Knowledge Application Program

KAP Keys for Clinicians

Based on TIP 47

*Substance Abuse: Clinical Issues in Intensive Outpatient Treatment*

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

[www.samhsa.gov](http://www.samhsa.gov/)

Contents

Introduction

Other Treatment Improvement Protocols

Key 1. Typical Sequence of Topics Addressed in Psychoeducational Groups

Key 2. Case Management Services

Key 3. A Protocol for Ambulatory Detoxification and Disulfiram Induction

Key 4. Effective Interviewing Techniques

Key 5. ABC Model for Psychiatric Screening

Key 6. Mild Withdrawal Symptoms for Four Drug Classes That Can Be
Managed in Partial Hospitalization or Day Treatment Detoxification
(Level II.5)

Key 7. A Treatment Calendar for Family Members

Key 8. A Relapse Prevention Quiz

Key 9. Urine Toxicology Detection Periods for Different Substances

Key 10. Effectiveness of Drug Detection Methods That Use Different
Biological Products

Ordering Information

Introduction

KAP Keys were developed to accompany the Treatment Improvement Protocol
(TIP) Series published by the Center for Substance Abuse Treatment
(CSAT), Substance Abuse and Mental Health Services Administration
(SAMHSA). These KAP Keys are based entirely on TIP 47 and are designed
to meet the needs of the busy clinician for concise, easily accessible
"how to" information.

For more information on the topics in these KAP Keys, readers are
referred to TIP 47.

Other Treatment Improvement Protocols (TIPs) that are relevant to these
KAP Keys:

TIP 25: *Substance Abuse Treatment and Domestic Violence* (1997) BKD239

TIP 31: *Screening and Assessing Adolescents for Substance Use
Disorders* (1999) BKD306

TIP 32: *Treatment of Adolescents With Substance Use Disorders* (1999)
BKD307

TIP 39: *Substance Abuse Treatment and Family Therapy* (2004) BKD504

TIP 41: *Substance Abuse Treatment: Group Therapy* (2004) BKD507

TIP 45: *Detoxification and Substance Abuse Treatment* (2006) BKD541

TIP 46: *Substance Abuse: Administrative Issues in Outpatient Treatment*
(2006) BKD545

Key 1

Typical Sequence of Topics Addressed in Psychoeducational Groups

Treatment Engagement

-   Understanding motivation and committing to treatment

-   Counteracting ambivalence and denial

-   Determining the seriousness of the drug or alcohol problem

-   Conducting self-assessment, setting goals, and self-monitoring
    progress

-   Overcoming common barriers to treatment

Early Recovery

-   Learning about biopsychosocial disease and recovery processes

-   Understanding the effects of specific drugs and alcohol on the brain
    and body

-   Placing symptoms of substance use disorders in the context of other
    behavioral health problems

-   Learning about early and protracted withdrawal symptoms for specific
    drugs and alcohol

-   Knowing the stages of recovery and the client's place in the
    continuum of care

-   Learning strategies for quitting and finding the motivation to stop

-   Minimizing risks of HIV/AIDS, hepatitis C, and sexually transmitted
    diseases (STDs)

-   Identifying high-risk situations that are cues or triggers to
    substance use: people, places, and things

-   Identifying peer pressures and compulsive sexual behavior as
    triggers

-   Understanding cravings and urges, learning to extinguish thoughts
    about substance use, and coping with cravings

-   Structuring personal time

-   Coping with high-risk situations

-   Understanding abstinence and the use of prescription and
    over-the-counter medications

-   Understanding the goals and practices of various 12-Step or other
    mutual-help groups

-   Identifying and using positive support networks

Maintenance and Continuing Care

-   Understanding the relapse process and common warning signs

-   Identifying tools to prevent relapse

-   Developing personal relapse plans

-   Counteracting euphoria and the desire to test control

-   Improving coping and stress management skills

-   Learning anger management and relaxation techniques

-   Enhancing self-efficacy for handling risky situations

-   Responding safely to slips and avoiding escalation

-   Finding recovery resources

-   Structuring leisure time and finding recreational activities

-   Knowing the importance of personal health: diet, exercise, hygiene,
    and checkups

-   Taking a personal inventory

-   Handling shame, guilt, depression, and anxiety

-   Understanding family dynamics: enabling and sabotaging behaviors

-   Rebuilding personal relationships

-   Understanding sexual dysfunction and healthy sexual behavior

-   Developing educational and vocational skills

-   Learning daily living skills: money management, housing, and legal
    assistance

-   Embracing spirituality and recovery and finding meaning in life

-   Recognizing grief and loss and the relationship to substance use

-   Learning about parenting: basic needs of children and their
    developmental stages and developmental tasks

-   Maintaining balance in life

See TIP 47, pages 32--34.

Key 2

Case Management Services

Functions

-   Provide a core set of social services that includes assessment,
    planning, linkage, monitoring, and advocacy.

-   Provide the client with a single contact person who is responsible
    for finding and mobilizing needed resources, negotiating formal
    systems, and bartering informally with other service providers to
    gain access to appropriate services.

-   Respond to client's needs, tailoring resources to the individual
    rather than fitting the client into existing services.

-   Intervene with many systems and providers on behalf of the client.

-   Operate in the community and transcend facility boundaries.

-   Focus on pragmatic, immediate ways to meet needs (e.g., clothing,
    shelter).

-   React sensitively and competently to clients' ethnic, gender, and
    cultural differences.

Models

-   Single agency model. Case managers personally establish
    relationships with counterparts in other agencies to find and access
    services for individual clients.

-   Informal partnership model. Staff members from several agencies link
    into collaborative teams or networks that consult about individual
    cases and share services.

-   Formal consortium model. Case managers and service providers are
    joined through written agreements or contracts that define roles,
    responsibilities, shared services, and costs. This model usually is
    organized by a lead agency that has primary responsibility and
    receives most or all of the funding.

See TIP 47, pages 38--40.

Key 3

A Protocol for Ambulatory Detoxification and Disulfiram Induction

*First day:* Chlordiazepoxide 50 mg hourly until anxiety is
relieved---50 mg to 300 mg

*When BAL = 0:* Disulfiram 125 mg\*

*First night:* Chlordiazepoxide 50 mg at bedtime;^†^ repeat hourly x 2
until asleep (3 doses provided)

*Second day:* No medication

*Second night:* Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if
not asleep (2 doses provided)

*Third night:* Chlordiazepoxide 50 mg at bedtime; repeat in 1 hour if
not asleep (2 doses provided)

\*Disulfiram is dispensed only at the clinic.

^†^All unused chlordiazepoxide doses must be returned to the clinic the
following morning.

Source: G. Kolodner, M.D., personal communication, 2003.

See TIP 47, pages 56--57.

Key 4

Effective Interviewing Techniques

-   Begin with a brief overview of the topics to be covered, the
    expected duration of the interview, and confidentiality
    requirements.

-   Ask the least threatening questions first.

-   Listen attentively and reflectively. Restate what the individual
    said to determine the level of understanding. Provide enough time
    for the individual to express himself or herself.

-   Support self-efficacy by communicating that the individual can
    change, make autonomous decisions, and act in his or her best
    interests.

-   Affirm the strengths, and compliment the positive values of the
    client.

-   Explain everything that is happening or planned in treatment, and
    allow time for questions.

-   Ask open-ended questions that cannot be answered with a one-word
    response to encourage the individual to talk, describe feelings, and
    express opinions.

-   Convey empathy through voice tone, facial expression, and body
    language as well as with direct expressions of caring.

-   Observe the client for nonverbal expressions of feelings that may
    either be inconsistent with or confirm what the individual is
    saying.

-   Avoid argument, remain nonjudgmental, and adjust to any resistance.

-   Probe gently to clear up discrepancies and inconsistencies.

-   Be completely candid and honest.

-   Help the client move beyond anger, resentment, frustration, or
    defensiveness; even if the individual does not return, this single
    contact can be a constructive, positive influence.

See TIP 47, pages 61--63.

Key 5

ABC Model for Psychiatric Screening

Appearance, Alertness, Affect, and Anxiety

-   Appearance: How are general hygiene and dress?

-   Alertness: What is the level of consciousness? Confusion?

-   Affect: Are there signs of elation, anger, or depression in
    gestures, facial expression, and speech?

-   Anxiety: Is the person nervous, phobic, or panicky?

Behavior

-   Movements: Is the person hyperactive, hypoactive/subdued, abrupt,
    agitated, or calm?

-   Organization: Is the person coherent and goal oriented?

-   Purpose: Is behavior bizarre, dangerous, impulsive, belligerent, or
    uncooperative?

-   Speech: What are the rate, coherence, organization, content, and
    sound level?

Cognition

-   Orientation: To person, place, time, and condition

-   Calculation: Memory and capability to perform simple tasks

-   Reasoning: Insight, judgment, and problemsolving abilities

-   Coherence: Delusions, hallucinations, and incoherent thoughts

Source: Center for Substance Abuse Treatment. (1994). *Assessment and
Treatment of Patients With Coexisting Mental Illness and Alcohol and
Other Drug Abuse.* Treatment Improvement Protocol (TIP) Series 9 (DHHS
Publication No. SMA 94-2078.) Rockville, MD: Substance Abuse and Mental
Health Services Administration.

See TIP 47, pages 65--66.

Key 6

Mild Withdrawal Symptoms for Four Drug Classes That Can Be Managed in
Partial Hospitalization or Day Treatment Detoxification (Level II.5)

Alcohol. Mild withdrawal without need for treatment with
sedative-hypnotics; no hyperdynamic state; Clinical Institute Withdrawal
Assessment-Alcohol, Revised (CIWA-Ar) score of 8; no significant history
of morning drinking.

Sedative-hypnotics. Mild withdrawal with history of almost daily
sedative-hypnotic use; no hyperdynamic state; no need for treatment with
sedative-hypnotics; no complicating exacerbation of affective
disturbance; no dependence on other substances.

Opioids. Mild withdrawal in context of almost daily opioid use but no
need for substitute agonist therapy; withdrawal symptoms respond well to
symptomatic treatment; comfortable by the end of the day's monitoring.

Stimulants. Mild withdrawal involving lethargy, agitation, or
depression; the client has sufficient impulse control, coping skills, or
support to engage in treatment and to prevent immediate continued use.

Source: Mee-Lee, D., Shulman, G. D., Callahan, J. F., Fishman, M.,
Gastfriend D., Hartman, R., & Hunsicker, R. J. (Eds.). (2001). *Patient
Placement Criteria for the Treatment of Substance-Related Disorders:
Second Edition-Revised* (PPC-2R). Chevy Chase, MD: American Society of
Addiction Medicine.

See TIP 47, pages 70--72.

Key 7

A Treatment Calendar for Family Members

Beginning Stage: 1--5 Weeks

-   Commit to treatment.

-   Understand that a substance use disorder is a chronic illness.

-   Support abstinence.

-   Begin to identify and discontinue behaviors that support substance
    use.

-   Learn about the family support groups:

\- Al-Anon (www.al-anon.alateen.org)

> \- Nar-Anon (www.naranon.com)
>
> \- Families Anonymous
> ([www.familiesanonymous.org](http://www.familiesanonymous.org/)).

Middle Stage: 6--20 Weeks

-   Assess the relationship with the client.

-   Develop a realistic perspective on addiction-related behaviors so
    the family member remains involved with the client but establishes
    some protective personal distance.

-   Work to eliminate behaviors that encourage the client's substance
    use (i.e., enabling behaviors).

-   Move past behaviors that are primarily a response to the client's
    substance use (i.e., codependence).

-   Seek new ways to enrich the family member's life.

-   Begin practicing new communication methods.

Advanced Stage: 21+ Weeks

-   Work to develop a healthy, balanced lifestyle that supports the
    client and addresses personal needs.

-   Exercise patience with recovery.

-   Evaluate and accept changes, adaptations, and limitations.

Source: Matrix Center. (1989). *The Matrix Model of Outpatient Chemical
Dependency Treatment: Family Education Guidelines and Handouts.* Los
Angeles: The Matrix Center.

See TIP 47, pages 98--106.

Key 8

A Relapse Prevention Quiz

This quiz can be a tool to support and strengthen a client's readiness
to avoid relapse. Having senior members in a group answer the questions
reinforces their knowledge while they educate newer members in relapse
prevention skills.

-   What might you say to co-workers if they ask you to have a drink or
    get high with them?

-   Craving a drink or drug is quite natural for people who are
    dependent on alcohol or drugs. What three things can you do to get
    past the craving?

-   What are three common reasons for feeling that you don't belong in a
    support group such as Alcoholics Anonymous (AA) or Narcotics
    Anonymous (NA)?

-   What two things can you do if someone at an AA or NA meeting annoys
    you?

-   Why must recovery from your disease be your highest priority?

-   What three qualities should you look for in a sponsor?

-   Emotional discomfort takes a variety of forms. What are the three
    biggest problems for you? Anger, depression, self-pity, loneliness,
    boredom, worry, frustration, shame, guilt, or another emotion?

-   What three things can you do to handle each emotional discomfort you
    identified?

-   What are the key elements of an assertive response when offered
    alcohol or drugs?

-   Why is it important to avoid starting romantic relationships during
    early recovery?

See TIP 47, pages 117--119.

Key 9

Urine Toxicology Detection Periods for Different Substances

-   Amphetamines or methamphetamines: 2--4 days

-   Barbiturates

> \- Short-acting---Secobarbital: 1--2 days
>
> \- Long-acting---Pentobarbital: 2--4 days

-   Phenobarbital: 10--20 days

-   Benzodiazepines

\- Therapeutic dose: 3--7 days

\- Chronic dosing: Up to 30 days

-   Cocaine: 1--3 days

-   Cannabinoids

\- Casual use: 1--3 days

\- Daily use: 5--10 days

\- Chronic use: Up to 30 days

-   Ethanol (alcohol): 12--24 hours

-   Opioids (e.g., codeine, morphine): 1--3 days

-   Methadone: 2--4 days

-   Propoxyphene: 6--48 hours

-   Ecstasy/euphorics: 1--5 days

-   PCP

\- Acute use: 2--7 days

Chronic use: Up to 30 days

Copyright © 1999 by the American Psychological Association. Adapted with
permission. No further reproduction or distribution is permitted without
the written permission of the American Psychological Association.
(Preston, K. L., Silverman, K., & Cone, E. J. \[1999\]. Monitoring
cocaine use during contingency management interventions. In S. T.
Higgins & K. Silverman \[Eds.\], *Motivating Behavior Change Among
Illicit Drug Abusers* \[pp. 283--308\]. Washington, DC: American
Psychological Association.)

See TIP 47, pages 237--245.

Key 10

Effectiveness of Drug Detection Methods That Use Different Biological
Products

Body Product: Urine

Detection Time: 2--4 days

Major Advantages: Mature technique; established cutoffs for detecting
many drugs of abuse

Major Limitations: Detects only recent use; needs costly confirmation to
be accurate

Primary Use: Monitors recent drug use in many populations

Body Product: Breath (alcohol)

Detection Time: 12--24 hours

Major Advantages: Easy to use; readily available and well-established
method

Major Limitations: Short detection time

Primary Use: Confirms observed intoxication or impairment

Body Product: Saliva

Detection Time: 12--24 hours

Major Advantages: Easy to obtain samples; good correlation with blood
levels for some substances

Major Limitations: Very short detection time; new method; oral cavity is
contaminated easily

Primary Use: Links positive drug test to behavioral impairment and
intoxication

Body Product: Sweat

Detection Time: 1--4 weeks

Major Advantages: Cumulative measure; relatively tamper-proof collection
method

Major Limitations: High potential for contamination; new technique

Primary Use: Detects recent and less recent drug use

Body Product: Blood

Detection Time: 12--24 hours

Major Advantages: Accurate results; established method

Major Limitations: Invasive method; expensive; detects only current use
or intoxication

Primary Use: Detects drug effects on crashes, medical emergencies

Body Product: Hair

Detection Time: 4--6 months

Major Advantages: Measures long-term drug use; readily available
samples; accurate results

Major Limitations: New technique; costly and time-consuming; no
dose-response relation established

Primary Use: Confirms drug use in past 4 to 6 months; prevalence studies

Copyright © 1999 by the American Psychological Association. Adapted with
permission. No further reproduction or distribution is permitted without
the written permission of the American Psychological Association.
(Preston, K. L., Silverman, K., & Cone, E. J. \[1999\]. Monitoring
cocaine use during contingency management interventions. In S. T.
Higgins & K. Silverman \[Eds.\], *Motivating Behavior Change Among
Illicit Drug Abusers* \[p. 299\]. Washington, DC: American Psychological
Association.)

See TIP 47, pages 237--245.

Ordering Information

Three Ways to Obtain Free Copies of All TIP Products

1.  Call SAMHSA's National Clearinghouse for Alcohol and Drug
    Information (NCADI) at 800-729-6686, TDD (hearing impaired)
    800-487-4889.

2.  Visit NCADI's Web site at
    [www.ncadi.samhsa.gov](http://www.ncadi.samhsa.gov/).

3.  Access TIPs online at
    [www.kap.samhsa.gov](http://www.kap.samhsa.gov/).

Do not reproduce or distribute this publication for a fee without
specific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.

DHHS Publication No. (SMA) 07-4251

Printed 2007