cocaine use in patients with more port, education, and changes in lifestyle.
severe withdrawal symptoms (Kampman et al.
2000). Modafinil, an antinarcolepsy agent with
stimulant-like action, is currently under inves- Other Immediate Concerns
tigation by one research group as a cocaine Central nervous system stimulants exert most
detoxification agent (Dackis and O’Brien of their toxic effects through vasoconstriction
2002). One small study in Thailand found the (constriction of the blood vessels).
antidepressant mirtazapine (Remeron) was Consequently, a number of medical conditions
effective at reducing a number of the symptoms can arise from
associated with amphetamine withdrawal ischemia (lack of
(Kongsakon et al. 2005). None of these medica- proper blood supply)
tions, however, are approved for use in treating
Intensive
or infarction (death
stimulant withdrawal and further research is of tissue as the result
needed. Gorelick and colleagues (2004) review of lack of blood sup-
outpatient
the full range of clinical literature on pharma- ply) as a result of
cological intervention for cocaine addiction. stimulant use. treatment can
Myocardial (heart
muscle) infarction assist the patient
Patient Care and Comfort and stroke are widely
Since stimulant withdrawal is not associated recognized complica- to cease use long
with severe physical symptoms, adjunctive tions of stimulant use.
medications are seldom required. These However, other prob- enough for
patients often are sleep deprived and might be lems such as sponta-
unable to benefit from therapeutic activities neous abortion, bowel withdrawal
during the first 24 to 36 hours of abstinence. necrosis (tissue
They often are hungry and in need of large death), and renal
meal portions initially as their food intake may
symptoms to abate
(kidney) infarction
have been inadequate during active addiction. also have been
Stimulant users also may be irritable and care reported from entirely.
should be taken to avoid needless confrontation cocaine-induced vaso-
during the initial withdrawal phase. Headaches constriction. Cardiac
often are reported and can be treated symp- arrhythmias also are common. Other medical
tomatically. Persistent headaches should be problems that are associated with stimulant
evaluated, as cocaine can produce cerebrovas- dependence include dental disease, neuropsy-
cular disease. Similarly, chest pain of possible chiatric abnormalities, and movement distur-
cardiac origin should be evaluated medically bances/disorders.
with electrocardiography, cardiac enzymes,
and appropriate medical attention. On occa- Antidepressants, such as selective serotonin
sion, patients undergoing withdrawal from reuptake inhibitors, can be prescribed for the
cocaine or amphetamines report insomnia and depression that often accompanies metham-
may benefit from diphenhydramine (Benadryl) phetamine or other amphetamine withdrawal.
50 to 100mg, trazodone (Desyrel) 75 to 200mg,
82 Chapter 4
Figure 4-8
Commonly Abused Inhalants/Solvents
Type Example Chemicals in Inhalant/Solvent
“Room odorizers” Locker Room, Rush, Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal),
Poppers cyclohexyl
Source: Balster 2003.
84 Chapter 4
chronic obstructive lung disease, chronic drink, and others have shown that continued
bronchitis, and several types of cancer (lung, nicotine dependence may be a relapse trigger
stomach, head and neck, and bladder). Other for resumption of drinking (Stuyt 1997). The
problems associated with nicotine addiction concern that smoking cessation may precipi-
include gastro-esophageal reflux disease and tate relapse to other substances of abuse has
gastric ulcerations, cataracts, and premature not been supported in the literature (Hughes
wrinkling of the skin. There also appears to 1995).
be an antiestrogen effect (suppression of an
important hormone) that may lead to early Treatment programs that have attempted to
development of osteoporosis in women treat nicotine dependence in conjunction with
(Okuyemi et al. 2000). other drugs of addiction have met with limit-
ed success (Bobo and Davis 1993; Burling et
In 1988, the U.S. Surgeon General’s Report al. 1991; Hurt et al. 1994) and have generat-
concluded that nicotine is the principal addic- ed increased interest in smoking cessation as
tive agent in tobacco. Nicotine binds to nico- a part of a patient’s overall substance abuse
tinic acetylcholine receptors in the brain and treatment (Sees and Clark 1993). One study
has the direct ability to stimulate the release reported that forcing unmotivated patients
of dopamine in the nucleus accumbens area. (or patients who did not consider smoking a
The nucleus accumbens has long been consid- problem) to quit was countertherapeutic
ered the “reward center” in the brain. This (Trudeau et al. 1995).
increase in dopamine is similar to what occurs
when patients use stimulants and is felt to be Moreover, it has traditionally been accepted
an essential element in the reward process of that nicotine detoxification concurrent with
addiction (Glover and Glover 2001). detoxification from other substances makes
the undertaking more difficult. Several fac-
As many as 90 percent of patients entering tors are involved including the following: (1)
treatment for substance abuse are current patient ambivalence and/or lack of interest in
nicotine users (Perine and Schare 1999). smoking cessation; (2) physician ambivalence
There has long been controversy in the field about the importance of smoking cessation
of addiction medicine as to how best to handle early in treatment; (3) staff’s use of nicotine;
the problem of nicotine dependence in (4) staff’s ambivalence about the importance
patients seeking treatment for other types of of nicotine cessation early in treatment; (5)
substance abuse. Traditionally, it has been easy availability of cigarettes from peers,
argued that patients would find that trying to family, visitors, staff, and at 12-Step meet-
stop smoking while also contending with other ings; (6) lack of sufficient training and exper-
(more pressing) addiction problems would be tise on the part of physicians and staff in
too difficult and distracting in early absti- managing nicotine withdrawal; and (7) staff
nence. However, others argue that nicotine resistance to patient smoking cessation
dependence is a lethal disease and that physi- because withdrawal symptoms include irri-
cians have the responsibility to intervene in tability, anxiety, and depression, all of which
this addiction with the same aggressiveness can make patients more difficult to manage.
they show toward other addictive substances.
This pro-intervention position has received
increasing attention from clinicians, inasmuch Withdrawal Symptoms
as it is now understood that alcohol consump- Associated With Nicotine
tion is associated with increased nicotine The Diagnostic and Statistical Manual of
usage (Henningfield et al. 1984). Gulliver and Mental Disorders, 4th edition, text revision
colleagues (1995) have demonstrated that the (DSM-IV-TR) (APA 2000) notes that typically,
urge to smoke is correlated with the urge to a person in nicotine withdrawal will have four
Figure 4-9
DSM-IV-TR on Nicotine Withdrawal
A. Daily use of nicotine for at least several weeks.
B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24
hours by 4 or more of the following signs:
1. Dysphoric or depressed mood
2. Insomnia
3. Irritability, frustration, or anger
4. Anxiety
5. Difficulty concentrating
6. Restlessness
7. Decreased heart rate
8. Increased appetite or weight gain
C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another
mental disorder.
86 Chapter 4
Figure 4-10
Items and Scoring for the Fagerstrom Test for Nicotine Dependence
Questions Answers Points
1. How soon after you wake up do you smoke your Within 5 minutes 3
first cigarette? 6–30 minutes 2
31–60 minutes 1
After 60 minutes 0
3. Which cigarette would you hate most to give up? The first thing in the morning 1
All others 0
6. Do you smoke if you are so ill that you are in bed Yes 1
most of the day? No 0
To better understand a patient’s level of nico- tine replacement therapy and patients often
tine dependence, providers can assess bio- find it a helpful motivator in their attempt to
chemical markers including nicotine, coti- maintain abstinence (Benowitz 1983).
nine, and carbon monoxide. Nicotine and its
metabolite cotinine can be measured in urine,
blood, or saliva. Cotinine continues to be pre- Medical Complications of
sent in bodily fluids for up to 7 days after ces- Withdrawal From Nicotine
sation. Clinicians should use caution when There are no major medical complications pre-
interpreting the meaning of nicotine and coti- cipitated by nicotine withdrawal itself.
nine assays, as they are not specific to tobac- However, patients frequently experience
co-derived nicotine and may indicate the uncomfortable withdrawal symptoms starting
patient’s compliance with nicotine replace- within a few hours of cessation. In addition to
ment therapy rather than smoking. the symptoms previously noted, patients may
Carbon monoxide is easily measured in complain of increased coughing, a desire for
expired breath and can show whether the sweets, and difficulty concentrating (Hughes
patient has been smoking within a few hours and Hatsukami 1992). Clinicians should be
prior to the test. It can be used to monitor aware that withdrawal symptoms can masquer-
smoking cessation for patients receiving nico-
Please indicate your choice by circling the number that best reflects your choice.
(Specific to Questions 3–11).
0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always
5. If you find yourself without cigarettes, will you have difficulties in concentrating
before attempting a task? 0 1 2 3 4
6. If you are not allowed to smoke in certain places, do you then play with your
cigarette pack or a cigarette? 0 1 2 3 4
7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa,
room, car, or drinking alcohol)? 0 1 2 3 4
9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,
chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or
frustration, etc.? 0 1 2 3 4
10. Does part of your enjoyment of smoking come from the steps (ritual) you take
when lighting up? 0 1 2 3 4
11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe,
secure, or more confident if you are holding a cigarette? 0 1 2 3 4
TOTAL_______
Scoring for Behavioral Dependence
<12 Mild
12–22 Moderate
23–33 Strong
>33 Very Strong
88 Chapter 4
ade as other psychiatric conditions, especially lent pharmaceutical guide. Figure
anxiety and depression (see Figure 4-12). 4-13 (p. 90) shows the effects of abstinence
from smoking on blood levels of a number of
Smoking cessation also may affect the medications.
metabolism of other drugs primarily through
the Cytochrome P 450 (CYP450) system. This
system is one of many hepatic liver enzyme sys- Management of Withdrawal
tems that is responsible for the metabolic Without Medications
breakdown of various drugs into inactive com-
pound products. Different drugs and com- About one third of current smokers attempt
pounds have varying affinities for the CYP450 to quit smoking each year and more than 90
system. The higher the affinity, the faster the percent of these try to do so without any for-
breakdown of the drug or compound in the mal nicotine cessation treatment. Most smok-
body. Some compounds can slow the ers will make several attempts on their own to
metabolism or breakdown of other drugs with a quit and ultimately, only about 50 percent are
lower affinity, leading to a buildup of that drug successful over a lifetime (U.S. DHHS 2000b).
or compound in the body. While some smokers are able to quit on their
own, others may require intervention in the
During detoxification from nicotine, some form of behavioral treatment and/or pharma-
medications will have their metabolism cotherapy.
altered, including theophylline, caffeine,
tacrine, imipramine, haloperidol, penta- There are insufficient data available to deter-
zocine, propranolol, flecainide, and estradiol; mine who will benefit most from a particular
in general, these effects are short-lived and type of treatment. Some patients may prefer
seldom drastic. Nicotine also reduces beta to stop smoking without the use of medica-
blockers’ ability to lower blood pressure and tion. An elevated score on the GN-SBQ would
heart rate and decreases the amount of seda- indicate a strong behavioral component to
tion from benzodiazepines as well as de- smoking that might guide the clinician in rec-
creases the amount of pain relief provided by ommending behavioral treatment as a prima-
some opioids, most likely because of its stimu- ry intervention. Patients who also have ele-
lant effects (Zevin and Benowitz 1999). A vated FTQ scores may benefit by a combina-
complete discussion of nicotine’s effects on tion of behavioral and pharmaceutical inter-
medications is beyond the scope of this TIP vention.
and physicians are encouraged to consult the
Physicians’ Desk Reference (2004) or equiva-
Figure 4-12
Some Examples of Nicotine Withdrawal Symptoms That Can Be
Confused With Other Psychiatric Conditions
Anxiety
Depression
Increased REM (rapid eye movement) sleep
Insomnia
Irritability
Restlessness
Weight gain
Abstinence Increases Blood Abstinence Does Not Increase Effect of Abstinence on Blood
Levels Blood Levels Levels Is Unclear
The U.S. Public Health Service’s Treating interventions alone have not been very suc-
Tobacco Use and Dependence: Clinical cessful at helping people achieve abstinence
Practice Guideline is a comprehensive review from tobacco. The Guideline suggests, howev-
of the smoking cessation literature (Fiore et er, that self-help can be a useful adjunct to
al. 2000a). It discusses a range of nonphar- other forms of treatment (Fiore et al. 2000a).
macological interventions for the management
of withdrawal from nicotine; these can be sep- One type of self-help intervention that shows
arated into two basic categories: self-help some promise is the use of computer-generat-
interventions and behavioral interventions ed personalized written feedback for patients.
(Anderson and Wetter 1997). The computer makes recommendations based
on an individual’s response to standardized
questions about her smoking (Etter and
Self-help interventions Perneger 2001; Shiffman et al. 2000).
Many tobacco users prefer to attempt to quit
without any assistance from professionals. A Behavioral interventions
number of self-help products are available
that can assist them in their cessation The U.S. Public Health Service study noted
attempts. These include a wide array of pam- that when physicians took as little as 3 min-
phlets, manuals, video- and audiotapes (e.g., utes to advise their patients to stop smoking,
from the American Lung Association and the long-term quit rates were modestly improved
National Cancer Institute), 12-Step self-help from 7.9 percent to 10.2 percent (Fiore et al.
support groups, and telephone helplines. The 2000a). Westmaas and colleagues note that
U.S. Public Health Service’s Guideline, which “simple, clear advice from a physician can be
analyzed all types of self-help interventions considered an easy, cost-effective intervention
together, found that the self-help approach to that not only moves smokers closer to the
cessation yielded results only slightly better decision to quit, but also may motivate some
than no intervention at all. To date, self-help smokers to make an actual attempt”
90 Chapter 4
(Westmaas et al. 2000, p. 58). The greater the effective but not routinely recommended
amount of time in face-to-face interventions, (Fiore et al. 2000a).
the higher the success rate for patients, but
interventions as short as 3 minutes have been
found to be effective (Fiore et al. 2000a). A Management of Withdrawal
counseling session of longer than 10 minutes With Medications
produced a cessation rate of 20.1 percent A U.S. Public Health Service panel recom-
compared to a rate of 10.9 percent for no mends that all primary care physicians pro-
treatment. The guideline also indicated that if vide a five-step intervention, known as the “5
cessation information is given by multiple A’s,” to all tobacco users. The panel recom-
types of providers (e.g., physician, psycholo- mends that all smokers who want to quit
gist, dentist, nurse, and pharmacist) it can should be offered active medication that has
have a dramatic effect on cessation rates, been approved for assisting in smoking cessa-
increasing the rate to 23 percent compared to tion unless there is a medical contraindication
10.8 percent for patients who had no (Fiore et al. 2000a). Figure 4-14 provides a
provider contact. summary of the “5 A’s” for brief intervention.
A review of behavioral intervention studies
concluded that both supportive care by a Nicotine Replacement
clinician and the ability of patients to develop
problemsolving and coping skills improved Therapy (NRT)
success rates for smoking cessation (Anderson Nicotine polacrilex gum was approved by the
and Wetter 1997). Other components such as FDA in 1984. In the 1990s other NRTs received
cigarette fading (gradually decreasing the FDA approval, including the nicotine transder-
number of cigarettes smoked over a period of mal patch, the nicotine nasal spray, and the
time), establishing a quit date, enhanced envi- nicotine inhaler. Nicotine gum and nicotine
ronmental support, improved diet and transdermal patch are now available over the
increased exercise, relaxation training, and counter. After the acute withdrawal period,
contingency contracting were not associated patients are then weaned off the medication
with improved outcome. Aversive condition- until they become nicotine free. All NRTs are
ing, such as rapid smoking techniques, is
Figure 4-14
The “5 A’s” for Brief Intervention
Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.
Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.
Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this
time?
Assist in quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacother-
apy to help him or her quit.
Arrange followup. Schedule followup contact, preferably within the first week after the quit date.
92 Chapter 4
• The antihypertensive CNS nicotinic receptor els, several clinical trials have evaluated the
blocker, mecamylamine effectiveness of combining available products.
• Oral dextrose tablets The simultaneous use of nicotine gum and the
nicotine patch has been evaluated in several
Although none of these agents has been studies. Short-term gains in cessation were seen
approved by the FDA for smoking cessation, with the combination compared to either medi-
clonidine, nortriptyline, and moclobemide have cation alone, but no long-term benefits in absti-
all been found to be effective treatments (Covey nence were demonstrated (Anderson and
et al. 2000). Clonidine may be a helpful Wetter 1997). Blondal and colleagues (1999)
adjunct to nicotine replacement during acute compared the combination of nicotine nasal
nicotine withdrawal. Doses of 0.05mg to 0.1mg spray and the nicotine patch to the patch alone
three times a day can be tried as tolerated and found that at 3 months 37 percent of the
(sedation and low blood pressure are con- patients were smoke free (compared to 25 per-
cerns), and the medication needs to be tapered cent for the patch alone). An open-label study
when discontinued to avoid rebound hyperten- of the combined use of nicotine inhaler and the
sion. nicotine patch found a 12-week cessation rate
of 30 percent and good tolerability for the com-
The Public Health Service’s Treating bination (Westman et al. 2000).
Tobacco Use and Dependence: Clinical
Practice Guideline (Fiore et al. 2000a) has So-called “combination NRT” involves com-
classified nortriptyline and clonidine as sec- bining different types of nicotine replacement
ond-line treatments. Clonidine is an antihy- products, such as the patch and gum, on the
pertensive and may be appropriate for premise that doing so will boost nicotine
patients addicted to certain types of drugs but blood levels. Further rationale for this prac-
not appropriate for others. The antidepres- tice is that a “passive” nicotine delivery sys-
sant selective serotonin reuptake inhibitor tem (i.e., patch) produces relatively steady
(SSRI) fluoxetine has been tested in a number levels of nicotine in the body that prevent the
of multisite trials (Cook et al. 2004; Hitsman user from going below a threshold minimum
et al. 1999; Niaura et al. 2002) and found to while “active” NRTs (i.e., gum, inhaler,
have a small benefit at best, although for spray, sublingual tablet, etc.) permit the user
patients who experience mild depressive to respond to situational cravings with ad libi-
states it may be a worthwhile adjunctive tum dosing on an acute basis. Several clinical
treatment. The usefulness of other SSRIs for trials have evaluated the effectiveness of com-
smoking cessation is unknown, but studies bining available NRT products (for a review
have generally been unfavorable. More infor- see Silagy et al. 2000). After reviewing avail-
mation on smoking cessation for people with able data, the Guideline panel (Fiore et al.
co-occurring substance use and other mental 2000a) felt that there was moderately strong
disorders can be found in appendix D of TIP evidence to conclude that “Combining the
42, Substance Abuse Treatment for Persons nicotine patch with a self-administered form
With Co-Occurring Disorders (CSAT 2005c). of nicotine replacement therapy (either the
nicotine gum or nicotine nasal spray) is more
efficacious than a single form of nicotine
Combination drug therapy replacement, and patients should be encour-
Combining NRT products aged to use such combined treatments if they
NRT products typically provide less than half are unable to quit using a single type of first-
the nicotine plasma levels that cigarette users line pharmacotherapy” (Fiore et al. 2000a, p.
achieve through smoking (Benowitz et al. 1997; 77).
Dale et al. 1995; Gupta et al. 1995; Lawson et
al. 1998). To attempt to increase nicotine lev-
94 Chapter 4
should be familiar with the programs avail- no immediate medication during the detoxifi-
able in their communities in order to make cation period and usually are self-limiting.
referrals. However, the clinician should be aware of the
potential for more persistent problems.
Screening the patient for suicidal ideation or
Marijuana and Other other mental health
Drugs Containing THC problems is warrant-
ed. Some reviews Most experts now
Marijuana and hashish are the two sub- have advocated the
stances containing THC (delta-9-tetrahydro- use of buspirone as believe that a
cannabinol) commonly used today. The field an alternative to
of addiction medicine has given considerable benzodiazepines for THC-specific with-
attention to the question of whether there is a the management of
specific withdrawal syndrome associated with persistent general-
cessation from prolonged THC use. In the
drawal syndrome
ized anxiety (Gatch
past, many have stated that there is no acute and Lal 1998). Other
abstinence syndrome that develops in people common problems
does occur in some
who abruptly discontinue THC (CSAT encountered during
1995d). More recently this has been called withdrawal can be patients who are
into question and most experts now believe managed with nonad-
that a THC-specific withdrawal syndrome dictive, supportive heavy users,
does occur in some patients who are heavy medications. For
users (Budney et al. 2001), though cannabis patients with more though cannabis
withdrawal is not yet included in the APA’s persistent difficulty
Diagnostic and Statistical Manual of Mental sleeping, clinical withdrawal is not
Disorders. experience suggests
that Trazodone may yet included in the
The THC abstinence syndrome usually starts
be useful. Trazodone
within 24 hours of cessation. The amount of
can lead to low blood
THC that one needs to ingest in order to APA’s Diagnostic
pressure upon stand-
experience withdrawal is unknown. It can be
ing, dizziness, and
assumed, however, that heavier consumption
may increase falls, and Statistical
is more likely to be associated with withdraw-
particularly in indi-
al symptoms. The most frequently seen symp- Manual of
viduals over age 60.
toms of THC withdrawal are anxiety, restless-
Benzodiazepines and
ness and irritability, sleep disturbance, and Mental Disorders.
other addictive medi-
change in appetite (usually anorexia). Other
cations should be
symptoms of withdrawal are less frequently
avoided.
seen and appear to include tremor, diaphore-
sis (sweating), tachycardia (elevated heart The patient should be encouraged to maintain
rate), and GI disturbances, including nausea, abstinence from THC as well as other addic-
vomiting, and diarrhea. Cognitive difficulties tive substances. Some patients will require a
including depression also have been reported substance-free, supportive environment to
and may persist but usually improve with achieve and maintain abstinence. Clinicians
time. There are no medical complications of should educate all patients about the effects
withdrawal from THC, and medication is gen- of withdrawal, validate their complaints, and
erally not required to manage withdrawal. reassure them that their symptoms will likely
improve with time. Symptomatic relief may be
Clinicians may see a variety of the symptoms
provided in order to increase the patient’s
mentioned above, but these generally require
comfort.
98 Chapter 4
tioned) doses, GHB serves as a sedative-hyp- using the substance regularly over a 2-year
notic medication. GHB intoxication may look period, and Rosenberg and colleagues (2003)
like alcohol or sedative-hypnotic intoxication. note that in severe cases GHB withdrawal
may be life-threatening.
Although GHB is illegal, psychotropic com-
pounds similar to GHB such as gamma- Milder cases of GHB withdrawal syndrome
hydroxy lactone (GBL) and 1,4-butanediol may be managed with benzodiazepines such
(1,4-BD) are widely available chemical com- as lorazepam and supportive care. However,
pounds and may be obtained through catalogs in more severe cases high doses of intra-
and the Internet. These compounds produce venous benzodi-
effects similar to those of GHB. At the pre- azepines (e.g.,
sent, overdose syndromes are more likely to lorazepam) or barbi- Withdrawal
be seen than withdrawal syndromes. turates (e.g., pheno-
Overdose syndromes may require airway and barbital, pentobar- syndromes have not
respiratory management. GHB has been stud- bital) may be
ied in Europe (Addolorato et al. 1999a) in a required (Miotto been reported with
randomized, single-blind study comparing it and Roth 2001;
to diazepam as a treatment for alcohol with- Rosenberg et al. hallucinogens;
drawal. GHB was as effective as diazepam in 2003). Patients
suppressing alcohol withdrawal symptoms experiencing GHB however, consider-
and was said to be quicker in reducing anxi- withdrawal are like-
ety and agitation with less sedation than ly to have a high tol- able attention has
diazepam. Because of its history of abuse in erance for the seda-
the United States, it is unlikely to be viewed tive effects of benzo- been paid to
as a therapeutic agent any time in the near diazepines and
future. require large and residual effects such
frequent doses to
Miotto and Roth (2001) describe a GHB with- manage the with- as delayed
drawal syndrome, noting that it shares fea- drawal (Miotto and
tures of both alcohol and benzodiazepine Roth 2001); in cases perceptual illusions
withdrawal. They have found this syndrome where high doses of
most pronounced in patients who have taken lorazepam prove with anxiety,
GHB around-the-clock, at 2- to 4-hour inter- ineffective, pento-
vals. The GHB withdrawal syndrome has the barbital may be “flashbacks,”
prolonged duration of symptoms found in effective (Sivilotti et
benzodiazepine withdrawal and features al. 2001). Clonidine residual psychotic
delirium tremens that appear early (often may be used to treat
within an hour) with peak manifestations episodes of tachy- symptoms, and
occurring within 24 hours; the delirium may cardia (rapid heart
last up to 14 days. Confusion, psychosis, and rate) (Miotto and long-term cognitive
delirium are the most prominent features of Roth 2001).
GHB withdrawal, and the autonomic effects impairment.
(i.e., tremor, diaphoresis [sweating], hyper-
tension, and temperature changes) are less Ecstasy
severe than found in alcohol withdrawal. MDMA (3, 4-methylenedioxy-metham-
They note that brief periods of significant phetamine) commonly known as ecstasy, was
tachycardia (rapid heart rate) begin early in synthesized around the turn of the century and
GHB withdrawal. Garvey and Fitzmaurice patented by Merck Pharmaceuticals in 1914
(2004) also report seizure activity in a case of (Christophersen 2000; Parrot et al. 2000).
GHB withdrawal in a male who had been These drugs are phenel-ethylene stimulants
100 Chapter 4
overdoses, intentionally or accidentally, that In an evaluation of admissions to publicly
they will require airway management and funded detoxification programs in
ventilatory support for some hours. The Massachusetts between 1984 and 1996,
behavioral management of the agitation and McCarty and colleagues (2000) found a steady
violence that may be seen is best managed in increase in the number of patients using both
a controlled environment with limited stimuli alcohol and other substances in the month
and very close supervision. Occasionally, oral prior to admission. In 1988, 26 percent of
or parenteral uses of sedating medications admissions reported using two or more sub-
such as benzodiazepines will be required. In stances in the previous month; by 1996 that
extreme cases, restraints may be required for number had nearly
protection of the patient and staff. doubled to 50 per-
cent (McCarty et al.
Following acute management, assessment of 2000). There is no One of the most
persistent mood and cognitive effects must be reason to believe that
made prior to any treatment attempts. The this trend has not
persistence of psychotic symptoms may repre-
significant changes
appeared elsewhere
sent an underlying psychiatric disorder that in this country. As
may require medication treatment. There are in detoxification
Miller and colleagues
no studies to guide the treatment of ketamine (1990a) note, “For
or PCP detoxification. The need to manage the contemporary
services in recent
withdrawal symptoms from these drugs is drug addict, multiple
unlikely, but if it should arise, benzodi- drug use and addic- years has been the
azepines should be administered. tion that includes
alcohol is the rule” increase in the
Other (p. 597).
number of
Rohypnol is a benzodiazepine that is sold In the Massachusetts
under trade names in Europe and Mexico as a evaluation, which
patients requiring
sedative-hypnotic. Rohypnol is occasionally did not include mari-
used as a club drug and at dance clubs. In the juana or nonopioid
last decade it began to be smuggled into the prescription medica- detoxification
United States and was commonly used among tion use, the most
homeless youth involved in the sex industry. commonly seen com- from more than
Rohypnol has a reputation as a “date rape” bination of sub-
drug because it can produce powerful amnestic stances was alcohol one substance.
and hypnotic effects, as well as coma. For fur- and cocaine. Thirty
ther details on benzodiazepines, see the benzo- percent of patients
diazepine section regarding intoxication and admitted for detoxifi-
potential withdrawal reactions. cation in 1996 reported using this combina-
tion; 12 percent used alcohol, cocaine, and
heroin together; 10 percent combined alcohol
Management of and cocaine; and 7 percent combined heroin
Polydrug Abuse: An and cocaine (McCarty et al. 2000). Other
studies, evaluating patient populations at
Integrated Approach inpatient treatment centers, found that
One of the most significant changes in detoxi- between 70 and 90 percent of patients who
fication services in recent years has been the reported cocaine abuse also abused alcohol.
increase in the number of patients requiring Rates of alcohol dependence among
detoxification from more than one substance. methadone patients and patients dependent
on heroin were between 50 and 75 percent,
102 Chapter 4
nance for an extended period of time follow- screening, even a hand-held screening, can be
ing the completion of sedative withdrawal. an expensive item for what often is a very limit-
ed budget. Besides, in this case, the patient was
If the patient has been abusing multiple seda- believed to be a known quantity—someone who
tive-hypnotic substances or a sedative-hypnotic only used heroin.
and alcohol, withdrawal should be handled in
the same way as withdrawal from one such sub- This scenario is not uncommon. It is likely that
stance. The patient should be administered a the patient himself was unaware of what was in
regularly decreasing dosage of sedative-hypnot- his body. One of the more frightening facts con-
ic, usually a benzodiazepine that the clinician is cerning the purchase of illicit drugs is the lack
comfortable with and accustomed to using. The of knowledge of what is in them. To make buy-
dosage should be decreased according to the ers believe that they are buying a higher-quali-
patient’s physiologic response. Providers also ty product than they are, drugs often are cut
may administer an anticonvulsant such as car- with adulterants (inferior ingredients) that can
bamazepine (Tegretol XR), even in the absence produce effects similar to the drug they think
of epilepsy or withdrawal seizures, to help they are buying. In this case, Mr. L may have
ensure patient safety (Wilkins et al. 1998). been buying barbiturates and benzodiazepines
Phenobarbital also may be used for detoxifying in his heroin for some time without knowing it,
patients who have been abusing both alcohol a fact that could have had deadly conse-
and benzodiazepines. When the dose of alcohol quences. Both are sedating and could have
and sedative-hypnotics that a patient is taking given him some of the comfortable sedation and
is not known, tolerance testing as previously euphoria he was seeking from his drug of
described can be helpful in determining the choice. Unfortunately, however, where opioid
dose of phenobarbital. withdrawal is not life-threatening, withdrawal
from barbiturates can be. Furthermore, he
When treating patients detoxifying from sub- could have gotten PCP in the marijuana he
stances other than sedative-hypnotics, manage- occasionally used, again without knowing it.
ment of opioid detoxification should be the next
priority. Generally, other substances of abuse,
including stimulants, marijuana, hallucinogen- Alternative
ics (LSD and similar drugs), and inhalants, will
not require specific treatment in patients who Approaches
are being detoxified from sedative-hypnotics Alternative methods that have been studied sci-
and/or opioids. entifically do not claim to be stand-alone with-
drawal methods, nor stand-alone treatment
Patients may abuse a wide range of substances
modalities. Alternative approaches are
in various combinations, and the clinician must
designed to be used in a comprehensive, inte-
be vigilant in assessing and treating withdrawal
grated substance abuse treatment system that
from multiple substances. The case study above
promotes health and well-being, provides pal-
illustrates some of the serious problems the
liative symptom relief, and improves treatment
clinician faces in evaluating and treating
retention. Therefore, because isolation of any
patients withdrawing from multiple substances.
of these approaches as an independent variable
In the private sector, where money for toxico- in rigorous controlled studies is difficult, if not
logical screening is readily available, the first impossible, there are no conclusive data on the
question many would ask concerning the case effectiveness of alternative methods
of Mr. L. is, “Why wasn’t the drug screen done (Trachtenberg 2000).
sooner?” However, those working in public
Auricular (ear) acupuncture has been used
facilities will recognize that such screenings
throughout the world, beginning in Hong Kong,
often are unavailable or available only after an
as an adjunctive treatment during opioid
extended turnaround time. Toxicological
104 Chapter 4
Considerations for strong linkages to agencies that provide the
above-mentioned services and should set up
Specific Populations systems to ensure that pregnant women can
All individuals undergoing detoxification are access the additional services they need.
especially vulnerable. Patients who experience Pregnant women who present for detoxification
negative attitudes from staff may experience will benefit from a comprehensive medical
further loss of self-esteem, may leave detoxifi- examination that includes a careful obstetrical
cation prematurely, or may experience other component. Since it is estimated that approxi-
psychologically damaging feelings. Negative mately 44 to 70 percent of women who abuse
experiences can undermine the recovery pro- substances have a his-
cess. It is important to recognize that individu- tory of physical, emo-
als do not fit into just one population category. tional, and sexual
A person will be a member of several popula- Pregnant women
abuse (Moylan et al.
tions (e.g., a Latina woman who is pregnant, 2001; Stevens et al.
bisexual, and has psychiatric diagnoses of post- 1997), care should be
who present for
traumatic stress disorder and major depres- given to the comfort
sion) and may benefit from a number of the of the patients during detoxification will
considerations discussed below. It also should the examination. One
be noted that the information in the specific of the major internal benefit from a
populations sections should not be used to cate- barriers that prevents
gorize individuals or leave the reader with the pregnant women from comprehensive
impression that the information below will fit seeking treatment is
all individuals who are members of a group. the shame and stigma medical examina-
attached to substance
Pregnant Women use, especially during tion that includes
pregnancy. Any nega-
While in detoxification, pregnant women tive experience
should receive comprehensive medical care, a careful
encountered during
especially since this may be the first time they detoxification can
have sought any type of care or treatment. lead these women to obstetrical
Ideally, programs detoxifying pregnant women leave treatment and
from alcohol and illicit drugs should include not return. component.
the following services:
• Detoxification on demand Detoxification during
pregnancy poses a
• Woman-centered medical services
special risk in that
• Transportation services to and from detoxifi- care should be taken
cation (as well as to substance abuse treat- to ensure the health and safety of both the
ment afterward) mother and fetus. From a clinical standpoint,
• Childcare services before giving any medications to pregnant
• Counseling and case management services women it is of vital importance that they
understand the risks and benefits of taking
• Access to drug-free, safe, affordable housing these medications and sign informed consent
• Help with legal, nutritional, and other social forms verifying that they have received and
service needs understand the information provided to them.
Since pregnant women often present to treat-
While it is recognized that provision of all of ment in mid- to late-second trimester and poly-
these services is an ideal to be striven for, at a drug use is the norm rather than the exception
minimum detoxification programs must have (Jones et al. 1999), it is important first to
106 Chapter 4
Medication-Assisted Treatment for Opioid but may be associated with a withdrawal syn-
Addiction in Opioid Treatment Programs drome in the neonate (Jones and Johnson
(CSAT 2005d). In contrast, it is possible to 2001).
detoxify women dependent on heroin who are
abusing illicit opioids by using a methadone A National Institutes of Health consensus
taper. panel recommended methadone maintenance
as the standard of care for pregnant women
Before starting a detoxification, women with opioid dependence. Methadone currently
should weigh the risks and benefits of detoxi- is the only medication recommended for med-
fication, since many women eventually ication-assisted treatment for pregnant
relapse to drug use and thus place themselves women. Clinical trials are being conducted to
and their fetuses at risk for adverse conse- determine the efficacy and safety of
quences (Jones et al. 2001b). During pregnan- buprenorphine with pregnant women but it
cy, the protein binding of many drugs, includ- has not yet been approved for use with this
ing methadone and diazepam (a benzodi- population. Two early studies on treatment of
azepine), is decreased (e.g., Adams and pregnant women with opioid dependence with
Wacher 1968; Dean et al. 1980; Ganrot 1972) buprenorphine showed promising results
with the greatest decrease noted during the (Fischer et al. 2000; Johnson et al. 2001).
third trimester (Perucca and Crema 1982). Comer and Annitto (2004) conclude, from
This decreased binding may be due to the their review of the research literature, that
decreased levels of albumin reported during buprenorphine should be used more aggres-
pregnancy (Yoshikawa et al. 1984). From a sively to detoxify pregnant women who want
clinical standpoint, it may be that pregnant to be opioid-free at delivery.
women could be at risk for developing greater
toxicity and side effects, yet at the same time Because of the potential for premature labor
an increase in metabolism of the drug may and delivery and risks of morbidity and mor-
result (such as found with methadone). This tality to the fetus related to withdrawal from
may result in reduced therapeutic effect from opioids, it is recommended that a pregnant
the drug, since many women require an woman who is dependent on opioids be main-
increase in their dose of methadone during tained during pregnancy (Kaltenbach et al.
the last trimester (Pond et al. 1985). 1998). Other reasons to stabilize a pregnant
woman on methadone rather than attempt
Other medications used to treat the withdraw- withdrawal are the risks of relapse, conse-
al signs and symptoms include clonidine. quences associated with HIV and use of multi-
Clonidine is used as a second-line drug to ple needles, and the potential lack of prenatal
treat hypertension (high blood pressure) dur- care.
ing pregnancy and appears to lack teratogenic
effects (McElhatton 2001). It has reportedly The Federal government mandates that pre-
been abused by pregnant women. Some preg- natal care be available for pregnant women
nant women take clonidine with their on methadone. It is the responsibility of treat-
methadone because it is hard to detect in ment providers to arrange this care. More
urine and it increases the high they get from than ever, there is need for collaboration
methadone. However, little is known about its involving obstetric, pediatric, and substance
effects on the baby following therapeutic abuse treatment caregivers. Comprehensive
doses given in a detoxification context or care for the pregnant woman who is opioid
doses taken in higher than therapeutic dependent must include a combination of
amounts (Anderson et al. 1997a). methadone maintenance, prenatal care, and
Buprenorphine has been examined in preg- substance abuse treatment.
nancy and appears to lack teratogenic effects
108 Chapter 4
are undergoing detoxification, they should be Marijuana, anabolic steroids,
offered education about the risk of cigarette
smoking during pregnancy and, ideally, pre-
and club drugs
vented from smoking. This is especially impor- The principles of detoxification from these
tant since cigarette smoking is strongly associat- drugs is the same for pregnant and nonpreg-
ed with decreased birth weight, which is a pre- nant women. The use of anabolic steroids dur-
dictor of developmental problems in newborns ing pregnancy is rare; however, these can be
(Ernst et al. 2002). If women are unable to stop catastrophic to a pregnancy, and if use is
smoking using behavioral interventions, nico- found, a detailed ultrasound examination is
tine replacement products may be used; how- recommended to determine the morphological
ever, the woman should fully understand the (physical or structural) development of the
possible risks and benefits of these pharma- fetus (Scialli 2001).
cotherapies (Jones and Johnson 2001).
Although the class of
It also is important to point out to patients club drugs is rela- While women are
that there are data to suggest that women may tively new there have
derive less benefit from NRT than do men been a few reports undergoing
and that they may derive greater benefit from (McElhatton et al.
some non-NRT medications (e.g., bupropion), 1999) suggesting that detoxification,
thus producing quit rates in women compara- there is an increased
ble with those in men (Perkins 2001). risk of congenital they should be
However, the data regarding the use of malformation in
bupropion during pregnancy are limited. neonates prenatally offered education
exposed to ecstasy.
Examinations of the acute effects of NRT in Other club drugs
pregnant women reveal that nicotine has min- about the risk of
such as fluni-
imal impact on the maternal and fetal cardio- trazepam (Rohypnol)
vascular systems. NRT may well be viewed as may have effects sim- cigarette smoking
the lesser of two evils, inasmuch as smoking ilar to those of some
cigarettes delivers, in addition to nicotine, benzodiazepines; during pregnancy
thousands of chemicals. Among these are however, this is spec-
many that also are viewed as developmental ulative. For compre- and, ideally,
toxins (e.g., carbon monoxide and lead). It is hensive information
doubtful that the reproductive toxicity of on the treatment of prevented from
cigarette smoking is primarily related to nico- this specific popula-
tine. Thus, if NRT is to be used during preg- tion, see the forth- smoking.
nancy, the dose of nicotine in NRT should be coming TIP
similar to the dose of nicotine that the preg- Substance Abuse
nant woman received from her ad lib (when- Treatment:
ever desired) smoking. Although intermittent- Addressing the Specific Needs of Women
use formulations of NRT (e.g., chewing gum) (CSAT in development e).
have been recommended over continuous-use
formulations (e.g., transdermal patch) due to
reductions in the total dose of nicotine deliv- Older Adults
ered to the fetus (Dempsey and Benowitz It has been recommended that, when treating
2001), it is unknown what the impact of inter- older adults, there should be a policy of using
mittent acute doses followed by withdrawal of age-specific group treatment that is both sup-
nicotine has on the fetus. portive and nonconfrontational (Royer et al.
2000; West and Graham 1999). Older adults
may be dealing with depression, loneliness,
110 Chapter 4
whether congenital or acquired, can have ties (WHO 1980). This complex system has
diverse effects on organs and body systems. been simplified here into four main cate-
Conditions (and diseases) such as multiple gories:
sclerosis, traumatic brain injury, spinal cord
injury, diabetes, and cerebral palsy can lead 1. Physical impairments are caused by con-
to impairments, such as impaired cognitive genital or acquired diseases and disorders
ability, paralysis, blindness, or muscular dys- or by injury or trauma. For example,
function. These impairments in turn cause spinal cord injury is a disorder that can
disabilities, which limit an individual’s ability cause paralysis, an impairment.
to function in various areas of life, such as 2. Sensory impairments include blindness
learning, reading, and mobility. While dis- and deafness, which may be caused by
eases, impairments, and disabilities are dis- congenital disorders, diseases such as
tinct categories, they often are used inter- encephalopathy or meningitis, or trauma
changeably. These essential terms are defined to the sensory organs or the brain.
in Figure 4-15. 3. Cognitive impairments are disruptions of
thinking skills, such as inattention, memo-
The field of disability services has developed ry problems, perceptual problems, disrup-
its own terminology to discuss physical, senso- tions in communication, spatial disorienta-
ry, and cognitive disabilities (see definitions tion, problems with sequencing (the ability
below), and many treatment providers of peo- to follow a set of steps in order to accom-
ple with substance use disorders will not be plish a task), misperception of time, and
familiar with these terms as the profession perseveration (constant repetition of
defines them. WHO has devised a method for meaningless or inappropriate words or
the classification of impairments and disabili- phrases).
Figure 4-15
Some Definitions Regarding Disabilities
Disease: An interruption, cessation, or disorder of body functions, systems, or organs.
Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in
the manner or within the range considered normal for a human being. A disability is always perceived
in the context of certain societal expectations, and it is only within that context that the disadvantages
resulting from a disability can be properly evaluated.
Functional capacities: The degree of ability possessed by an individual to meet or perform the behav-
iors, tasks, and roles expected in a social environment.
Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain
social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation),
physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deaf-
ness), or affective (e.g., depression) in origin and nature. They represent substandard performance on
the part of the individual in meeting life activities and reflect the interaction between the person and the
environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure
4-16, p112.)
Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.
Sensory Blindness
Hearing impairment
Deafness
Deaf-blindness
Visual impairment
Affective Depression
Bipolar disorder
Schizophrenia
Eating disorder
Anxiety disorder
Posttraumatic stress disorder
4. Affective impairments are disruptions in abilities and co-occurring medical and/or psy-
the way emotions are processed and chiatric conditions. The failure to recognize
expressed. For the purposes of this discus- these problems in patients can result in poor
sion, affective impairments are considered outcomes (Cook et al. 1992). Additionally,
to include problems caused by both affec- intoxicated individuals with co-occurring
tive and mood disorders, such as major depressive disorders are at high risk for sui-
depression and mania. These impairments cide attempts. Of course, an individual
include the symptoms of mental disorders, patient may present with two or more disabil-
such as disorganized speech and behavior, ities and/or co-occurring disorders. Clinicians
markedly depressed mood, and anhedonia treating people with co-occurring substance
(joylessness). use and mental disorders should consult TIP
42, Substance Abuse Treatment for Persons
One of the most important practices that With Co-Occurring Disorders (CSAT 2005b).
should be in place as a standard in any detox-
ification setting is routine screening for dis-
112 Chapter 4
All programs should make a good faith effort al. Physical therapy and exercise, chiroprac-
to provide equal access in as comprehensive a tic care, biofeedback, hypnotism, and thera-
manner as possible for all patients. Individual peutic heat or cold are some other approach-
unique needs should be taken into account es to caring for persons with physical prob-
when providing services. For example, lems. Most of these alternative treatments
patients with physical, sensory, or cognitive have limited or no research support of their
disabilities may need help with self-care (e.g., efficacy; yet some clinicians believe they
eating, grooming), moving (e.g., using stairs, work. Thus, consultation with experts on
walking), communication (e.g., reading, their use is necessary before starting a person
speaking), learning, social skills, and execu- with chronic pain on these remedies.
tive functions (e.g., planning and organiza-
tion, decisionmaking). Unresponsiveness to An alternative model supports the idea that
instructions, lack of participation in discus- patients should be treated simultaneously in
sions and activities, forgetfulness, or confu- substance abuse treatment, mental/physical
sion by an individual with cognitive disabili- health, and detoxification settings, yet treat-
ties should not be viewed as a lack of motiva- ments may occur in separate facilities and be
tion, resistance, or denial. Programs may conducted by separate staff. The consequent
need to develop the expertise or engage an task for all is to be supportive and knowl-
expert on cognitive disabilities to determine edgeable about each other’s interventions.
the limitations resulting from the substance The severity of the addiction and
abuse and those resulting from the disability. medical/psychiatric problems at the time of
Both require patience in the response. detoxification entry should determine which
Information presented to the person with a acute services the patient receives first.
cognitive disability should include different Naturally, a person’s medical and psychiatric
and complementary media; for example, visu- disabilities must be accounted for in the
al and tactile materials can reinforce the preparation of any treatment plan. In some
usual verbal interaction. cases, substance abuse treatment cannot
begin until issues relating to medical and psy-
Programs also may need to alter their policies chiatric disabilities are settled.
regarding the use of drugs prescribed for pain
control, since most medications of this class There are a number of resources for clini-
are drugs with a high abuse potential. A num- cians to employ, including experts in the field
ber of patients with substance use disorders of disability services. Figure 4-17 (p. 114) dis-
also live with chronic pain. Living in a drug- cusses ways of locating expert help for treat-
free state may not be desirable if it is associ- ing patients with disabilities and/or co-occur-
ated with unrelieved pain, which can be quite ring disorders.
disabling. The clinician should explore with Finally, integrated treatment combines sub-
patients what pain management options have stance abuse treatment, treatment for co-
been tried in the past, and which management occurring disorders, and detoxification services
medications are being used currently. into one program. For more complete informa-
Patients should be encouraged to discuss tion on the treatment of many of these disor-
their feelings about pain and how it affects ders, see chapter 5.
their daily life, and especially to what extent
it curtails or prevents their participation in
the activities of daily living. African Americans
There are a number of alternative treatments For African Americans, entrance into detoxifi-
for chronic pain. Acupuncture is already in cation has been associated with enrolling in fur-
use in some treatment programs for detoxifi- ther treatment, reductions in HIV/AIDS risk
cation to help relieve symptoms of withdraw- behaviors, and linkages with social and health-
care services (Lundgren et al. 1999). African mind the standard of respecting the client as
Americans are at greater risk than other popu- an equal partner in treatment. For further
lations for the co-occurrence of diabetes and information on this subject (as well as infor-
hypertension (high blood pressure) that can mation on working with members of other
predispose them to a risk of stroke. This cultural/ethnic groups), see the forthcoming
should be taken into account when placing and TIP Improving Cultural Competence in
monitoring them on withdrawal medications. Substance Abuse Treatment (CSAT in devel-
opment a).
In treating African-American patients, treat-
ment efficacy and therapist efficacy may be The previously discussed protocols for detoxi-
associated with the therapist’s understanding fication from all substance of abuse appear
of how race plays a role in recovery adequate for the detoxification of African
(Luborsky et al. 1988; Pena et al. 2000). In Americans. However, there are a few further
addition, when working with counselors from aspects to consider:
other cultures, African Americans may dis- • If treating African Americans with beta
play mistrust and a reluctance to show any blockers, propranolol is less effective in
weakness. To overcome this mistrust and to treating African Americans than Caucasians
build rapport, especially when the clinician is (Pi and Gray 1999).
discussing the detoxification process, it is par-
• African Americans are more likely (15 to 25
ticularly important for the clinician to keep in
percent) to have less of the enzyme activity
114 Chapter 4
needed to eliminate diazepam than others, so quate for the detoxification of Asians and
it may have a longer half-life in African Pacific Islanders. During the detoxification
Americans than it does in other ethnic groups process, there are a number of issues to con-
(Pi and Gray 1999). sider:
• Since co-occurring disorders such as depres- • If possible and appropriate, incorporate tra-
sion frequently are seen in people with sub- ditional healing methods (e.g., meditation
stance use disorders, it is important to know and religious exercises). These can help
that African Americans may require lower reduce stress and anxiety and promote recov-
doses and may be at greater risk of develop- ery (Chang 2000). While there is a large
ing toxic side effects when prescribed antide- immigrant population among many Asian-
pressants, since they are likely to metabolize American groups, it is erroneous to assume
tricyclic antidepressants and SSRIs less effi- that all are foreign born. Variation in prac-
ciently than Caucasians (Pi and Gray 1999). tice of traditional healing methods is consid-
• Although the clearance of nicotine is similar erable and consistent with generational dif-
for African Americans and Caucasians, the ferences. When considering detoxification,
clearance of cotinine, a metabolite of nico- recognize the importance of bicultural prac-
tine, is slower in African Americans, which tices, values, and beliefs that might influence
may cause different smoking patterns than responsiveness to treatment.
found in Caucasians (Ahijevych 1998). • When discussing detoxification medications,
discuss with patients their feelings about tak-
Asians and Pacific Islanders ing “Western” medications for detoxification.
In some Southeast Asian cultures, Western
This group is the most diverse in nations of medications are believed to be too strong for
origin and has widely differing languages, the Asian person. It is important to assess a
beliefs, practices, dress, and values. Often person’s feelings about these since the patient
the only common thread among these people may not wish to disagree with the clinician
is their geographic origin (Chang 2000). yet may be noncompliant in taking the medi-
Although this group appears to have lower cations. Compliance with detoxification medi-
rates of alcohol and illicit drug use, these cation may be better achieved if doses are
problems should not be overlooked; members reduced or regimens shortened, yet this
of this group may not seek treatment until the should only be attempted if it is in the best
problems are quite severe. Successful treat- interest of the patient.
ment involves the family and important val-
ues include balance, harmony, wisdom, and • Racial differences in alcohol sensitivity
modesty. Thus, it may be important to talk to among Asians and Caucasians have long been
the family about the process of detoxification recognized, with more than 80 percent of
and dispel their fears and concerns as well as some Asians compared to 10 percent of
the patient’s. Caucasians being sensitive to alcohol (i.e.,
having a flushing reaction) (Wolff 1972,
Asians and Pacific Islanders tend to be con- 1973). This is the result of genetic differences
cerned about the clinician’s credibility and in alcohol metabolizing enzymes.
trustworthiness. Generally speaking, male- Approximately 50 percent of Asians lack the
ness, mature age, the projection of self-confi- enzyme ALDH2, found in the liver, that helps
dence, possession of sound cultural compe- the body get rid of alcohol (Hsu et al. 1985;
tence skills, good educational background, Yoshida et al. 1985). One reason for lower
and level of experience are of importance. In drinking rates among Asians may be the
addition, a concrete logical approach to the flushing reaction in the face and body follow-
problem at hand is valued (Brems 1998). The ing alcohol ingestion and an increase in skin
previously discussed protocols for detoxifica- temperature. Other uncomfortable signs and
tion from all substances of abuse appear ade- symptoms associated with the negative reac-
116 Chapter 4
dition that can be helpful in the treatment Spanish or Portuguese does not guarantee
process (Canino et al. 1987; Coyhis 2000). cultural sensitivity or competence. For
The previously discussed protocols for detoxi- instance, it is important that the treatment
fication from all substances of abuse appear staff understand the role of the family. The
adequate for the detoxification of American functional family can be extended and should
Indians. The following are some issues to con- take into account people who have day-to-day
sider during detoxification. contact with and a role in the family
• Fetal Alcohol Syndrome is 33 times higher in (Markarian and Franklin 1998).
this population than the national average Hispanics/Latinos are likely to view drug
(CSAT in development a). This may be dependency as moral failing or personal
important for pregnant women coming to weakness. Traditional healing such as folk
detoxification and also may be important if remedies and folk
the adult has FAS. healers may provide
benefit. The previ- Hispanics/Latinos
• Indian women who drink have a six-fold
ously discussed pro-
increase in cirrhosis of the liver relative to
tocols for detoxifica- are now the
Caucasian women (Heath 1989).
tion from alcohol,
• Although some American Indians have opioids, benzodi-
reported a flushing response to alcohol, it largest ethnic
azepines, stimulants,
appears that the flushing reaction in solvents, nicotine,
American Indians is milder and less adverse marijuana, anabolic
minority group in
than that experienced by Asians (Gill et al. steroids, and club
1999). drugs appear ade- America.
• If Alcoholics Anonymous or other 12-Step quate for the detoxi-
programs are to be introduced, framing the fication of Assessment of the
steps in terms of a circle rather than a ladder Hispanics/Latinos.
may be better received, since the circle is patient’s level of
important concept in Indian culture (CSAT
in development a). Gays and acculturation can
• If possible and appropriate, other traditional Lesbians
methods that can help recovery are sweat Approximately 5 to
be helpful in
lodges, vision quests, smudging ceremonies, 33 percent of all les-
sacred dances, and four circles (Abbott bian and gay individ- understanding
1998). uals are estimated to
have a substance substance abuse
• Overall, detoxification for this population is
the same as for other populations, but abuse problem
American Indians are likely to seek treatment (Cochran and Mays patterns.
later and have more medical complications 2000; Hughes and
and poorer nutrition (Abbott 1998). Wilsnack 1997). A
contributing factor may be the stress and
anxiety associated with the social stigma
Hispanics/Latinos attached to homosexuality. Further, alcohol
Hispanics/Latinos are now the largest ethnic and drugs may serve as an escape and ease
minority group in America. Assessment of the social interactions at social settings such as
patient’s level of acculturation can be helpful bars. More information on this subject will be
in understanding substance abuse patterns. available in the forthcoming TIP Improving
Language is one of the most difficult barriers Cultural Competence in Substance Abuse
to treatment entry and success for Treatment (CSAT in development a). The
Hispanics/Latinos. However, simply knowing previously discussed protocols for detoxifica-
118 Chapter 4
• Abrupt withdrawal from opioids or benzo- • Many correctional facilities have restric-
diazepines is not life-threatening but can tions on the use of methadone or LAAM and
cause severe withdrawal signs and symp- special provisions for maintaining or taper-
toms and great distress. ing the individual may need to be made.
• It should be determined whether depen- • If medications are provided to medically
dence on either opioids or benzodiazepines detoxify inmates, the Federal Bureau of
is the result of illicit use and not the result Prisons’ Clinical Practice Guidelines for
of taking medications that have been pre- Detoxification of Chemically Dependent
scribed to treat pain or anxiety disorders. Inmates (2000) suggest retaining strict con-
• If medically supervised withdrawal is indi- trol over access to these medications to pre-
cated, the substitution of a long-acting drug vent diversion or misuse (e.g., eating cloni-
from the same class of substances the dine patches to obtain a state of euphoria).
patient is using (e.g., giving methadone to TIP 44, Substance Abuse Treatment for
treat heroin dependence) and the gradual Adults in the Criminal Justice System (CSAT
tapering of that substance (no faster than 2005b), and TIP 30, Continuity of Offender
10 to 20 percent per day) should be con- Treatment for Substance Use Disorders From
ducted under closely monitored settings. Institution to Community (CSAT 1998b), pro-
• There are cases when individuals main- vide more detailed information about the
tained on opioid agonist medications are treatment of this population. TIP 21,
detained or incarcerated. If the incarcera- Combining Alcohol and Other Drug Abuse
tion is 30 days or less, the individual should Treatment With Diversion for Juveniles in
be maintained on her usual dosage. If the the Justice System (CSAT 1995b), also pro-
incarceration is longer, the individual may vides information about incarcerated youth.
be appropriate for gradual dose tapering.
• Persons who transition from a state of opi-
oid dependence to a drug- or medication-
free state are at greater risk of overdose
upon relapse to opioid use.
121
General Principles of on the overall health of patients, staff mem-
bers are in a position to help patients see the
Care for Patients With importance of engaging in treatment for their
substance use disorders. Patients should have
Co-Occurring Medical appointments for followup care made prior to
Conditions detoxification discharge for all chronic medi-
cal conditions, conditions needing further
Patients who use substances can present with
evaluation, and substance abuse treatment.
any of the conditions or combinations of con-
ditions that can be found in the general popu- This section highlights the conditions most
lation. In most cases, the management of the frequently seen in individuals who abuse sub-
medical condition in the patient with a sub- stances, though it is not inclusive. Disorders
stance use disorder diagnosis does not differ of the following systems will be covered: gas-
from that of any other patient. However, the trointestinal (including the gastrointestinal
medication used for detoxification and the [GI] tract, liver, and pancreas), cardiovascu-
actual detoxification protocol may need to be lar system, hematologic (blood) abnormali-
modified to minimize potentially harmful ties, pulmonary (lung) diseases, diseases of
effects relevant to the co-occurring condition. the central and peripheral nervous system,
infectious diseases, and special miscellaneous
Detoxification staff providing support should
disorders. Where special considerations are
be familiar with the signs and symptoms of
needed for a patient presenting with a given
common co-occurring medical disorders.
disorder in a detoxification setting they are
Likewise, personnel at medical facilities (i.e.,
listed following the heading “Special
emergency rooms, physicians’ offices) should
Considerations.”
be aware of the signs of withdrawal and how
it affects the treatment of the presenting med-
ical conditions. Gastrointestinal Disorders
The setting in which detoxification is carried Frequently, the use of substances can present
out should be appropriate for the medical a range of gastrointestinal problems. Cocaine
conditions present and should be adequate to use, for example, can result in various gas-
provide the degree of monitoring needed to trointestinal complications, including gastric
ensure safety (e.g., oximetry [a measurement ulcerations, retroperitoneal fibrosis, visceral
of the amount of oxygen present in the infarction, intestinal ischemia, and gastroin-
blood], greater frequency of taking vital testinal tract perforations (Linder et al.
signs, etc.). Acute, life-threatening conditions 2000). Gastrointestinal disorders may affect
need to be addressed concurrently with the many different organs and organ systems
withdrawal process and intensive care unit (e.g., liver, pancreas), making diagnosis diffi-
monitoring may be indicated. cult. Since symptoms can be vague and
patients are not always able to articulate the
Clinicians should keep in mind that consulta- specific problem, diagnosis can be difficult.
tion with specialists in infectious diseases, For a simple rule of thumb, urgent attention
cardiology, pulmonary medicine, hematology, is needed if the patient is diagnosed with any
neurology, and surgery may be warranted. of the following:
Whenever possible, consent should be sought
• Appendicitis
to involve the patient’s primary healthcare
provider in the coordination of care. • Abdominal aortic aneurysm
Attending medical staff should be aware that • Perforated peptic ulcer
co-occurring medical conditions present an • Boerhaave’s Syndrome (spontaneous
opportunity to engage patients. By focusing esophageal rupture)
on the adverse effects of the substance abuse
• Obstructed or strangulated bowel
122 Chapter 5
• Ischemic bowel disease (a condition that may decrease lower esophageal sphincter pres-
results from inadequate blood supply to the sure and aggravate reflux (Dell’Italia 1994).
intestines)
• Abcess of the pancreas or liver Mallory–Weiss Syndrome
• Ruptured spleen or other trauma to the
Mallory–Weiss Syndrome is caused by torn
abdominal area
mucosa of the esophagus at the gastro-
Other possible diagnoses of abdominal pain esophageal junction due to protracted or vio-
include: lent vomiting. Mallory–Weiss Syndrome is the
etiology of 5 to 15 percent of all upper GI
• Hepatitis
bleeds (Schuylze-Delrieu and Summers 1994).
• Peptic ulcer (nonperforating)
• Peritonitis
Boerhaave’s
• Acute pancreatitis
syndrome
• Pelvic inflammatory disease
Boerhaave’s syn-
• Endometriosis
drome is manifested
• Nephrolithiasis (kidney stones) Co-occurring
by rupture of the
• Inflammatory bowel disease esophagus. Patients
presenting with this medical conditions
• Ovarian cysts
condition complain of
Clinicians should also be aware of some decep- acute epigastric pain present an
tive causes of abdominal pain: (83 percent of
• Myocardial infarction patients), vomiting opportunity to
(79 percent), and
• Pulmonary emboli shortness of breath engage patients in
• Herpes zoster (shingles) (39 percent) as the
• Acute pylonephritis (kidney infection) predominant, nonspe- treatment for
cific symptoms. This
Specific co-occurring gastrointestinal disorders lack of specificity can
requiring special attention in patients undergo-
their substance
delay making the cor-
ing detoxification are discussed below. rect diagnosis (Brauer
et al. 1997).
use disorders.
Tachycardia,
Reflux esophagitis cyanosis, and subcu-
Reflux esophagitis can be a result of alcohol’s taneous emphysema
effect on the lower esophageal sphincter (i.e., also can be seen. If
relaxation) and a decrease in peristalsis of the this condition is left
distal esophagus, allowing gastric contents to untreated, the prognosis is severe.
come into contact with the lower esophagus.
Typical symptoms include burning in the epi-
gastric or retrosternal area (commonly called Gastritis
“heartburn” or “indigestion”). Esophageal Gastritis is described as the disruption of the
bleeding can result from reflux esophagitis and gastric mucus lining that allows gastric acid to
esophageal varices (resulting from portal contact the mucosa with resultant inflammation
hypertension). and possible bleeding. The patient presents
with nausea, vomiting, and abdominal pain
Special considerations (Ivey 1981). Alcohol increases gastric acid
Several drugs used in typical protocols, such as secretion and reduces the mucosal cell barrier,
beta blockers and calcium channel blockers,
Co-Occurring Medical and Psychiatric Conditions 123
allowing back-diffusion of the gastric acid into ered as an appropriate agent, as it can be
the mucosa. This frequently causes an occur- administered intravenously or intramuscular-
rence of erosive gastritis in the individual with ly. Opioids may have to be used to control
an alcohol use disorder (Fenster 1982). pain.
Special considerations
Aspirin and nonsteroidal medications should be Liver disorders
avoided in the withdrawal protocols. Liver disease can range from fairly benign
fatty liver, which presents usually as an
asymptomatic enlargement of the liver associ-
Pancreatitis ated with mild elevation of the serum liver
Pancreatitis can be enzymes, to a broad spectrum of viral infec-
caused by many fac- tions and the toxic consequences of alcohol
Detoxification tors, although stud- and other drug use. The end point of liver
ies suggest that alco- disease is liver necrosis or failure. Midway in
staff providing hol may be a factor the progression of liver disease is acute alco-
in anywhere from 5 holic hepatitis. The presentation is one of
support should be to 90 percent of all liver tenderness, jaundice, fever, ascites, and
cases (Apte et al. an enlarged liver. The patient is quite sick
1997), with some and frequently has nausea and vomiting.
familiar with the experts suggesting
about 60 percent of Special considerations
signs and all cases result from Alcoholic hepatitis usually needs acute medi-
excessive alcohol cal treatment to prevent electrolyte imbalance
symptoms of com- consumption and dehydration. Protocols may have to be
(Yakshe 2004). The adapted if the patient cannot take oral
mon co-occurring acute condition pre- agents.
sents with abdomi-
medical conditions. nal pain, which is
described as sharp, Portal hypertension
burning, and con- Portal hypertension is a frequent conse-
stant and is located quence of liver disease. If elevation of the
in the epigastric portal pressure goes untreated, esophageal
area of the varices develop and hemorrhage can ensue.
abdomen with radiation to the back. Treatment of acute hemorrhage includes
Presenting symptoms and signs can include endoscopic sclerotherapy or ligation. Initial
abdominal tenderness, decreased bowel therapy should include prompt and adequate
sounds, low-grade fever, tachycardia, nausea, intravascular volume replacement, correction
and vomiting. Pancreatitis can proceed to a of severe anemia and coagulopathies, and
chronic condition where pancreatic calcifica- adequate airway management.
tion, diabetes mellitus, malabsorption, and
chronic abdominal pain occur. Special considerations
Propranolol or isosorbide therapy is effective
Special considerations in the prophylaxis of variceal bleeding
There may be a need to forbid oral intake of (Trevillyan and Carroll 1997), though beta
food and medications, necessitating a change blockers can interfere with measuring the
of route of administration of both food and true heart rate that determines the content of
medications to intravenous forms. In alcohol many detoxification protocols. If bleeding is
withdrawal protocols, Ativan might be consid-
124 Chapter 5
present, changeover to intravenous medica- Cardiovascular Disorders
tion protocols is recommended, as the patient
will not be able to take oral medications. The presentation of chest pain or discomfort
remains one of the most difficult differential
diagnoses to sort through, as disorders of sev-
Cirrhosis eral systems can cause this single complaint.
Inability to correctly diagnose this symptom
Cirrhosis, or the formation of fibrous tissue
can be brought about by the patient’s inabili-
in the liver, leads to a state of increased resis-
ty to be interviewed and give succinct symp-
tance in the hepatic venous circulation. The
toms (the intoxicated or severely withdrawing
inability of blood to flow freely gives rise to
patient), a sociocultural or educational level
portal hypertension with ensuing esophageal
that does not allow for the verbal nuances
varices, splenomegaly, ascites, dilatation of
necessary to making a diagnosis, or fabrica-
superficial veins, peripheral edema, and hem-
tion of symptoms by a patient seeking to
orrhoids.
obtain pain medications or other drugs.
Liver necrosis can be seen in patients who use
A normal resting electrocardiogram does not
inhalants, particularly chronic use of benzene
rule out the presence of organic heart disease
and carbon tetrachloride. African Americans
and the presence of nonspecific changes does
and Hispanics/Latinos have higher mortality
not necessarily mean that heart disease is pre-
rates from cirrhosis of the liver resulting from
sent. Final diagnoses can range from reflux to
alcohol abuse than do Caucasians and Asians
myocardial infarction brought about by
and Pacific Islanders (Sutocky et al. 1993).
underlying ischemic heart disease or the use
Liver function test abnormality and jaundice
of cocaine. Frequently, lung diseases can have
can occur in individuals who use anabolic
as their presenting symptom chest discomfort.
steroids, but this usually resolves on cessation
The consensus panel believes that this condi-
of the drugs. Studies in the elderly show that
tion should never be overlooked or minimized
1-year mortality was 50 percent among
and it is imperative that an especially prompt
patients over age 60 with cirrhosis, versus 7
diagnosis be made and treatment be under-
percent for those under age 60 (Potter and
taken to ensure patient safety.
James 1987). Great care needs to be used
when giving diuretics to elderly patients with Underlying cardiac illness could be worsened
cirrhosis, since their total body water may by the presence of autonomic arousal (elevat-
already be decreased, making them more sus- ed blood pressure, increased pulse and sweat-
ceptible to fluid and electrolyte depletion ing) as seen in alcohol, sedative, and opioid
(Scott 1989). withdrawal. Thus prompt attention to these
findings and aggressive withdrawal treatment
Alcohol-related hepatic injury is seen in a
is indicated. Special considerations for the
higher proportion of women due to a possible
treatment of specific cardiac conditions are
potentiation (strengthening) of this effect by
outlined below.
estrogen (Brady and Randall 1999).
126 Chapter 5
Special considerations Arrhythmias
Beta-adrenergic blocking agents may exacer- Arrhythmias (irregular heartbeats) can be
bate cocaine-induced coronary arterial vaso- seen in the presence of ischemia and car-
constriction and thereby increase the myocar- diomyopathy. Two specific cases of arrhyth-
dial ischemia. Nitroglycerin and verapamil mogenic disorders are “holiday heart,” where
reverse cocaine-induced hypertension and the patient who has ingested alcohol presents
coronary arterial vasoconstriction and are with supraventricular arrhythmia
the medications of choice in the patient who (Greenspon and Schaal 1983), and the indi-
uses cocaine and presents with chest pain vidual who uses cocaine with the stimulant
(Pitts et al. 1999). Cocaine may cause platelet leading to significant atrial and ventricular
activation leading to acute coronary events— arrhythmias. Consumption of anabolic
thus more aggressive antiplatelet therapy may steroids also has
be indicated (Callahan et al. 2001). been associated with
hypertension,
Cocaine use is
ischemic heart dis-
Cardiomyopathy
ease, cardiomyopa-
Cardiomyopathy is caused by degenerative thy, and arrhythmia associated with
changes of the cardiac muscle with enlarge- (Sullivan et al.
ment of the heart (cardiomegaly) and left ven- 1999). various
tricular failure. Alcoholic cardiomyopathy
presents with a similar picture as cardiac fail- Special consider- cardiovascular
ure from other etiologies, with shortness of ations
breath on exertion, shortness of breath when Treatment of arrhyth- complications
the patient is lying flat, and edema of the mia in the person who
lower extremities. abuses substances is including angina
similar to that for the
Besides alcohol as the etiology, a dilated car-
patient who does not
diomyopathy can be seen with use of the pectoris,
abuse substances,
inhalant trichlorethylene. Cardiomyopathy in
though the setting of
the elderly patient with an already underlying
detoxification may myocardial
ischemic or atherosclerotic heart disease can
have to be altered to
be quite debilitating. Women have shown infarction, and
allow for cardiac
alcohol metabolism different from that of men
monitoring (teleme-
and distinct pathophysiologic mechanisms, sudden death.
try).
which frequently lead to a higher sensitivity
to alcohol-induced heart damage. The preva-
lence of cardiomyopathy in women is equal to Hematologic
that in men, despite cases in which women
have consumed far less ethanol (Fernandez-
Disorders
Sola and Nicolas-Arfelis 2002). Hematologic (blood) disorders can be seen due
to several factors, such as a direct toxic effect
Special considerations of the drug on the bone marrow, as seen in
Alcoholic cardiomyopathy may respond poor- alcohol and benzene use, or as a result of mal-
ly to digitalis with increased likelihood of digi- absorption of essential nutrients (B12, folate),
talis toxicity (Zakhari 1991). or as a general poor state of nutrition.
128 Chapter 5
Special considerations ularly in hospitalized patients. Evaluation for
Asthma medications can cause a significant infections and the use of oxygen, steroids,
increase in heart rate, which can affect the and inhalers is dictated by the clinical pic-
evaluation of withdrawal protocols that use ture. During detoxification, if nicotine use is
heart rate as one of the parameters. not allowed, there can be significant effects
on drug levels (see chapter 4).
Chronic Obstructive
Neurologic System
Pulmonary Disease
The neurologic system of patients with sub-
Chronic obstructive pulmonary disease stance use disorders is affected directly in the
(COPD) (emphysema, chronic bronchitis) fre- toxic effects on cell membranes, effects on
quently is due to cigarette use and the result- neurotransmitters, associated metabolic
ing alterations of the pulmonary immune sys- changes from other underlying disorders, and
tem, inflammation, and destruction of lung changes in blood flow. Researchers have
parenchyma. Presentation includes shortness found that the majority of those with an alco-
of breath on exertion, a cough producing hol use disorder (75 percent) have some
mucous, and wheezing. degree of cognitive impairment (Goldstein
African Americans who smoke cigarettes take 1987). Specific disorders found in patients
in more nicotine, and therefore more tobacco with substance use disorders can affect the
smoke toxins per cigarette, than Caucasians central nervous system and the peripheral
(Perez-Stable et al. 1998). system. For example, a broad array of neu-
ropathologic changes are seen in the brains of
Daily marijuana smoking has been shown to people who use heroin. The main findings are
have adverse effects on lung function includ- due to infections as a result of endocarditis or
ing a productive cough, wheezing, and exces- HIV infection. Other complications include
sive sputum production. However, the habitu- hypoxic-ischemic changes with cerebral
al marijuana-only smoker, in the absence of edema, ischemic neuronal damage thought to
alpha-1-antitrypsin deficiency, would have to be due to heroin-induced respiratory depres-
smoke four to five marijuana cigarettes per sion, stroke due to thromboembolism, vas-
day for a span of at least 30 years to develop culitis, septic emboli, and hypotension.
overt manifestations of COPD (Van Hoozen Myelopathy occurs as a result of possible iso-
and Cross 1997). lated vascular accident in the spinal cord,
and a distinct condition, leukoencephalopa-
Special considerations thy, has been described after the inhalation of
During nicotine withdrawal and cessation pre-heated heroin (Buttner et al. 2000).
treatment, different levels of nicotine absorp-
tion, as seen in some groups, will affect dosing As a final note, traumatic brain injury (TBI)
for nicotine replacement therapies (Perez- should always be considered in patients pre-
Stable et al. 1998). The patient with COPD, senting with neurological impairment. People
especially if elderly, would be sensitive to the who abuse substances are at high risk of falls,
sedating effects of many of the detoxification motor vehicle accidents, gang violence,
protocol medications, especially the benzodi- domestic violence, etc., which may result in
azepines, which may have to be reduced in head injury (Graham et al. 2003).
dosage to avoid respiratory depression and Unrecognized TBI can affect the treatment
worsening hypoxemia and hypercarbia outcome.
(decrease in oxygen and increase in carbon
dioxide). For smokers, always consider the
use of the nicotine replacement agents, partic-
130 Chapter 5
tively shorter acting agent lorazepam also There is a higher than normal incidence of
reduced the risk of a subsequent seizure com- hemorrhagic stroke and other intracranial
pared to placebo. However, in D’Onofrio’s bleeding among patients with heavy alcohol
study doses were small and the results were use, and a particular association of strokes
limited somewhat by use in an emergency within 24 hours of a drinking binge (Altura
room setting. 1986).
132 Chapter 5
may have a higher rate of endocarditis as a infected patient presents with complaints of
result of more frequent injections and the cough (most common finding), bloody spu-
reduced need to solubilize cocaine solutions tum, chest pain, fever, and weight loss.
with heat (Chambers et al. 1987). Recent immigrants from countries where TB
is prevalent, socioeconomically disadvantaged
populations, homeless persons, people who
Bacterial pneumonia use illicit drugs, incarcerated people, and
Bacterial pneumonia can result from immune people who live in areas where infection with
system dysfunction, interference with normal HIV is prevalent, are at increased risk for
respiratory defense mechanisms (from alcohol this disease and should be tested. Further-
or smoked drugs), direct toxicity, or aspiration. more, new strains of multidrug-resistant TB
are appearing, especially among the homeless
The treating physician should be aware that population (Borgdorff et al. 2000; Moss et al.
the usual pathogens found in community- 2000).
acquired pneumonia (i.e., Streptococcus
pneumoniae) may not be the causative agent TB is endemic in many areas of the world
in pneumonias seen in patients dependent on (Asia, Africa, and South and Central
alcohol. Haemophilis influenzae, Klebsiella America) (Gupta et al. 2004). As a public
pneumoniae, and other gram-negative health concern, testing all patients is of the
microorganisms must be suspected and treat- utmost importance, even more so for patients
ment given until definitive culture results are from regions where TB is endemic. It is
reported. Among patients who use parenteral important to remember that immunocompro-
drugs, pneumonia is the most common reason mised patients may not react to the skin tests
for admission to the hospital, accounting for (anergy). Diagnosis is made with tuberculin
38 percent of all hospitalizations in this popu- skin testing, sputum smears and cultures, and
lation (Marantz et al. 1987). radiographic findings. For more information
on dealing with tuberculosis in detoxification
Special considerations and treatment settings see TIP 18, The
Careful use of respiratory depressants is rec- Tuberculosis Epidemic: Legal and Ethical
ommended. Indications for hospitalization of Issues for Alcohol and Other Drug Abuse
the patient with pneumonia (Neu 1994) include Treatment Providers (CSAT 1995i).
the following:
• Old age Skin infections
• Dehydration
Skin infections frequently are seen as a result
• Vomiting and inability to take in oral fluids of the intravenous administration of drugs.
and medications Staphylococcus aureus and Streptococcus
• Multilobar disease pyogenes are frequently the infectious agents.
• Low white blood cell count The patient presents with tenderness,
swelling, pain, erythema, and warmth in the
• Respiratory acidosis injection area. The type and route of antibi-
• pO2 less than 55 mm Hg otic is determined by the infecting organism
• Significant concomitant diseases and the extent and severity of the infection.
Clinicians should remember that injection
• HIV
sites can be found virtually any place on the
body where there is access to the venous sys-
Tuberculosis tem.
Tuberculosis (TB) is caused by acid-fast rod
(Mycobacterium tuberculosis). Transmission Patients who use drugs intravenously,
is by droplets spread through the air. The patients with peripheral vascular disease, and
134 Chapter 5
loss could suggest many chronic diseases, disorders appear to be particularly prone to
though cancer should be considered in the accidents of all kinds, with a spectrum of com-
differential. There may be an increase in plications from head trauma to falls with frac-
head and neck cancers in persons with heavy tures. Chronic pain frequently is seen in
cannabis use (Donald 1991). Liver cancer patients as a result of trauma (treated or
may be seen in patients with hepatitis C and untreated), poor health maintenance, or an
those using anabolic steroids (Socas et al. inability to deal with pain without drug use.
2005). There is a particular interrelationship Chronic pain treatment and the issues of opioid
among alcohol intake, hepatitis C, and hepa- use have to be considered for each patient on
tocellular carcinoma (Yoshihara et al. 1998). an individual basis.
136 Chapter 5
therapeutic doses of medications should be times is the best way to assess the patient’s
continued through any withdrawal if the need for the medication; however, it may not
patient has been taking the medication as pre- be the best practice or in the best interest of
scribed. Decisions about discontinuing medi- the patient, particularly for those with a seri-
cations should be deferred until after the ous mental illness. For more information on
individual has completed detoxification. If, working with patients with co-occurring sub-
however, the patient has been abusing a medi- stance use and mental disorders, see TIP 42,
cation or the psychiatric symptoms were Substance Abuse Treatment for Persons With
clearly caused by substance abuse, then the Co-Occurring Disorders (CSAT 2005c).
rationale for discontinuing the medication is
strengthened. Finally, practitioners should
consider withholding medications that lower Treatment for Co-Occurring
the seizure threshold (e.g., bupropion or con- Conditions
ventional antipsychotics) during the acute The treatment of substance use disorders can
alcohol withdrawal period, or at a minimum be difficult without adequate treatment of any
prescribing a loading dose or scheduled taper co-occurring mental disorders. For instance,
of benzodiazepine. a patient with schizophrenia who is halluci-
During detoxification, some patients decom- nating and delusional, but who also abuses
pensate and lapse into psychosis, depression, substances, cannot participate in substance
or severe anxiety. In such cases, careful abuse treatment without adequate control
observation of the withdrawal medication reg- over the psychosis. Likewise, patients with
imen is of paramount importance. If the mania who are euphoric and delusional,
decompensation is a result of inadequate dos- patients who are depressed, or patients with
ing with withdrawal medication, the appro- agoraphobia who also have a substance use
priate response is to increase the dose of med- disorder, will have difficulty cooperating with
ication. If it appears that the withdrawal substance abuse treatment. Treatment of the
medication is adequate, other medications substance use disorder is necessary to
may be needed. Before choosing such an improve the course of both the substance
alternative, it is important to take into abuse and co-occurring mental disorder.
account additional considerations, such as the Psychotherapy should serve as one aspect of
side effects of the added medication and the rehabilitation, initially focused around
possibility of interaction with the withdrawal relapse prevention (Aviram et al. 2001).
medication. Highly effective treatment programs may
include a combination of therapeutic tech-
A patient with psychosis may need to take niques. Programs should be long-term and
neuroleptics. Medications that have a minimal approach recovery in stages. Drake and col-
effect on the seizure threshold are recom- leagues (2001) suggest that treatment for co-
mended, particularly if the patient is being occurring substance use and other mental dis-
withdrawn from alcohol or benzodiazepines. orders include skill building, illness manage-
Small, frequent doses of Haldol, such as 1mg ment, cultural sensitivity, and support to
every 2 hours, may be used until the patient’s patients for the pursuit of practical goals.
symptoms of psychosis begin to disappear.
The case for emergency use of antidepres-
sants is weaker than for other psychiatric Limitations of pharmacologi-
medications because of the 2- to 3-week lag cal agents in persons with
time between initiation of medication and substance dependence
therapeutic response. After detoxification,
the patient’s need for medication should be Pharmacologic agents have limitations in the
reassessed. A trial without medications some- population of persons with substance use dis-
138 Chapter 5
With an understanding of the interactions panic and phobia disorders, posttraumatic
between substance use and other mental dis- stress disorder, victimization, and eating dis-
orders, a rational approach can be applied to orders. Deficits in the management of mood
the use of pharmacologic therapies in co- disturbances may be self-medicated through
occurring conditions. The use of medications alcohol consumption in females. It has been
for psychiatric symptoms should begin only proposed that the outcomes of substance
after the knowledge of the natural history of abuse in women are different when compared
the addictive disorder and other psychiatric to those of men. For these reasons, the effica-
disorders is clarified. Further, it is important cy of treatment for substance use disorders
to be able to identify the respective roles of needs to be assessed independently for both
substance use and other mental disorders in genders (Becker and Walton-Moss 2001;
the generation of psychiatric symptoms. Brady and Randall 1999).
140 Chapter 5
syndrome of their own. Because of its anti- fered by the patient with an addictive disor-
cholinergic properties, imipramine is more der. Likewise, and analogous to the role of
sedating, but nortriptyline and the SSRIs can anxiety, depression also is a part of the heal-
produce anxiousness in some individuals and ing process that the patient with a substance
sedation in others. Not all individuals react use disorder experiences during recovery.
the same way to these medications.
Depressant drugs (e.g., alcohol) can produce
When medications are used, a specific target depression during intoxication which often
symptom should be the focus. Also, medica- resolves following abstinence. A survey of 69
tions should be tried in time-limited intervals, adults with alcohol use disorders showed a
such as weeks to months. A “drug holiday” strong correlation between the reduction in
(i.e., a brief period where the patient stops cravings for alcohol over 2 weeks of absti-
taking medications) should then be attempted nence and the lifting of depressive mood. The
to see if the medication is still necessary. patients’ cravings were assessed with the
Obsessive-Compulsive Drinking Scale (OCDS)
The patient should be instructed that the and their depressive symptoms measured with
medications will not “cure” the addiction, the Self-rating Depressive Scale (SDS).
that treatment of anxiety will not control the Between day 1 and day 14, their cravings
addiction, and that treatment of the addiction score dropped nearly a third, while the scores
will not necessarily ameliorate the anxiety dis- for severity of depression fell by about one
order. In essence, the substance use disorder fourth. The correlation between the reduction
must be treated independently of the anxiety in cravings and the lifting of depression per-
disorder and vice versa. sisted after controlling for sex, age, duration
and extent of alcohol abuse, and the amount
Depressive Disorders of clomethiazole administered (Anderson and
Kiefer 2004).
142 Chapter 5
(Malcolm et al. 2001). One theoretical expla- the neurotransmitter dopamine at its postsy-
nation for the mechanism of action for carba- naptic receptor sites.
mazepine involves suppression of mood cen-
ters in the limbic system that act like seizure
foci. In this context, a “kindling” model has Adverse
been proposed for both mood and addictive Effects
disorders (Gelenberg and Bassuk 1997).
Antianxiety A period of
Psychotic Disorders agents
confirmed
While benzodi-
General approach azepines are useful
in the short term, abstinence usually
Prevalence rates for co-occurrence of
schizophrenic and addictive disorders range their efficacy wanes
with long-term use, is necessary
from 40 to 80 percent, depending on the pop-
ulation studied, in epidemiologic and clinical probably because of
studies. the development of before mood-
pharmacologic toler-
Schizophrenia is a chronic illness character- ance and depen- stabilizing drugs
ized by bizarre thinking and behavior. dence. It should be
Hallucinations and delusions are “positive” noted that benzodi- are started.
symptoms of the psychotic process, while azepines can be
symptoms such as social withdrawal and addicting, particu-
poverty of emotions are “negative” symptoms larly in those already
(or deficit syndrome). Conventional neurolep- addicted to other
tics are more effective for positive symptoms, substances.
whereas behavioral, group, and individual
psychotherapy are more effective for negative
symptoms. New agents such as clozapine and Antipsychotic agents
risperidone may be more effective in treating Antipsychotics can produce sedation and
both the positive and negative symptoms. hypotension (at times causing lightheadedness
in some individuals), particularly with postu-
Psychosis can be caused by stimulant drug ral changes. Conventional neuroleptics pro-
use during intoxication and depressant duce acute extrapyramidal reactions, which
drug/alcohol use during withdrawal. A period include pseudoparkinsonism, dystonia, and
of weeks or months may be necessary to akathisia. Dystonia usually responds to treat-
assess the effects of substances of abuse, but ment with anticholinergic drugs such as ben-
as with anxiety, depression, or mania, medi- ztropine or diphenhydramine. Akathisia is
cations can be started at almost any time as the subjective feeling of anxiety and tension,
the psychosis is persistent and waiting is not causing the patient to feel compelled to move
possible. Moreover, the greater the number of about restlessly. This symptom usually
psychiatric admissions, the greater the proba- requires beta blocker, as a decrease in the
bility of a chronic mental disorder associated antipsychotic dose does not have the desired
with the co-occurring psychiatric disorder. effect. Alternatively, switching to risperidone
High- or moderate-potency neuroleptics (e.g., may accomplish the intended effect while
haloperidol or atypical agents) generally are avoiding intolerable neurologic syndromes.
the agents of choice in the treatment of
schizophrenia. The clinical potency correlates
with the drug’s ability to block the action of
144 Chapter 5
6 Financing and
Organizational
Issues
In This
Chapter… Preparing and Developing a
Preparing and Program
Developing a Developing a detoxification program is a major financial challenge,
Program whether the program requires building an entirely new organization
or is part of an existing treatment entity. The process of program
Working in development requires careful planning, especially to ensure adequate
Today’s Managed financial support for the operation. The decision to develop a detoxifi-
Care Environment cation program should be based on a well-developed strategic plan-
ning process (see chapter 2) and a clear understanding of what a
Preparing for the detoxification program entails. Because the new program will incur
Future major costs for office space, furniture, staff, computers, and other
equipment before clients can be provided with services and payment
can be received, significant amounts of initial capital may be needed.
145
by patients who have the documented finan- health plans may be necessary to ensure both
cial resources to pay for detoxification treat- private sector demand for services and
ment themselves. Signed contracts with appropriate reimbursement of the services.
expected payors may be useful to ensure ade-
quate cash flow and to establish a budget for Forming strategic alliances with other compo-
the new program’s fee structure. nents of the treatment environment can be
both an important source for referrals and a
Identifying and recruiting strategic partners resource for clients with needs other than
is one of the most important steps in the pro- detoxification. Vertical alliances facilitate
gram development process. Before and during referrals up and down the continuum of care.
the program development process, adminis- An alliance with a larger organization can
trators and planners should work closely with increase leverage when negotiating with an
potential referral and payment sources to MCO.
determine their needs and to see if the detoxi-
fication program will fit those needs.
Programs also will need to learn whether The Dramatically Changing
referral sources are open to new partners, the Pattern of Utilization of
types of contracts they utilize, their time- Detoxification Services
frames for reimbursement, and the process
for negotiating a contract. Among useful tac- The settings for detoxification services have
tics to employ is holding focus groups and changed dramatically over the last decade, as
strategy meetings with individuals from have patients’ primary substances of abuse. As
potential referral sources; these groups can the setting for detoxification services has shift-
suggest the types of services they need and for ed from inpatient to outpatient, the primary
which they will reimburse. Potential referral substance abuse problem of clients has shifted
sources will be more invested in the program from alcohol and cocaine/crack to heroin and
if they are involved throughout the planning other opioids. This shift has created significant
process. All potential stakeholders should be opportunities in the market for detoxification
informed regularly of the developing plans services for community-based and
and milestones achieved. entrepreneurial providers that are not part of
hospitals, or for freestanding detoxification
Program planners should follow up on all facilities that are owned by hospitals.
potential leads for both funding sources and
potential referral sources. Relationships with Changes in practice patterns and in the epi-
referral sources are important to build and demiology of substance abuse in the last
maintain. Obviously, referral sources need to decade have been dramatic. Between 1993
be carefully assessed to ensure that they can and 2000, the number of admissions to hospi-
provide patients who have needs and tal inpatient settings for detoxification of
resources appropriate for the services the patients with a primary problem of alcohol
program will provide. Leads for potential abuse declined by 79.6 percent. During the
sources of funding and referrals may include same period, the total admissions to inpatient
the contacts made during a focus group pro- hospital detoxification services declined by
cess, public system payors and planners, pri- 69.3 percent, from 23.5 percent of total
vate insurance plans, contracting agents for detoxification admissions in 1993 to 8.8 per-
private insurance (e.g., managed care organi- cent of total detoxification admissions in
zations [MCOs]), and local employers large 2000, while admissions to 24-hour free-stand-
enough to have employee assistance programs ing detoxification units increased by the same
(EAPs) or managed behavioral health plans 14.7 percentage points, from 60.5 percent of
that cover detoxification services. Direct con- total admissions in 1993 to 75.1 percent of
tact with the EAPs or managed behavioral total admissions for detoxification services in
146 Chapter 6
2000. During this same period, the number of the reporting needs and performance require-
alcohol admissions to free-standing clinics ments of each purchaser, to provide informa-
decreased by 32.0 percent and the number of tion that meets their requirements, and to
cocaine/crack admissions decreased by 42.5 generate the appropriate bills/invoices.
percent. Concurrently, heroin admissions (to Detoxification program administrators must
free-standing clinics) increased substantially be knowledgeable about efficient business
from just under a quarter of total detoxifica- practices, the use of data-based performance
tion admissions in 1993 to just over a third of measures, accounting, budgeting, financing,
total admissions in 2000. and financial and clinical reporting.
Of course, these statistics reflect national It also is important to reach out to other
trends and regional differences in patterns of potential sources of support such as founda-
both practice and substance abuse. Changes tions, board mem-
in specific geographic areas will vary. bers, and local or
Prospective programs should carefully national corporate
Identifying and
research their own local market for detoxifi- donation programs
cation services and should obtain data on for any assistance
current utilization of and demand for detoxi- that will help to recruiting
fication in their local area before proceeding reduce costs,
with program development. increase revenue, or strategic partners
improve productivity
and effectiveness is one of the most
Funding Streams and Other and aid in the suc-
Resources in the Substance cess of the organiza- important steps in
Abuse Treatment Environment tion. Searching for
support does not end the program
Substance abuse treatment and detoxification with ensuring initial
services in the United States are financed funding. Planners
through a diverse mix of public and private development
must make good use
sources, with substantially more being spent of the Internet to
by the public sector. Public sources account uncover potential
process.
for 64 percent of all substance abuse treat- cash and in-kind
ment spending, a much higher percentage donations that can
than public expenditure for the rest of health supplement major funding sources, discussed
care (Coffey et al. 2001). The existence of below.
diverse funding streams presents both man-
agement challenges and opportunities for pro- Entrepreneurial, for-profit programs may be
gram independence and stability. However, a able to attract private capital. Not-for-profit
program with only one major funding source entities that are similarly entrepreneurial
is financially and clinically vulnerable to may be able to take advantage of this poten-
changes in its major source’s budget and pri- tial source of funding through establishment
orities, and this situation should be avoided. of a for-profit subsidiary. Detoxification pro-
Diversification of funding sources should be a grams in particular, as opposed to some other
major goal for detoxification programs. areas of substance abuse treatment, may be
attractive candidates for private financing
Usually, each funding stream has different because of their potential to serve privately
approval and reporting requirements. insured and self-pay patients. However,
Because of this, any new or existing detoxifi- acceptance of private capital usually carries
cation program requires a fairly sophisticated with it requirements for rapid growth in rev-
management and accounting system to meet
148 Chapter 6
more intensive review than admissions to or be channeled through regional or county
non–facility-based detoxification programs. intermediary agencies. Services may be paid
Program planners should consider carefully for through grants, contracts, fee-for-service,
all alternatives; decisions concerning affilia- and/or managed care arrangements. The
tion with a hospital or pursuit of a facility Children’s Health Act of 2000 mandated a
license have far-reaching financial and politi- gradual transition from SAPT Block Grants
cal ramifications and should be made with as to Performance Partnership Grants (PPGs).
much information as possible. Providers should follow developments
through their SSA, which include
Following is a discussion of the key funding
• Changes in reimbursement. Treatment
streams and resources that are available for
purchasing systems may evolve over time;
programs providing detoxification services.
managed care arrangements and require-
ments are increasingly common.
SAPT Block Grant • Performance outcome data. In accordance
The Substance Abuse Prevention and with Federal legislation, PPGs eventually
Treatment (SAPT) Block Grant program is will replace SAPT Block Grants and will
the cornerstone of Federal funding for sub- provide more flexibility for States as well as
stance abuse treatment and detoxification require more accountability based on out-
programs. These funds are sent to the State’s come and other performance data. The
Single State Agency (SSA) for substance Center for Substance Abuse Treatment
abuse for distribution to counties, municipali- (CSAT) and the States are establishing per-
ties, and designated programs. Some of the formance outcome measures for funding
funds are subject to required set-asides for programs under the block grants. All data
special populations. Each program should for core measures are collected from States
check to see if the clients it intends to serve receiving PPG dollars.
are eligible for block grant funding, either for
set-asides or for other funds. Each State Medicaid
maintains its own criteria for eligibility and Medicaid, administered by the Centers for
the criteria and definitions vary greatly Medicare and Medicaid Services (CMS) in
among States. Multistate providers will need conjunction with the States, provides finan-
to check specifically in each State in which cial assistance to States to pay for medical
they operate. care of specifically defined eligible persons.
The Substance Abuse and Mental Health Medicaid is being used by many States as a
Services Administration (SAMHSA) provides vehicle for experimentation with public sector
funding for substance abuse treatment and managed care in an effort to expand medical
prevention through the block grants as well as coverage to the uninsured. About 2 percent of
a large variety of other mechanisms, includ- total Medicaid expenditures nationally are for
ing both discretionary grants and contracts. substance abuse treatment services (Mark et
A portion of the SAMHSA Web site is devoted al. 2003a) but Medicaid supports about 20
to various funding opportunities. (See percent of national expenditures for sub-
www.samhsa.gov/budget/index.aspx.) stance abuse services (Coffey et al. 2001). The
level of expenditure varies greatly by State.
The most recent available data indicate that Medicaid is an entitlement program with sev-
the SAPT Block Grant accounts for approxi- eral distinct eligible groups: low-income chil-
mately 40 percent of public funds nationally dren, pregnant women, the elderly, and peo-
expended for prevention and treatment of ple who are blind or disabled, all or some of
substance abuse (U.S. Department of Health whom can be enrolled in a detoxification pro-
and Human Services 2003). Funds from the gram population. Some substance abuse
block grant may come directly from the SSA treatment programs will want to target pro-
150 Chapter 6
Medicaid link to bursed under Part B are required to pay 50
percent of Medicare-approved amounts. For
Supplemental Security more information, contact the Social Security
Income Administration, Medicare provider enroll-
Supplemental Security Income (SSI) is a pro- ment department, State Medicare services, or
gram financed through general tax revenues. see www.cms.hhs.gov/home/medicare.asp.
SSI recipients are one of the mandated popu-
lations for Medicaid, but specific provisions
vary by State. SSI disability benefits are
Medicare link to Social
payable to adults or children who are blind Security Disability Insurance
or have certain other disabilities that make it The Social Security Administration provides
impossible for them to work, who have limit- Social Security Disability Insurance (SSDI) to
ed income and resources, who meet the living individuals and certain members of their fam-
arrangement requirements, and who are oth- ily if they have
erwise eligible. Congress has excluded a pri- worked long enough
mary diagnosis of substance abuse as a quali- and paid Social Medicaid supports
fying disability under the Social Security Security taxes.
Administration’s programs, but if there is Recipients of SSDI
another primary disability that qualifies the
about 20 percent
benefits are covered
person for SSI, a secondary substance abuse by Medicare follow-
diagnosis remains acceptable. Many SSI ing a 2-year waiting
and Medicare
recipients with a mental disorder diagnosis period. SSDI is a
have a co-occurring substance abuse program financed supports about
diagnosis. with Social Security
taxes paid by work- 8 percent
ers, employers, and
Medicare self-employed per- of national
Medicare provides coverage to individuals sons. In order to be
over age 65, people under the age of 65 with eligible for a Social expenditures for
certified disabilities, and people with end- Security benefit, the
stage renal disease. Medicare supports about worker must earn substance abuse
8 percent of national expenditures for sub- sufficient credits
stance abuse treatment services. Medicare based on taxable
may provide Part A coverage to clients in treatment
work. Disability
detoxification programs that are based in hos- benefits are payable
pitals certified by Medicare. However, detoxi- to disabled workers, services.
fication programs that provide only a struc- disabled widow(er)s,
tured environment, socialization, and/or or adults disabled
vocational rehabilitation are not covered by since childhood, who are otherwise eligible. A
Medicare. Medicare imposes very strict substance abuse diagnosis was excluded by
review requirements for detoxification pro- Congress as a qualifying disability for SSDI,
grams based in hospitals and detoxification but a secondary substance abuse diagnosis is
programs that are considered to be partial acceptable if the person is qualified by anoth-
hospitalization programs, and for patients in er primary diagnosis, such as mental illness,
those detoxification programs. Alternatively, which often co-occurs. For more information
Medicare may provide Part B coverage to see the Social Security Administration’s Web
clients in detoxification programs with site at www.ssa.gov/dibplan/index.htm.
Medicare-certified medical practitioners;
however, clients whose services are reim-
152 Chapter 6
ries. Medically necessary treatment of sub- Development Boards, and similar bodies at
stance abuse is a covered benefit; beneficiaries the State and community levels. Although
are entitled to three substance use disorder States may not use TANF funds for “medi-
treatment benefit periods in their lifetimes. For cal” services, States have considerable lati-
more information see http://www.va.gov/hac/ tude in the definition of “medical,” and
forbeneficiaries/champva/champva.asp. have used TANF funds to support the fol-
lowing substance abuse treatment services:
Social Services screening/assessment, detoxification, outpa-
Funding for substance abuse treatment, tient treatment, non-hospital residential
which may include detoxification services, treatment, case management, education/
also may be available through arrangements prevention, housing, employment services,
with agencies funded by the U.S. Depart- and monitoring (Rubinstein 2002). Even if
ments of Labor, Housing and Urban these funds are not available for substance
Development (HUD), and Education (ED). abuse treatment in a State or program, the
Some Federal sources of funding for sub- program’s clients may be able to access this
stance abuse treatment under these programs source of assistance for employment train-
may prohibit use of funds for “medical” ser- ing, child care, and other support needs.
vices. However, services performed by those For more information on TANF, see
not in the medical profession (e.g., coun- www.acf.hhs.gov/programs/ofa/.
selors, technicians, social workers, psycholo- • Social Services Block Grant. Under Title
gists) and services not provided in a hospital XX of the Social Security Act, the
or clinic (including 24-hour care programs) Administration for Children and Families
may be considered nonmedical. The precise provides a block grant to each State for the
definition of “medical” under some of these purpose of furnishing social services. Funds
Federal programs may be determined by each may not be used for medical services
State individually, so administrators need to (except initial detoxification of an individu-
check with their State authorities to deter- al who is alcohol or drug dependent). In
mine exactly which services may be funded 2002, these funds provided close to $8 mil-
through these sources. Even if funding for lion for substance abuse treatment in 14
detoxification services is not available States (Administration for Children and
through these programs, programs may be Families 2002).
able to link their clients to them for support • Public housing. HUD funds substance
for services that enable them to initiate and abuse treatment of public housing residents
complete treatment successfully. Oppor- under the Public Housing Drug Elimination
tunities include the following: Program. HUD awards grants to public
• Temporary Assistance to Needy Families housing authorities, tribes, or tribally des-
(TANF). Under the TANF programs, each ignated housing entities to fund treatment.
State receives a Federal block grant to fund Funds are channeled to local public housing
treatment for eligible unemployed persons authorities, which contract with service
and their children, usually women with providers. In addition, special housing pro-
dependent children. Services that overcome grams are available for people who are
barriers to employment (e.g., substance homeless and have substance use disorders.
abuse treatment) are eligible for formula For more information see www.hud.gov.
grants—with one quarter of the money allo- • Vocational rehabilitation. Federal ED
cated to local communities through a com- funds support services that help people with
petitive grant process. The funding chan- disabilities participate in the workforce.
nels vary by State. Funds may be directed Treatment of substance use disorders is eli-
through Private Industry Councils, gible for funding. Funds are channeled to
Workforce Investment Boards, Workforce
154 Chapter 6
County and local efits offered by their health plans are inade-
quate.
governments
• Contracts with EAPs. Some employers have
County and local governments often contract EAPs that can provide direct service con-
for the delivery of substance abuse treatment tracts for a particular detoxification pro-
services using locally available funds. The gram.
annual availability of these funds depends in
part on State fiscal conditions.
Contributions
By developing relationships with people in the
Schools community, an administrator can find new
Local public schools may be a source of fund- sources for support of capital and operations.
ing for assessments; however, they rarely pay Even if a source is reluctant to provide funds to
for ongoing treatment. Some services may be support treatment
reimbursable under the special entitlements for services directly,
children with disabilities. other aspects of pro-
gram development, Many public and
organizational
Private Payors growth, and opera- private benefit
Private sources of revenue include a range of tions or equipment
entities from large MCOs to local or self- may be eligible for plans still classify
insured national employers. Most health support. A variety of
plans offered by large employers operate support may be detoxification as a
under managed care arrangements. available from
Sometimes, a health plan may cover some sources in the com- medical rather
substance abuse treatments under the mental munity, ranging from
health benefit portion of their plan; others financial support to
than a substance
may provide coverage through the medical donations of time,
component. In many cases, substance abuse expertise, used or
treatment benefits, when offered, are provid- low-cost furniture abuse treatment
ed through Managed Behavioral Healthcare and equipment, and
Organizations (MBHOs) (see “Working In space for a variety of service.
Today’s Managed Care Environment,” p. activities. Some
157, for a more detailed discussion of man- potential sources
aged care arrangements). Because substance include
abuse coverage is a minor cost to employers, • Fundraisers. People who do fundraising
accounting for about 0.4 percent of the cost can help the program develop a campaign.
of health insurance overall (Schoenbaum et Many States and the District of Columbia
al. 1998), it may be difficult to get employers’ require that charitable organizations regis-
attention, despite the high profile that sub- ter and report to a governmental authority
stance abuse problems sometimes present. In before they solicit contributions in their
general, three broad categories of private jurisdiction (a list of State regulating
funding may be distinguished: authorities is available at
• Contracts with health plans, MCOs, and www.labyrinthinc.com/index.asp).
MBHOs. • Foundations and local charities. A pro-
• Direct service contracts with local employers. gram may qualify as a recipient of funds for
Local employers may contract directly with capital, operations, or other types of sup-
substance abuse services providers if the ben- port such as board development from foun-
156 Chapter 6
Where To Get Information on Grants
• SAMHSA provides information about the grants it provides at www.samhsa.gov/grants/index.html.
Information on grants throughout the Federal government is available from www.grants.gov.
• The Web site www.cybergrants.com provides information about corporate foundations.
• The National Center on Addiction and Substance Abuse at Columbia University’s Web site at
www.casacolumbia.org provides links to several helpful sites.
• The Substance Abuse Funding Week provides public and private funding announcements for alcohol,
tobacco, and drug abuse programs. It is available by subscription in print or on the Web at
www.cdpublications.com/pubs/.
• Several useful publications on grant seeking and grant writing can be ordered from www.grantsand-
funding.com.
• The Grantsmanship Center at www.tgci.com offers some useful information.
• The Non-Profit Resource Center, www.not-for-profit.org, has information on a variety of funding
sources.
158 Chapter 6
does not meet criteria for medical necessity, it electronic data interchange with network
is likely to be denied and referred to a higher providers to facilitate claims submission.
level clinician for review, delaying approval
and payment. It makes sense to obtain each
MCO’s protocols, as well as any specific Elements of Financial Risk in
arrangements and benefit plans for customers Managed Care Contracts
whose employees or enrollees are in the
detoxification program’s client population. Cost of services
Case management programs operated in the To assess and negotiate a managed care con-
private sector often are utilization review tract and to monitor a program’s perfor-
programs rather than the clinical case man- mance under that contract, it is imperative to
agement programs typical in the public sec- know what it costs the detoxification program
tor. Moreover, the process of case manage- to provide each unit of service that is pro-
ment in the private sector often differs from duced. The cost of services includes staff time
the one found in traditional public sector spent with clients, administrative time spent
mental health or substance abuse treatment on meetings and paperwork, and capital and
agencies. Instead, it primarily involves tele- operating expenses. Only when the actual cost
phone contact, usually with a nurse, in high- of delivering a unit of a particular service is
risk or high-cost cases. Case management known can an agency negotiate a reasonable
usually is not performed onsite or in person rate for specific services when negotiating
in MCOs unless under contract to a public contracts and a fiscally prudent arrangement.
agency that requires this. If a detoxification Determining the cost of services often entails
program client has a public sector and a man- many challenges but is absolutely essential in
aged care case manager, the detoxification the current environment of accountability.
program will have to interact with both to See the text box on page 160 for a list of
obtain initial and continuing approvals of resources from the literature. Following are
treatment in what is called a case or utiliza- the recognized but evolving cost methodolo-
tion management program. gies developed specifically for substance
abuse services:
In general, programs will be required to
• The first systematic cost data collection
obtain utilization management approval
method, the Drug Abuse Treatment Cost
and/or case management approval for any
Analysis Program (DATCAP) (French 2003a,
proposed treatment plan before they can bill
b), was developed in the early 1990s by
the MCO. Programs will have to bear the cost
economists at Research Triangle Institute
of pursuing denials and requesting exceptions
(French et al. 1997). The Treatment Services
as well. The more the program’s staff can
Review used with DATCAP provides unit ser-
develop a relationship with the MCO’s utiliza-
vice costs (French et al. 2000).
tion management and case management staff,
the more they will learn about the internal • The Uniform System of Accounting and
criteria and protocols that drive approval or Cost Reporting for Substance Abuse
denial decisions and the more latitude they Treatment Providers is a cost estimation
will have to request special arrangements for method developed about the same time by
a particular client. Most MCOs and MBHOs CSAT (1998d).
have Web sites with provider portals. Once a • Another estimation approach has been
program identifies the name of the managed developed by Yates (1996, 1999): the
care plan from which payment is to be Cost–Procedure–Process–Outcome
requested staff should be sure to check its Analysis.
Web site. Some managed care plans offer • Anderson and colleagues (1998) have devel-
oped a cost of service methodology.
160 Chapter 6
• The Substance Abuse Services Cost Analysis For more information on managed care pur-
Program (Zarkin et al. 2004) is an emerging chasing and negotiation from the perspective
treatment services cost estimation method. of a purchaser, see TAP 22, Contracting for
• Variants of these methods have been applied Managed Substance Abuse and Mental Health
to several treatment studies (Flynn et al. Services: A Guide for Public Purchasers
2003; Koenig et al. 1999; Mojtabai and (CSAT 1998c).
Zivin 2003).
vices, and the qualifications and standards fication benefits may be considered either
they must meet so that the MCO can modify medical or behavioral benefits.
its policies appropriately. MCOs often are
more willing to contract with organizations In addition to the credentials of the staff and
that have a facility license from their State practitioners, the program itself may have to
than with individual substance abuse treat- be accredited by one of the major national
ment providers who may not possess creden- healthcare accrediting organizations. These
tials that meet the MCO’s licensure criteria. include the Commission on Accreditation of
Rehabilitation Facilities (CARF;
Many managed care plans have separate www.carf.org), the National Committee for
provider networks for behavioral health ser- Quality Assurance (NCQA;
vices. It is important for detoxification www.ncqa.org/index.htm) and the Joint
providers to participate in both medical and Commission on Accreditation of Healthcare
behavioral health networks, given that detoxi- Organizations (JCAHO; www.jcaho.org/). In
general, accreditation from CARF is consid-
162 Chapter 6
Figure 6-1 (continued)
Financial Arrangements for Providers
Capitation Agreement. A managed care company The two critical elements are the per member/per
may establish a stipulated dollar amount to cover month (pm/pm) rate and the utilization rate. If
treatment costs for a group of people using one many more people than are predicted require
per-person rate for everyone, which is the MCO’s treatment, the provider may not be able to cover
capitation rate. The MCO may then subcapitate a service delivery costs, much less make a profit/sur-
stipulated dollar amount to a treatment provider plus. The key is to have reliable information on
or organization, and the MCO and the treatment the historical use rates of a given managed care
provider negotiate an agreement in which the plan’s enrollees. If the provider bears in mind
provider is paid a fixed amount per subscriber these caveats, this regular, guaranteed payment
per month, rather than billing on a fee-for-service can be an excellent arrangement but carries with it
basis. The provider agrees to provide all or some the risks of both “overutilization” (when com-
of the treatment services for an expected number pared to the assumption used in developing the
of managed care “covered lives” (e.g., for 100,000 rate) and the need for a greater intensity of treat-
subscribers). Usually only large service providers ment than the capitation rate can cover. In some
have the assets and volume of services to engage in cases a program may want to accept a somewhat
capitated agreements. speculative capitation rate in order to join a panel
and then renegotiate that rate after the program
has collected data that show that it needs a higher
rate to cover its costs. In any case, it is crucial to
track actual dollars against the budget in real time
to avoid unexpected deficits.
Case Rate Agreement. The case rate is a fixed A case rate agreement removes some of the utiliza-
rate per client paid for delivery of specific ser- tion risk from the service provider. However, the
vices to specified types of consumers. For this fee, risk remains that clients will need services more
a provider such as a clinic covers all the services frequently or at higher levels than the case rate
that a client requires for a specific period. In covers. It is essential that programs track costs by
essence, the MCO is saying, “You provide the specific client in order to assess the adequacy of a
client what he needs from this set of services and I proposed case rate. However, it is a mistake to
will pay you this set amount.” What usually dis- consider a case rate as a cap for any specific
tinguishes case rate from capitation is that essen- patient; the goal is to ensure that the average cost
tially all of the case rate clients are anticipated to per case is lower than the negotiated case rate, not
be receiving some service; that is, at least case that the cost for each case is less than the negotiat-
management. Usually those receiving services ed rate. Once again, it is crucial to track actual
under capitation are a small minority of those average dollars per case against the contracted
covered. The case rate may be “risk-adjusted” to case rate in real time to avoid unexpected deficits.
compensate for the higher costs of serving clients
who predictably need more services than average.
164 Chapter 6
fied four major “domains” for substance from the formal treatment system and that the
abuse treatment measures: lack of substance abuse treatment following
1. Prevention/Education detoxification has been getting worse instead of
better (Mark et al. 2002). It is incumbent on
2. Recognition or Identification of Substance
providers of detoxification services to ensure
Abuse
that clients are linked to substance abuse treat-
3. Treatment ment following detoxification.
•Initiation of alcohol and other plan ser-
vices
Recordkeeping and manage-
•Linkage of detoxification and alcohol and
other drug plan services ment information systems
•Treatment engagement Like indemnity insurers, MCOs also require
detailed records of services provided to
•Use of interventions for family members
clients in order for
and significant others
them to pay for ser-
4. Maintenance of Treatment Effects vices received. The
These and other substance abuse performance
program’s account- Performance
ing system needs to
measures are now used in NCQA’s MCO
track counselors’ measurement is
accreditation process. The WCG and others
time spent on the
have defined a variety of such measures and
phone, on paper- becoming an
administrators should think of these measures
work, and directly
as ways to improve their own performance, as
with clients. Clinical
an essential element in the reporting system, increasingly
records should
and as a means for documenting success to
reflect accurately
their customers and other stakeholders. important compo-
the claims records
Performance measurement is becoming submitted to the
increasingly important outside of managed care MCO. Periodically, nent of managed
contracts as well as inside them. For example, payors and MCOs
as mentioned in the previous section on fund- may audit the clini- and fee-for-service
ing, SAMHSA began integrating performance cal records to
measurement into the SAPT Block Grant as of ensure that the ser- care in both the
fiscal year 2004. Each State will expect pro- vices billed for actu-
grams to understand and be able to measure ally have been pro- public and private
the required indicators accurately and in a vided. Failure to
timely way. adequately docu- sectors.
ment clinical ser-
One of the most important performance mea- vices can result in
sures in the future for detoxification programs nonpayment and
is likely to be linkages to substance abuse treat- put a contract in jeopardy. On the other
ment following detoxification (Mark et al. hand, individuals’ private information and
2002). Research has shown that patients who identity must be handled in a confidential
receive continuing care following detoxification manner pursuant to the Health Insurance
have better outcomes in terms of drug absti- Portability and Accountability Act (HIPAA)
nence and readmission rates than those who do and Federal confidentiality requirements for
not receive continuing care. This focus on link- persons with substance abuse (for more infor-
ages is a likely result of research indicating that mation on HIPAA see
many people who undergo detoxification do not www.hipaa.samhsa.gov).
receive subsequent substance abuse services
166 Chapter 6
and be well trained in conducting professional additional costs of these services need to be
relationships over the telephone, be familiar a component of a program’s rate and con-
with the criteria and protocols employed by tract. Having highly reputable, recognized,
the MCOs with which the program has con- and efficient providers is a major marketing
tracts, and have easy access to the multitude and regulatory advantage for the health
of clinical and service information required plan, as well as for the program. All these
by an MCO to help them complete a review program characteristics can be marketing
and authorize services. Excellent records are advantages. Programs also may apply to
essential. Program staff also should be famil- SAMHSA’s National Registry of Evidence-
iar with each MCO’s appeal or exceptions based Programs and Practices, which rec-
process for those occasions when the outcome ognizes model, effective, and promising pro-
of a first-level review is unsatisfactory. grams. Check SAMHSA’s Web site
(www.modelprograms.samhsa.gov) to find
Utilization management cannot proceed if the out how to apply for this status, which is a
program is not recognized as an eligible net- major achievement and marketing asset.
work provider; the program will have to
ensure that it is an accepted network • Serve specific populations. Providing low-
provider before it can participate in the uti- cost, high-quality treatment to a population
lization management or case management no other program serves (e.g., adolescents,
process. clients with HIV/AIDS, clients with co-
occurring mental disorders, pregnant
women, women with young children, clients
Strengthening the Financial who are deaf) also is a possible marketing
Base and Market Position of a advantage. Treating these clients can result
in client referrals from a larger geographic
Program area and multiple sources. Such clients may
The following strategies may strengthen the bring with them higher reimbursement rates
market position of a detoxification program to too, but this also may simply reflect higher
facilitate both larger numbers of patients and costs to provide care to the population.
greater revenues per patient: Using special capabilities to attract clients is
• Achieve recognition for the quality and a good idea, but not at the cost of inade-
effectiveness of services. If a program has quate payment for services.
a reputation for providing effective care, • Develop economies of scale. Adding clinic
then managed care enrollees and other sites or increasing the number of branch
potential clients will want to use it. A pro- clinics may permit spreading some fixed
gram can be of value to a client, a purchas- costs (e.g., management, information,
er, and/or an MCO if it can reduce repeated financial systems, executive staff) among a
detoxification, repeated treatment, and re- larger number of patients, thus driving
admissions, and thus manage unnecessary down a program’s per capita costs.
costs and interventions. Effective substance However, larger size requires greater
abuse treatment provided promptly may administrative coordination, which itself
reduce medical care and hospitalization can be costly.
costs in the long run. A program that effec- • Gain community visibility and support.
tively manages the care of high-utilization Having governmental, community agency
substance abuse clients by also providing executives, or political figures (e.g., the
psychiatric treatment, case management, mayor, council members) as board members
and housing support is a good candidate for raises the program’s profile in the commu-
“preferred” or “core” status with one or nity. Of course, programs should be sure to
several MCOs or MBHOs. Of course, the include board members who have specific
168 Chapter 6
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222 Appendix A
Appendix B: Common
Drug Intoxication
Signs and Withdrawal
Symptoms
Cocaine Alcohol Heroin Cannabis
(marijuana)
Intoxication
Withdrawal
Onset Depends upon 24–48 hours after Within 24 hours Some debate
type of cocaine blood alcohol level of last use about this, may be
used: for crack drops a few days
will begin within
hours of last use
223
Cocaine Alcohol Heroin Cannabis
(marijuana)
224 Appendix B
Appendix C: Screening
and Assessment
Instruments
Please note that this list of screening and assessment instruments has
been divided into two sections. The first section comprises those instru-
ments used for patients with suspected alcohol abuse or dependence
only; the second lists instruments used to screen and assess for abuse of
or dependence on any substances. Thus those tools that screen for all
substances of abuse are listed in section II.
Groups with whom this instrument has been used: Adults, particular-
ly primary care, emergency room, surgery, and psychiatric patients;
DWI offenders; offenders in court, jail, and prison; enlisted men in
the armed forces; workers receiving help from employee assistance
programs and in industrial settings.
225
Norms: Yes, heavy drinkers and people with Administrator training and qualifications: No
alcohol use disorders training required.
226 Appendix C
Clinical Institute Withdrawal Norms: N/A
Assessment (CIWA-Ar) Format: Consists of 25 questions
Purpose: Converts DSM-III-R items into
Administration time: Ten minutes
scores to track severity of withdrawal; mea-
sures severity of alcohol withdrawal. Scoring time: Five minutes
Clinical utility: Aid to adjustment of care Computer scoring? No
related to withdrawal severity.
Administrator training and qualifications: No
Groups with whom this instrument has been training required.
used: Adults
Fee for use: Fee for a copy, no fee for use
Norms: N/A
Available from: Can be downloaded from
Format: A 10-item scale for clinical quantifi- Project Cork Web site: http://www.project-
cation of the severity of the alcohol withdraw- cork.org/clinical_tools/index.html
al syndrome.
Addiction Severity Index (ASI) Clinical utility: The CSSA is able to predict a
patient’s response to treatment and could be
Purpose: The ASI is most useful as a general
used to identify patients at greater risk for
intake screening tool. It effectively assesses a
treatment failure so that these patients could
client’s status in several areas, and the com-
be targeted for additional interventions. This
posite score measures how a client’s need for
instrument could also be used to evaluate the
treatment changes over time.
effectiveness of medications intended to treat
Clinical utility: The ASI has been used exten- cocaine abstinence symptoms.
sively for treatment planning and outcome
Groups with whom this instrument has been
evaluation. Outcome evaluation packages for
used: Adults
individual programs or for treatment systems
are available. Norms: N/A
Groups with whom this instrument has been Format: Eighteen items
used: Designed for adults of both sexes who
are not intoxicated (on illicit drugs or alcohol) Administration time: Less than 10 minutes
when interviewed. It is also available in
Spanish. Scoring time: N/A
Norms: The ASI has been used with males Computer scoring? No
and females with substance use disorders in Administrator training and qualifications:
both inpatient and outpatient settings. Requires little training; clinician-adminis-
Format: Structured interview tered
Administration time: Fifty minutes to 1 hour Available from: Kampman, K.M., Volpicelli,
J.R., McGinnis, D.E., Alterman, A.I.,
Scoring time: Five minutes for severity rating Weinrieb, R.M., D’Angelo, L., and
Epperson, L.E. Reliability and validity of the
Computer scoring? Yes
228 Appendix C
Cocaine Selective Severity Assessment. Format: A psychiatric interview form in
Addictive Behaviors 23(4):449–461, 1998. which diagnosis can be made by the examiner
asking a series of approximately 10 questions
of a client.
Objective Opiate Withdrawal
Scale (OOWS) Administration time: Administration of Axis I
and Axis II batteries may require more than 2
Purpose: Used to record symptoms of opiate hours each for patients with multiple diag-
withdrawal. noses. The Psychoactive Substance Use
Clinical utility: Allows staff to share informa- Disorders module may be administered by
tion about a client’s withdrawal, especially itself in 30 to 60 minutes.
objective signs observed by staff. Scoring time: Approximately 10 minutes
Groups with whom this instrument has been Computer scoring? No. Diagnosis can be
used: Adults made by the examiner after the interview.
Norms: N/A Administrator training and qualifications:
Format: Thirteen manifestations of with- Designed for use by a trained clinical evalua-
drawal; observer scores tor at the master’s or doctoral level, although
in research settings it has been used by bach-
Computer scoring? No elor’s level technicians with extensive train-
ing.
Administrator training and qualifications:
Staff must be familiar with withdrawal signs Fee for use: Yes
(e.g., registered nurse, physician) or trained.
Available from:
Available from: Handelsman, L., Cochrane, American Psychiatric Publishing, Inc.
K.J., Aronson, M.J., Ness, R., Rubinstein, 1400 K Street, N.W.
K.J., and Kanof, P.D. Two new rating scales Washington, DC 20005
for opiate withdrawal. American Journal of www.appi.org/
Alcohol Abuse. 13:293–308, 1987.
Stages of Change Readiness
Structured Clinical Interview and Treatment Eagerness
for DSM-IV Disorders (SCID) Scale (SOCRATES)
Purpose: Obtains Axis I and II diagnoses Purpose: Designed to assess client motivation
using the DSM-IV diagnostic criteria for to change drinking- or drug-related behavior.
enabling the interviewer to either rule out or Consists of five scales: precontemplation, con-
to establish a diagnosis of “drug abuse” or templation, determination, action, and main-
“drug dependence” and/or “alcohol abuse” or tenance. Separate versions are available for
“alcohol dependence.” alcohol and illicit drug use.
Clinical utility: A psychiatric interview Clinical utility: The SOCRATES can assist
clinicians with necessary information about
Groups with whom this instrument has been
client motivation for change, an important
used: Psychiatric, medical, or community-
predictor of treatment compliance and out-
based normal adults.
come, and aid in treatment planning.
Norms: No
Groups with whom this instrument has been
used: Adults
230 Appendix C
Appendix D:
Resource Panel
Brad Austin
Public Health Advisor
Division of State and Community Assistance PPG Program Branch
Center for Substance Abuse Treatment
Rockville, Maryland
Christina Currier
Public Health Analyst
Practice Improvement Branch
Division of Services Improvement
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
Herman Diesenhaus
Public Health Analyst
Scientific Analysis Branch
Office of Evaluation, Scientific Analysis and Synthesis
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Rockville, Maryland
231
Robert Lubran, M.S., M.P.A. Dennis Scurry, M.D.
Director Chief Medical Officer
Division of Pharmacologic Therapies Addiction of Prevention and Recovery
Center for Substance Abuse Treatment Administration
Substance Abuse and Mental Health Government of the District of Columbia
Services Administration Department of Health
Rockville, Maryland Washington, DC
232 Appendix D
Appendix E:
Field Reviewers
Karen C.O. Batia, M.A., Ph.D.
Senior Director
Mental Health and Addiction Services
Heartland Health Outreach
Chicago, Illinois
Patricia T. Bowman
Probation Counselor
Fairfax Alcohol Safety Action Program
Fairfax, Virginia
233
David A. Chiriboga, Ph.D. Robert Holden, M.A.
Professor Program Director
Department of Aging and Mental Health Partners in Drug Abuse Rehabilitation
Florida Mental Health Institute Counseling
University of South Florida Washington, DC
Tampa, Florida
Kyle M. Kampman, M.D.
Carol J. Colleran, CAP, ICADC Associate Professor of Psychiatry
Director of Primary Programs Medical Director
Center of Recovery for Older Adults Treatment Research Center
Hanley-Hazelden Center University of Pennsylvania
West Palm Beach, Florida Philadelphia, Pennsylvania
234 Appendix E
Jay Renaud Leslie R. Steve, M.A.
Member/Editor Native American Coordinator
J & M Reports Center for the Application of Substance
Guidepoints: Acupuncture in Recovery Abuse Technologies
Vancouver, Washington University of Nevada
Reno, Nevada
Joseph P. Reoux, M.D.
Assistant Professor Richard T. Suchinsky, M.D.
Department of Psychiatry and Behavioral Associate Chief for Addictive Disorders and
Sciences Psychiatric Rehabilitation
VA Puget Sound Health Care System Mental Health and Behavioral Sciences
University of Washington School of Services
Medicine Department of Veterans Affairs
Seattle, Washington Washington, DC
238 Index
H linkages
hallucinogens, 98 to followup medical care, 45
hepatitis, and GGT levels, 51 to ongoing psychiatric services, 44
Hispanics/Latinos, 117 to treatment and maintenance activities, 42
history of detoxification services, 2–3
HIV/AIDS, 134 M
detoxification as a means to inhibit spread malnutrition, 28
of, 3 managed care
homeless patients, 43 accreditation, 161–162
contracts, 158–159
I financial risk in, 159–161
incarcerated persons, 118–119 performance measurement, 164–165
Indian Health Service, 152 recordkeeping, 165–166
infectious disease, 26–27, 132–134 marijuana, 95
inhalant/solvent withdrawal and pregnant women, 109
management with medication, 83 market position, strengthening, 167–168
management without medication, 82 MCV levels, 51
medical complications of, 82 Medicaid, 149–150
patient care and comfort, 83–84 medically monitored inpatient detoxification, 17
signs and symptoms, 82 medical model of detoxification, 3
inhalants/solvents, commonly abused, 83–84 Medicare, 151
inpatient detoxification programs, versus methadone
outpatient programs, 20, 21 detoxification, 72
instruments, for dependence and withdrawal, 49 and opioid withdrawal, 69–70
intensive outpatient programs, 18–19 and pregnant women, 106
interventions motivational enhancements, 34
Community Reinforcement and Family
Training, 34 N
Johnson Intervention, 35 nicotine, 84–85
intoxication, signs and symptoms, 52, 53 assessing severity of dependence, 86–87
Fagerstrom Test for Nicotine Dependence, 87
J Glover-Nilsson Smoking Behavioral
Johnson Intervention, 35 Questionnaire, 88
Joint Commission on Accreditation of and pregnant women, 108–109
Healthcare Organizations, 17, 27 Treating Tobacco Use and Dependence:
Clinical Practice Guidelines, 90, 93
nicotine replacement therapy, 91–92
K combining, 93–94
ketamine, 100–101 and pregnant women, 109
kindling effect, 54, 56 nicotine withdrawal, 86
effects of abstinence on blood levels of
L psychiatric medications, 90
least restrictive care, 12 interventions, 90–91, 91
levels of care, 39 management with medication, 91–94
acute care inpatient settings, 20 management without medication, 89–90
Adult Detoxification, 13 medical complications of, 87–89
ambulatory detoxification, 14 patient care and comfort, 94
clinically managed residential signs and symptoms, 85–86, 89
detoxification, 17 nutrition
intensive outpatient programs, 18–19 deficits, 29–30
medically monitored inpatient evaluation, 28–29
detoxification, 17
urgent care facilities and ERs, 16
Index 239
O public housing, 153
office-based detoxification. See detoxification, public intoxication, prior to 1970s, 2–3
outpatient
older adults, 109–110 R
opioid withdrawal rapid detoxification, 73
and buprenorphine, 71–72 recordkeeping, 165–166
and clonidine, 70–71 referral sources, 146
management with medication, 68–69 Rehabilitation Act of 1973, 110
management without medication, 68 reimbursement systems, 8
and methadone, 69–70 relapse
signs and symptoms, 66–68, 67 chronic, 33
outpatient programs, versus inpatient prevention, 62–63
programs, 20, 21 research funding, 156
rohypnol, 101
P Ryan White CARE Act, 154
parents, 31
partial hospitalization programs. See intensive S
outpatient programs scope of this TIP, 2
patient care and comfort, 66, 73–74 sedative-hypnotics, and phenobarbital
anabolic steroid withdrawal, 97 withdrawal equivalents, 78
inhalant/solvent withdrawal, 83–84 seizures, 63–66
nicotine withdrawal, 94 alcohol withdrawal, 64–65, 130
stimulant withdrawal, 81 what to do in the event of, 65
patient education, 33 self-pay patients, 156
Patient Placement Criteria, ASAM, 12–13, 39 service costs, resources on, 160
performance measurement, 164–165 service delivery, pitfalls of, 8
pharmacotherapy social detoxification, 3, 17, 55–57
and anxiety disorders, 140–141 Social Security Disability Insurance, 151
and bipolar disorders, 142–143 social services, 153–154
and depressive disorders, 141–142 Social Services Block Grant, 153
nonnicotine, 92–93 solvents, and pregnant women, 108
phenobarbital withdrawal stabilization, definition of, 4
and benzodiazepine, 77 staffing issues
and sedative-hypnotics, 78 acute care inpatient settings, 20
physicians, and preparing patients to enter inpatient detoxification programs, 18
detoxification, 13 intensive outpatient programs, 19
placement matching, challenges to, 11–12 in outpatient detoxification, 14
polydrug abuse, 101–102 stages of change, 35–37, 36
prioritizing substances of abuse, 102–103 State Children’s Health Insurance Program, 152
pregnant women, 43, 105–106 steroids, anabolic, 96
and alcohol, 106 stimulants, 76
and marijuana, 109 and pregnant women, 108
and nicotine, 108–109 stimulant withdrawal
and opioids, 106–108 management with medication, 81
and solvents, 108 management without medication, 80
and stimulants, 108 medical complications of, 80, 81
principles for care during detoxification, 24 patient care and comfort, 81
Provider’s Introduction to Substance Abuse symptoms, 79–80
Treatment for Lesbian, Gay, Bisexual, substance
and Transgender Individuals, A, 118 changing patterns of use, 3
psychiatric services, linkages to, 44 definition of, 5
psychosocial evaluation domains, 25 dependence, chronic, 45
psychotic disorders, 143 -induced psychiatric conditions, 139
240 Index
intoxication, definition of, 5 Substance Abuse Among Older Adults (TIP 26),
-related disorder, definition of, 5 110
withdrawal, definition of, 5 Substance Abuse: Clinical Issues in Intensive
substance abuse epidemiology, 146–147 Outpatient Treatment (in development), 19
Substance Abuse Prevention and Treatment Substance Abuse Treatment: Addressing the
Block Grant, 149 Specific Needs of Women (in development),
substance abuse treatment 39, 106, 108, 109
as distinct from detoxification, 4 Substance Abuse Treatment and Domestic
funding issues, 147–148, 155, 156, 157, Violence (TIP 25), 32
162–163 Substance Abuse Treatment for Adults in the
linkage with detoxification, 8 Criminal Justice System (TIP 44), 119, 154
suicide, 27 Substance Abuse Treatment for Persons With
Supplemental Security Income, 151 Child Abuse and Neglect Issues (TIP 36), 44
support systems, 33–34 Substance Abuse Treatment for Persons With
symptom-triggered benzodiazepine therapy, Co-Occurring Disorders (TIP 42), 27, 45, 93,
58–59 112, 121, 137
Substance Abuse Treatment for Persons With
T HIV/AIDS (TIP 37), 134
tapering dosages, benzodiazepine, 59 Substance Abuse Treatment: Men’s Issues (in
Temporary Assistance to Needy Families, 153 development), 39
THC abstinence syndrome, 95 Substance Use Disorder Treatment for People
therapeutic alliance, 37–38 With Physical and Cognitive Disabilities (TIP
and clinician characteristics, 38 29), 44, 110
TIPs cited Treatment of Adolescents With Substance Use
Clinical Guidelines for the Use of Disorders (TIP 32), 31, 118
Buprenorphine in the Treatment of Opioid Tuberculosis Epidemic: Legal and Ethical Issues
Addiction (TIP 40), 71 for Alcohol and Other Drug Abuse
Combining Alcohol and Other Drug Abuse Treatment Providers, The (TIP 18), 133
Treatment With Diversion for Juveniles in transtheoretical model. See stages of change
the Justice System (TIP 21), 119, 154 Treating Tobacco Use and Dependence: Clinical
Comprehensive Case Management for Practice Guidelines, 90, 93
Substance Abuse Treatment (TIP 27), 44, 45 treatment
Continuity of Offender Treatment for definition of, 5–6
Substance Use Disorders From Institution to initiation of, 42
Community (TIP 30), 119, 154 settings, 41
Detoxification From Alcohol and Other Drugs TRICARE, 152
(TIP 19), 1
Enhancing Motivation for Change in Substance U
Abuse Treatment (TIP 35), 34, 35 ultrarapid detoxification, 73
Improving Cultural Competence in Substance Uniform Alcoholism and Intoxication Treatment
Abuse Treatment (in development), 7, 44, Act, 3
114, 116, 117 urgent care facilities, and ERs, 15
Medication-Assisted Treatment for Opioid urine drug screens, 50
Addiction in Opioid Treatment Programs utilization and case management, 166–167
(TIP 43), 58, 69, 107
Role and Current Status of Patient Placement
Criteria in the Treatment of Substance V
Use Disorders, The (TIP 13), 13, 41 violence, 27
Screening and Assessing Adolescents for domestic, 31
Substance Use Disorders (TIP 31), 31, 118 vocational rehabilitation, 153–154
Screening for Infectious Diseases Among
Substance Abusers (TIP 6), 132
Index 241
W National Institute on Drug Abuse, 156
Washington Circle Group, 4, 164 Patient Placement Criteria, ASAM, 166
Web sites public housing, 153
American Cancer Society, 94 Research Assistant, The, 156
American Lung Association, 94 Ryan White CARE Act, 154
Byrne Formula Grant Program, 154 SAMHSA funding opportunities, 149
children’s protective services, 154 Social Security Disability Insurance, 151
Civilian Health and Medical Program of the State Children’s Health Insurance Program,152
Veterans Administration, 152–153 Temporary Assistance to Needy Families, 153
Commission on Accreditation of TRICARE, 152
Rehabilitation Facilities, 17, 20, 21, 27, 162 vocational rehabilitation, 154
grant funding sources, 157 Washington Circle Group, 164
Health Insurance Portability and withdrawal, 24–26, 33. See also alcohol with-
Accountability Act, 165 drawal; anabolic steroid withdrawal; benzodi-
Indian Health Service, 152 azepine withdrawal; inhalant/solvent withdraw-
Joint Commission on Accreditation of al; nicotine withdrawal; opioid withdrawal;
Healthcare Organizations, 17, 20, 21, 27, 162 stimulant withdrawal
legal aspects of prescribing buprenorphine, 72 women, pregnant, 43, 105–106
Medicaid, 150 wraparound services, 43
Medicare, 151
model programs, 167 Z
National Committee for Quality Assurance, Zyban, 92
162
National Institute on Alcohol Abuse and
Alcoholism, 156
242 Index
CSAT TIPs and Publications Based on TIPs
What Is a TIP?
Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians,
researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treat-
ment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of the
Nation’s alcohol and drug abuse treatment service system.
TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 12 Combining Substance Abuse Treatment With
TIP 43 Intermediate Sanctions for Adults in the Criminal
Justice System—Replaced by TIP 44
TIP 2* Pregnant, Substance-Using Women— BKD107
Quick Guide for Clinicians QGCT02 TIP 13 Role and Current Status of Patient Placement
Criteria in the Treatment of Substance Use
KAP Keys for Clinicians KAPT02
Disorders—BKD161
TIP 3 Screening and Assessment of Alcohol- and Other Quick Guide for Clinicians QGCT13
Drug-Abusing Adolescents—Replaced by TIP 31 Quick Guide for Administrators QGAT13
KAP Keys for Clinicians KAPT13
TIP 4 Guidelines for the Treatment of Alcohol- and Other
Drug-Abusing Adolescents—Replaced by TIP 32 TIP 14 Developing State Outcomes Monitoring Systems for
Alcohol and Other Drug Abuse Treatment—BKD162
TIP 5 Improving Treatment for Drug-Exposed Infants—
BKD110 TIP 15 Treatment for HIV-Infected Alcohol and Other Drug
Abusers—Replaced by TIP 37
TIP 6 Screening for Infectious Diseases Among Substance
Abusers—BKD131 TIP 16 Alcohol and Other Drug Screening of Hospitalized
Quick Guide for Clinicians QGCT06 Trauma Patients—BKD164
KAP Keys for Clinicians KAPT06 Quick Guide for Clinicians QGCT16
KAP Keys for Clinicians KAPT16
TIP 7 Screening and Assessment for Alcohol and Other
Drug Abuse Among Adults in the Criminal Justice TIP 17 Planning for Alcohol and Other Drug Abuse
System—Replaced by TIP 44 Treatment for Adults in the Criminal Justice System—
Replaced by TIP 44
TIP 8* Intensive Outpatient Treatment for Alcohol and Other
Drug Abuse—BKD139 TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues
for Alcohol and Other Drug Abuse Treatment
TIP 9 Assessment and Treatment of Patients With Coexisting Providers—BKD173
Mental Illness and Alcohol and Other Drug Abuse— Quick Guide for Clinicians QGCT18
Replaced by TIP 42
KAP Keys for Clinicians KAPT18
TIP 10 Assessment and Treatment of Cocaine-Abusing TIP 19 Detoxification From Alcohol and Other Drugs—
Methadone-Maintained Patients—Replaced by TIP 43 Replaced by TIP 45
TIP 11 Simple Screening Instruments for Outreach for TIP 20 Matching Treatment to Patient Needs in Opioid
Alcohol and Other Drug Abuse and Infectious Substitution Therapy—Replaced by TIP 43
Diseases— BKD143
Quick Guide for Clinicians QGCT11
KAP Keys for Clinicians KAPT11
*Under revision
243
TIP 21 Combining Alcohol and Other Drug Abuse Treatment TIP 29 Substance Use Disorder Treatment for People With
With Diversion for Juveniles in the Justice System— Physical and Cognitive Disabilities—BKD288
BKD169 Quick Guide for Clinicians QGCT29
Quick Guide for Clinicians and Administrators Quick Guide for Administrators QGAT29
QGCA21
KAP Keys for Clinicians KAPT29
TIP 22 LAAM in the Treatment of Opiate Addiction—
Replaced by TIP 43 TIP 30 Continuity of Offender Treatment for Substance Use
Disorders From Institution to Community—BKD304
TIP 23 Treatment Drug Courts: Integrating Substance Abuse Quick Guide for Clinicians QGCT30
Treatment With Legal Case Processing—BKD205 KAP Keys for Clinicians KAPT30
Quick Guide for Administrators QGAT23
TIP 31 Screening and Assessing Adolescents for Substance
TIP 24 A Guide to Substance Abuse Services for Primary Use Disorders—BKD306
Care Clinicians—BKD234 See companion products for TIP 32.
Concise Desk Reference Guide BKD123
TIP 32 Treatment of Adolescents With Substance Use
Quick Guide for Clinicians QGCT24 Disorders—BKD307
KAP Keys for Clinicians KAPT24 Quick Guide for Clinicians QGC312
TIP 25 Substance Abuse Treatment and Domestic Violence— KAP Keys for Clinicians KAP312
BKD239
TIP 33 Treatment for Stimulant Use Disorders—BKD289
Linking Substance Abuse Treatment and
Domestic Violence Services: A Guide for Treatment Quick Guide for Clinicians QGCT33
Providers MS668 KAP Keys for Clinicians KAPT33
Linking Substance Abuse Treatment and Domestic
Violence Services: A Guide for Administrators MS667 TIP 34 Brief Interventions and Brief Therapies for Substance
Abuse—BKD341
Quick Guide for Clinicians QGCT25
Quick Guide for Clinicians QGCT34
KAP Keys for Clinicians KAPT25
KAP Keys for Clinicians KAPT34
TIP 26 Substance Abuse Among Older Adults— BKD250
TIP 35 Enhancing Motivation for Change in Substance Abuse
Substance Abuse Among Older Adults: A Guide
Treatment—BKD342
for Treatment Providers MS669
Quick Guide for Clinicians QGCT35
Substance Abuse Among Older Adults: A Guide
for Social Service Providers MS670 KAP Keys for Clinicians KAPT35
Substance Abuse Among Older Adults:
TIP 36 Substance Abuse Treatment for Persons With Child
Physician’s Guide MS671
Abuse and Neglect Issues—BKD343
Quick Guide for Clinicians QGCT26
Quick Guide for Clinicians QGCT36
KAP Keys for Clinicians KAPT26
KAP Keys for Clinicians KAPT36
TIP 27 Comprehensive Case Management for Substance Helping Yourself Heal: A Recovering Woman’s Guide
Abuse Treatment—BKD251 to Coping With Childhood Abuse Issues—PHD981
Case Management for Substance Abuse Treatment: A Available in Spanish: PHD981S
Guide for Treatment Providers MS673 Helping Yourself Heal: A Recovering Man’s Guide to
Case Management for Substance Abuse Treatment: A Coping With the Effects of Childhood Abuse—HD1059
Guide for Administrators MS672 Available in Spanish: PHD1059S
Quick Guide for Clinicians QGCT27
TIP 37 Substance Abuse Treatment for Persons With
Quick Guide for Administrators QGAT27
HIV/AIDS—BKD359
TIP 28 Naltrexone and Alcoholism Treatment—BKD268 Fact Sheet MS676
Naltrexone and Alcoholism Treatment: Physician’s Quick Guide for Clinicians MS678
Guide MS674 KAP Keys for Clinicians KAPT37
Quick Guide for Clinicians QGCT28
KAP Keys for Clinicians KAPT28
244
*Under revision
TIP 38 Integrating Substance Abuse Treatment and TIP 43 Medication-Assisted Treatment for Opioid Addiction
Vocational Services—BKD381 in Opioid Treatment Programs—BKD524
Quick Guide for Clinicians QGCT38 Quick Guide for Clinicians QGCT43
Quick Guide for Administrators QGAT38 KAP Keys for Clinicians KAPT43
KAP Keys for Clinicians KAPT38
TIP 44 Substance Abuse Treatment for Adults in the Criminal
TIP 39 Substance Abuse Treatment and Family Therapy— Justice System—BKD526
BKD504 Quick Guide for Clinicians QGCT44
Quick Guide for Clinicians QGCT39 KAP Keys for Clinicians KAPT44
Quick Guide for Administrators QGAT39
TIP 45 Detoxification and Substance Abuse Treatment—
TIP 40 Clinical Guidelines for the Use of Buprenorphine in BKD541
the Treatment of Opioid Addiction—BKD500 Quick Guide for Clinicians QGCT45
Quick Guide for Physicians QGPT40 KAP Keys for Clinicians KAPT45
KAP Keys for Physicians KAPT40 Quick Guide for Administrators QGAT45
245
Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health Services
Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT)
Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below.
*Under revision
+QG = Quick Guide; KK = KAP Keys
Name:
Address:
City, State, Zip:
Phone and e-mail:
You can either mail this form or fax it to (301) 468-6433. Publications also can be ordered by calling SAMHSA’s NCADI at
(800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
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FOLD
Detoxification and
Substance Abuse Treatment
Collateral Products
Based on TIP 45
Quick Guide for Clinicians
KAP Keys for Clinicians