**KAP Keys**

**For Clinicians**

**Based on TIP 45**

***Detoxification and Substance Abuse Treatment***

**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 45 and are designed
to meet the needs of the busy clinician for concise, easily accessed
"how-to" information.

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

**TIP 33**: *Treatment for Stimulant Use Disorders* **BKD289**

**TIP 35**: *Enhancing Motivation for Change in Substance Abuse
Treatment* **BKD342**

**TIP 40**: *Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction* **BKD500**

**TIP 43**: *Medication-Assisted Treatment for Opioid Addiction in
Opioid Treatment Programs* **BKD524**

**Symptoms and Signs of Conditions That Require Immediate Medical
Attention 1**

-   Change in mental status

-   Increasing anxiety and panic

-   Hallucinations

-   Seizures

-   Insomnia

-   Changes in responsiveness of pupils

-   Significant increases and/or decreases in blood pressure and heart
    rate

-   Upper and lower gastrointestinal bleeding

-   Abdominal pain

-   Temperature greater than 100.4° (these patients should be considered
    potentially infectious

-   Heightened deep tendon reflexes and ankle clonus, a reflex beating
    of the foot when pressed rostrally (i.e., toward the mouth of the
    patient), indicating profound central nervous system irritability
    and the potential for seizures

**Intoxication and Withdrawal from Cocaine, Methamphetamine and Other
Stimulants 2**

*Fast Facts:*

-   Cocaine and amphetamines are the most frequently abused central
    nervous system stimulants.

-   Stimulants are intensely rewarding and are actually
    self-administered by laboratory animals to the point of death

*Symptoms of Cocaine and Other Stimulant Intoxication*

-   Dilated pupils

-   Profuse sweating, often with chills

-   Elevated blood pressure

-   Elevated temperature

-   Increased heartbeat

-   Slowed heart action

-   Teeth grinding

-   Tremors

-   Seizures---mostly for cocaine users

*Withdrawal Symptoms of Cocaine and Other Stimulants*

-   Depression

-   Hypersomnia or Insomnia

-   Fatigue

-   Anxiety

-   Pychomotor retardation (slow reflexes)

-   Paranoia

-   Drug craving

*Management of Withdrawal from Cocaine, Methamphetamine, and Other
Stimulants*

-   No medication has been developed for the purpose of treating
    stimulant withdrawal.

-   The most effective means of treating stimulant withdrawal involves
    establishing a period of abstinence from these agents.

-   Stimulant withdrawal is not usually associated with medical
    complications.

-   Amantadine may help reduce cocaine use in patients with more severe
    withdrawal symptoms.

-   Modafinil, an anti-narcolepsy agent with stimulant-like action, is
    currently under investigation by one research group as a cocaine
    detoxification agent.

-   Antidepressants, such as selective serotonin reuptake inhibitors,
    can be prescribed for the depression that often accompanies
    methamphetamine or other amphetamine withdrawal.

> **Intoxication and Withdrawal from Alcohol 3**
>
> *Fast Facts:*

-   The clinical presentation of intoxication from alcohol varies widely
    depending in part on blood alcohol level and level of previously
    developed tolerance.

-   Since the elimination rate of alcohol from the body generally is
    10mg to 30mg percent per hour, the goals for the treatment of
    alcohol intoxication are to preserve respiration and cardiovascular
    function until alcohol levels fall into a safe range.

> *Symptoms of alcohol intoxication*

+--------------------------+-------------------------------------------+
| Blood alcohol level is   | -   Mood and behavioral changes           |
| 20mg-100mg percent       |                                           |
|                          | -   Reduced coordination                  |
|                          |                                           |
|                          | -   Impairment of ability to drive a car  |
|                          |     or operate machinery                  |
+--------------------------+-------------------------------------------+
| Blood alcohol level is   | -   Reduced coordination of most          |
| 101mg-200mg percent      |     activities                            |
|                          |                                           |
|                          | -   Speech impairment                     |
|                          |                                           |
|                          | -   Trouble walking                       |
|                          |                                           |
|                          | -   General impairment of                 |
|                          |     thinking/judgment                     |
+--------------------------+-------------------------------------------+
| Blood alcohol level is   | -   Marked impairment of thinking,        |
| 201mg-300mg percent      |     memory, and coordination              |
|                          |                                           |
|                          | -   Marked reduction in level of          |
|                          |     alertness                             |
|                          |                                           |
|                          | -   Memory blackouts                      |
|                          |                                           |
|                          | -   Nausea and vomiting                   |
+--------------------------+-------------------------------------------+
| Blood alcohol level is   | -   Worsening of above symptoms with      |
| 301mg-                   |     reduction of body temperature and     |
|                          |     blood pressure                        |
| 400mg percent            |                                           |
|                          | -   Excessive sleepiness                  |
|                          |                                           |
|                          | -   Amnesia                               |
|                          |                                           |
|                          | ```{=html}                                |
|                          | <!-- -->                                  |
|                          | ```                                       |
|                          | -   Nausea and vomiting                   |
+--------------------------+-------------------------------------------+
| Blood alcohol level is   | -   Difficulty waking the patient (coma)  |
| 401mg-800mg percent      |                                           |
|                          | -   Serious decreases in pulse,           |
|                          |     temperature, blood pressure, and rate |
|                          |     of breathing                          |
|                          |                                           |
|                          | -   Urinary and bowel incontinence        |
|                          |                                           |
|                          | -   Death                                 |
+--------------------------+-------------------------------------------+

> *Alcohol Withdrawal Symptoms*

-   Restlessness, irritability, anxiety, agitation

-   Anorexia, nausea, vomiting

-   Hallucinations (auditory, visual, or tactile)

-   Insomnia, intense dreaming, nightmares

-   Grand mal seizures

-   Hyperthermia

-   Increased sensitivity to sound, light, and tactile sensations

-   Delusions, usually of paranoid or persecutory varieties

-   Tremor, elevated heart rate, increased blood pressure

-   Poor concentration, impaired memory and judgment

-   Delirium/disorientation with regard to time, place, person, and
    situation; fluctuation in level of consciousness

> *Management of Withdrawal from Alcohol*

-   The course of alcohol withdrawal is unpredictable; it is hard to
    tell who will or will not experience life-threatening complications.

-   Deciding whether or not to use medical management for alcohol
    withdrawal requires that patients be separated into three groups:

1.  Clients who have a history of the most extreme forms of withdrawal,
    that of seizures and/or delirium. The medication treatment of this
    group should proceed as quickly as possible.

2.  Patients who are already in withdrawal and demonstrating moderate
    symptoms of withdrawal also require immediate medication.

3.  The third group includes patients who may still be intoxicated, or
    who have, at the time of admission, been abstinent for only a few
    hours and have not developed signs or symptoms of withdrawal. A
    decision regarding medication treatment for this group should be
    based on advancing age, number of years with alcohol dependence, and
    the number of previously treated or untreated severe withdrawals.

    -   The major goal of medical detoxification is to avoid seizures
        and a special state of delirium called delirium tremens (DTs)
        with aggressive use of the primary detoxification drug.

    -   Several medications used in the treatment of alcohol withdrawal
        are: benzodiazepine, barbiturates, anticonvulsants, beta
        blockers/alpha adrenergic agonists, antipsychotics, relapse
        prevention agents.

> **Intoxication and Withdrawal from Heroin and Other Opioids 4**
>
> *Fast Facts:*

-   Opioids are highly addicting.

-   Chronic use of opioids leads to withdrawal symptoms that, although
    not medically dangerous, can be highly unpleasant and produce
    intense discomfort.

> *Signs and Symptoms of Opioid Intoxication*

  ----------------------------------- -----------------------------------
  **Opioid Intoxication Signs**       **Opioid Intoxication Symptoms**

  Slow pulse                          Euphoria

  Low body temperature                Pain-killing effects

  Pinpoint pupils                     Calmness

  Slurred speech                      

  Low blood pressure                  

  Sedation                            

  Slowed movement                     

  Head nodding                        

  **Opioid Withdrawal Signs**         **Opioid Withdrawal Symptoms**

  Fast Pulse                          Abdominal cramps

  High body temperature               Vomiting

  Enlarged pupils                     Nausea

  Sweating                            Diarrhea

  Increased respiratory rate          Anxiety

  Yawning                             Bone and muscle pain

  High blood pressure                 

  Insomnia                            

  Abnormally heightened reflexes      

  Gooseflesh                          

  Tearing (as in crying)              

  Runny noose                         
  ----------------------------------- -----------------------------------

> *Management of Withdrawal from Heroin and Other Opioids*

-   It is not recommended that clinicians attempt to manage significant
    opioid withdrawal symptoms without effective detoxification agents.

-   The management of opioid withdrawal with medication is most commonly
    achieved through the use of methadone.

-   The initial dose requirements for methadone are determined by
    estimating the amount of opioid use and gauging the patient's
    response to administered methadone.

-   Methadone can be given once daily and generally tapered over 3 to 5
    days in 5 to 10mg daily reductions.

-   Clonidine can also be used to treat opioid withdrawal, but it is
    usually ineffective for common symptoms such as insomnia, muscle
    aches, and drug craving.

> **Intoxication and Withdrawal from Cannabis (Marijuana) 5**
>
> *Fast Facts:*

-   Marijuana and hashish are the two substances containing THC
    (delta-9-tetrahydrocannabinol) commonly used today.

-   The THC abstinence syndrome usually starts within 24 hours of
    cessation. The amount of THC that one needs to ingest in order to
    experience withdrawal is unknown. It can be assumed, however, that
    heavier consumption is more likely to be associated with withdrawal
    symptoms.

> *Symptoms of Cannabis Intoxication*

-   Impaired short term memory

-   Impaired attention, judgment, and other cognitive functions

-   Impaired coordination and balance

-   Increased heart rate

> *Cannabis Withdrawal Symptoms*

-   Anxiety

-   Restlessness

-   Irritability

-   Sleep disturbance

-   Change in appetite

-   Tremor

-   Sweating

-   Elevated heart rate

-   Nausea, vomiting, diarrhea

> *Management of Withdrawal From Cannabis*

-   There are no medical complications of withdrawal from THC, and
    medication is generally not required to manage withdrawal.

-   Screening the patient for suicidal ideation or other mental health
    problems is warranted.

-   The patient should be encouraged to maintain abstinence from THC as
    well as other addictive substances.

**Intoxication and Withdrawal From Other Drugs: An Overview 6**

> *Nicotine*
>
> Two issues regarding tobacco smoking merit consideration by staff of
> substance abuse detoxification programs. The first is the program
> management's desire to establish a smoke-free treatment environment to
> comply with workplace ordinances and to safeguard the health and
> comfort of patients from exposure to second hand smoke. The second
> issue is the patient's dependence on nicotine as a drug of abuse.
>
> *Drugs That Do Not Produce a Withdrawal Syndrome*
>
> Chronic use of PCP can cause toxic psychosis that takes days or weeks
> to clear; however, PCP does not have a withdrawal system. LSD and
> ecstasy do not produce physical dependence.
>
> *Polydrug Use*
>
> People who abuse substances rarely use just one substance. Typical
> combinations and preferred modes of treatment are as follows:

-   Alcohol and stimulant: Treat alcohol abuse.

-   Cocaine and opiate: Treat opiate dependence

-   Cocaine and amphetamine: No detoxification protocol is knows.

**Initial Evaluation Domains 7**

  ----------------------------------- -----------------------------------
  **Biomedical**                      

  **General Health History**          What is the patient's medical and
                                      surgical history? Are there any
                                      psychiatric 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 w/    This will ascertain the patient's
  Neurological Exam**                 general health and identify any
                                      medical or psychiatric disorders of
                                      immediate concern.

  **Temperature, Pulse, Blood         These are important indicators and
  Pressure**                          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   This should include the course and
  or Detoxification**                 number of previous withdrawals, as
                                      well as any complications that may
                                      have occurred.

  **Psychosocial**                    

  **Demographic Features**            Gather information on gender, age,
                                      ethnicity, culture, language, and
                                      educational level.

  **Living Conditions**               Is the patient homeless or living
                                      in a shelter? What is the living
                                      situation? Are significant 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 violence?

  **Transportation**                  Does the patient have adequate
                                      means to get to appointments? Do
                                      other arrangements 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     Does the client have disabilities
  Disabilities                        that require consideration?
  ----------------------------------- -----------------------------------

**Recommended Areas for Assessment to Determine Appropriate
Rehabilitation Plans** **8**

  -------------------------- --------------------------------------------
  **Domain**                 **Description**

  Medical Conditions and     Infectious illnesses, chronic illnesses
  Complications              requiring intensive or specialized
                             treatment, pregnancy, and chronic pain

  Motivation/Readiness to    Degree to which the client acknowledges that
  Change                     substance use behaviors are a problem and is
                             willing to confront them honestly

  Physical, Sensory, or      Physical conditions that may require
  Mobility Limitations       specially designed facilities or staffing

  Relapse History and        Historical relapse patterns, periods of
  Potential                  abstinence, and predictors of abstinence;
                             client awareness of relapse triggers and
                             craving

  Substance Abuse/Dependence Frequency, amount, and duration of use;
                             chronicity of problems; indicators of abuse
                             or dependence

  Developmental and          Ability to participate in confrontational
  Cognitive Issues           treatment settings, and benefit from
                             cognitive interventions and group therapy

  Family and Social Support  Degree of support from family and
                             significant others, substance-free friends,
                             involvement in support groups

  Co-Occurring Psychiatric   Other psychiatric symptoms that are likely
  Disorders                  to complicate the treatment of the 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 complicate
                             rehabilitation

  Treatment History          Prior successful and unsuccessful
                             rehabilitation experiences that might
                             influence 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

  Language                   Language or speech issues that make it
                             difficult to communicate, or require an
                             interpreter familiar with substance abuse
  -------------------------- --------------------------------------------

**Commonly Abused Inhalants 9**

  -------------------- ---------------------- ----------------------------
  **Type**             **Examples**           **Chemicals in Inhalant**

  Adhesives            Airplane glue          Toluene, ethyl acetate

                       Other glues            Hexane, toluene, methyl
                                              chloride, acetone, methyl
                                              ethyl ketone, methyl butyl
                                              ketone

                       Special cements        Trichloroethylene,
                                              tetrachloroethylene

  Aerosols             Spray paint            Butane, propane (U.S.),
                                              fluorocarbons, toluene,
                                              hydrocarbons, "Texas shoe
                                              shine" (a spray containing
                                              toluene)

                       Hair spray             Butane, propane (U.S.),
                                              chlorofluorocarbons (CFCs)

                       Deodorant; air         Butane, propane (U.S.), CFCs
                       freshener              

                       Analgesic spray        CFCs

                       Asthma spray           CFCs

                       Fabric spray           Butane, trichloroethane

                       PC cleaner             Dimethyl ether,
                                              hydrofluorocarbons

  Anesthetics          Gaseous                Nitrous oxide

                       Liquid                 Halothane, enflurane

                       Local                  Ethyl chloride

  Cleaning agents      Dry cleaning           Tetrachloroethylene,
                                              trichloroethane

                       Spot remover           Xylene, petroleum
                                              distillates,
                                              chlorohydrocarbons

                       Degreaser              Tetrachloroethylene,
                                              trichloroethane,
                                              trichloroethylene

  Solvents and gases   Nail polish remover    Acetone, ethyl acetate

                       Paint remover          Toluene, methylene chloride,
                                              methanol acetone, ethyl
                                              acetate

                       Paint thinner          Petroleum distillates,
                                              esters, acetone

                       Correction fluid and   Trichloroethylene,
                       thinner                trichloroethane

                       Fuel gas               Butane, isopropane

                       Lighter                Butane, isopropane

                       Fire extinguisher      Bromochlorodifluoromethane

  Food products        Whipped cream          Nitrous oxide

                       Whippets               Nitrous oxide

  "Room odorizers"     Locker Room, Rush,     Isoamyl, isobutyl, isopropyl
                       Poppers                or butyl nitrate (now
                                              legal), cyclohexyl

  *Source:* Balster,                          
  R.L. The                                    
  pharmacology of                             
  inhalants. In:                              
  Graham, A.W.,                               
  Schultz, T.K.,                              
  Mayo-Smith, M.F.,                           
  Ries, R.K., and                             
  Wilford, B.B., eds.                         
  *Principles of                              
  Addiction Medicine*.                        
  3d ed. Chevy Chase,                         
  MD: American Society                        
  of Addiction                                
  Medicine, 2003. pp.                         
  295--304.                                   
  -------------------- ---------------------- ----------------------------

*Management of withdrawal from Inhalants*

-   It is crucial to provide the patient with an environment of safety
    that removes him or her from access to inhalants.

-   Patients presenting with only inhalant withdrawal are unusual;
    clinicians should promptly ascertain if the patient has been abusing
    other substances and proceed with appropriate detoxification as
    clinically indicated.

-   No systemic detoxification protocol has been established for
    inhalant abuse.

**Ordering Information**

**TIP 45**

***Detoxification and Substance Abuse Treatment***

+-----------------------------------------------------------------------+
| **Three Ways to Obtain FREE Copies**                                  |
|                                                                       |
| **of All TIPs 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.  You can also access TIPs online at:                               |
|     [www.kap.samhsa.gov](http://www.kap.samhsa.gov/).                 |
+-----------------------------------------------------------------------+

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Department of Health and Human Services.