**Number range CHAPTERContents**

Why a Quick Guide? 2

What is a TIP? 3

Introduction 4

Levels of Care and Patient Placement 9

Psychosocial and Biomedical Issues 11

Strategies for Engagement and

Retention 17

Referrals and Linkages 20

Biopsychosocial Screening and

Assessment 23

Detoxification Services for Specific

Substances of Abuse 26

**Quick Guide for Clinicians**

Based on TIP 45

*Detoxification and Substance Abuse Treatment*

**WHY A QUICK GUIDE?**

This Quick Guide was developed to accompany *Detoxification and
Substance Abuse Treatment*, Number 45 in the Treatment Improvement
Protocol (TIP) series published by the Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA). This Quick Guide is based entirely on TIP 45
and is designed to meet the needs of the busy clinician for concise,
easily accessed "how-to" information.

The Guide is divided into nine sections (see *Contents*) to help readers
quickly locate relevant material. For more information on the topics in
this Quick Guide, readers are referred to TIP 45.

Note: This Quick Guide cannot substitute for clinical guidance in the
management of detoxification. It is meant only as an abbreviated
overview of the general features of detoxification. The details required
for the clinical management of patients going through withdrawal are
dealt with more fully in TIP 45.

**WHAT IS A TIP?**

The TIP series has been in production since 1991. This series provides
the substance abuse treatment and related fields with consensus-based,
field-reviewed guidelines on substance abuse treatment topics of vital
current interest.

TIP 45, *Detoxification and Substance Abuse Treatment*

-   Provides clinicians with up-to-date information and expands on
    issues commonly encountered in the delivery of detoxification
    services.

-   Focuses on what the substance abuse treatment clinician needs to
    know and provides that information in an accessible manner.

*See the inside back cover for information on how to order TIPs and
other related products.*

**INTRODUCTION**

Prior to the 1970s, public intoxication was commonly treated as a
criminal offense. People arrested for it were held in "drunk tanks"
where they often underwent withdrawal with no medical intervention. As
society moved toward a more humanitarian view of people with substance
use disorders, several methods of detoxification evolved.

The "medical model" of detoxification is characterized by the use of
physicians and nursing staff and the administration of medication to
assist people through withdrawal safely. The "social model" relies more
on a supportive non-hospital environment than on medication to ease the
passage through withdrawal.

**Definitions**

*Detoxification* is a series of interventions aimed at managing acute
intoxication and withdrawal. It denotes a clearing of toxins from the
body of the patient who is acutely intoxicated and/or dependent on
substances of abuse. Detoxification seeks to minimize the physical harm
cause by the abuse of substances.

  -----------------------------------------------------------------------
  Detoxification alone is not sufficient in the treatment and
  rehabilitation of substance use disorders.

  -----------------------------------------------------------------------

*Evaluation* entails testing for the presence of substances of abuse in
the bloodstream, measuring their concentration, and screening for
co-occurring mental and physical conditions. Evaluation also includes a
comprehensive assessment of the patient's medical, psychological, and
social situation.

*Stabilization* includes the medical and psychosocial process of
assisting the patient through acute intoxication and withdrawal to the
attainment of a medically stable, fully supported, substance-free state.

*Fostering the patient's entry into treatment* involves preparing a
patient for entry into treatment by stressing the importance of
following through with a complete continuum of care.

**Guiding Principles/Assumptions**

The panel of experts who created TIP 45 agreed to the following
assumptions, which served as a basis for their work:

1\. Detoxification alone is not sufficient treatment for substance
dependence but is one part of a continuum of care for substance-related
disorders.

2\. The detoxification process consists of the following three
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. Placement should be appropriate to a
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 treatment program for substance use
disorders after detoxification.

6\. Ultimately, insurance coverage for the full range of detoxification
services and follow-up treatment services is cost effective. If
reimbursement systems do not provide payment for the complete
detoxification process, patients may be released prematurely, leading to
medically or socially unattended withdrawal.

7\. Patients seeking detoxification have diverse cultural and ethnic
backgrounds as well as unique health needs and life situations. Programs
offering detoxification services should be equipped to tailor treatment
to their client populations.

8\. A successful detoxification process can be measured, in part, by
whether an individual who is substance dependent enters, remains in, and
is compliant with the treatment protocol of a substance abuse
treatment/rehabilitation program after detoxification.

**Overarching Principles for Care During Detoxification Services**

-   Detoxification services do not offer a "cure" for substance use
    disorders; they are often a first step toward recovery and a "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 weakness.

-   Patients should be treated with respect and dignity at all times.

-   Patients should be treated in a nonjudgmental and supportive manner.

-   Services planning should be completed in partnership with the
    patient and his or her social support network, including family,
    significant others, or employers.

-   All health professionals involved in the care of the patient will
    maximize opportunities to promote rehabilitation and maintenance
    activities and to link the patient to appropriate substance abuse
    treatment immediately after the detoxification phase.

-   Active involvement of the family and other support systems, while
    respecting the patient's right to privacy and confidentiality, are
    to be encouraged.

-   Patients are treated with due consideration for individual
    background, culture, preferences, sexual orientation, disability,
    vulnerabilities, and strengths.

**LEVELS OF CARE AND PATIENT PLACEMENT**

In addition to the general placement criteria for the treatment of
substance-related disorders, the Patient Placement Criteria, Second
Edition, Revised (PPC-2R) of the American Society of Addiction Medicine
(ASAM) also indicates a second set of placement criteria, which are more
important for the purposes of TIP 45 and this Quick Guide---the five
"Adult Detoxification" placement levels of care within Dimension 1 (ASAM
2001). These "Adult Detoxification" levels of care are

1.  *Level I-D: Ambulatory Detoxification Without Extended Onsite
    Monitoring* (e.g., physician\'s office, home health care agency).
    This level of care is an organized outpatient service monitored at
    predetermined intervals.

2.  *Level II-D: Ambulatory Detoxification With Extended Onsite
    Monitoring* (e.g., day hospital service). This level of care is
    monitored by appropriately credentialed and licensed nurses.

3.  *Level III.2-D: Clinically Managed Residential Detoxification*
    (e.g., non-medical or social detoxification setting). This level
    emphasizes peer and social support and is intended for patients
    whose intoxication and/or withdrawal is sufficient to warrant
    24-hour support.

4.  *Level III.7-D: Medically Monitored Inpatient Detoxification* (e.g.,
    freestanding detoxification center). Unlike Level III.2.D, this
    level provides 24-hour medically supervised detoxification services.

5.  *Level IV-D: Medically Managed Intensive Inpatient Detoxification*
    (e.g., psychiatric hospital inpatient center). This level provides
    24-hour care in an acute care inpatient settings.

It is important to note that ASAM PPC-2R criteria are only guidelines,
and that there are no uniform protocols for determining which patients
are placed in which level of care. For further information on patient
placement, readers are advised to consult TIP 13, *The Role and Current
Status of Patient Placement Criteria in the Treatment of Substance Use
Disorders* (CSAT 1995).

**PSYCHOSOCIAL AND BIOMEDICAL ISSUES**

Detoxification presents an opportunity to intervene during a period of
crisis and to encourage a client to make changes in the direction of
health and recovery. Hence, a primary goal of the detoxification staff
should be to build a therapeutic alliance and motivate patients to enter
treatment. This process should begin as the patient is being medically
stabilized.

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

-   Change in mental status

-   Increasing anxiety

-   Hallucinations

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

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

-   Insomnia

-   Abdominal pain

-   Upper and lower gastrointestinal bleeding

-   Changes in responsiveness of pupils

-   Heightened deep tendon reflexes and ankle clonus, a reflex beating
    of the foot when pressed rostrally, indicating profound central
    nervous system irritability and the potential for seizures

**Immediate Mental Health Needs**

The following are mental health issues that require immediate attention:

*Suicide*

-   Patients receiving detoxification services should be evaluated for
    suicide risk.

-   During acute intoxication and withdrawal, it is important to provide
    an environment that minimizes opportunities for suicide attempts.

-   Frequent safety checks should be implemented.

-   Patients at risk for suicide should be placed in areas monitored by
    staff.

*Anger and aggression*

-   All patients who are intoxicated should be considered potentially
    violent.

-   Symptoms associated with increased risk for violence include
    hallucinations, paranoia, anxiety, and depression.

-   Physical restraint should be used as a last resort.

**Initial Biomedical and Psychosocial Evaluation Domains**

An initial evaluation will help detoxification staff foresee any
variables that might complicate withdrawal. The following is a list of
biomedical and psychosocial domains that can affect the stabilization of
the patient.

**Biomedical Domains**

-   *General health history*: What is the patient's medical and surgical
    history? Are there any psychiatric or medical conditions? Any known
    medication allergies? 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 medical or
    psychiatric disorders of immediate concern.

-   *Temperature, pulse, blood 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 were used
    and how frequently?

-   *Urine and toxicology screen for commonly abused substances*.

-   *Past substance abuse treatments or detoxification.*

**Psychosocial Domains**

-   *Demographic features*: Gather information on gender, age,
    ethnicity, culture, language and education level.

-   *Living conditions*: Is the patient homeless or living in a shelter?
    Are significant others in the home (and, if so, can they safely
    supervise)?

-   *Violence, suicide risk*: Is the patient aggressive, depressed, or
    hopeless? Is their 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 medication
    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 consideration?

**Considerations for Specific Populations**

*Adolescents*

-   Adolescents are more likely to drink large quantities of alcohol in
    a short period of time, making it important that staff be alert to
    escalating blood alcohol levels.

-   Adolescents are more likely to use drugs they cannot identify, to
    combine multiple substances with alcohol, to ingest unidentified
    substances, and to be unwilling to disclose drug use.

-   Asking open-ended questions and using street terminology for drugs
    can be helpful in both establishing rapport and in obtaining an
    accurate substance use history.

*Parents with dependent children*

-   It is of vital importance to ensure that the children of someone
    receiving detoxification services have a safe place to stay.

-   Working with patients to identify supportive family or friends may
    uncover temporary childcare resources.

-   A consult or referral to the treatment facility's social services
    while the patient is being detoxified is indicated when the care of
    children is uncertain.

*Victims of domestic violence*

-   Staff should know the signs of domestic violence and be prepared to
    follow procedures to ensure the safety of a patient.

-   Trained staff can help the victim create a long-term safety plan or
    at least make a proper referral.

-   All printed information about domestic violence should be disguised
    and none should be kept by the patient when leaving the safe
    facility.

-   It may be important that the abused person not be allowed to talk to
    the abuser while in detoxification.

*Culturally diverse patients*

-   Cultural sensitivity is tremendously important.

-   Expectations of detoxifications, feelings about the healthcare
    system in general, and social and community structures vary
    according to cultural backgrounds.

-   The practitioner should avoid defining the patients in terms of his
    culture; over- or under-emphasizing the patient's race or ethnicity
    can be detrimental.

-   For a list of questions that can guide a practitioner to better
    understand a patient's cultural frame work, see Figure 3-4 in TIP
    45.

**STRATEGIES FOR ENGAGEMENT AND RECOVERY**

It is essential that all clinicians offer hope and the expectation of
recovery. Throughout detoxification, staff should be unified in their
message that detoxification is only the beginning of the treatment
process and that rehabilitation and maintenance activities are critical
to sustained recovery.

**Educate the Patient on the Withdrawal Process**

-   During intoxication and withdrawal, it is useful to provide
    information on the typical withdrawal process based on the
    particular drug of abuse.

-   Providing information concerning withdrawal symptoms may reduce
    discomfort and the likelihood the individual will leave
    detoxification prematurely.

-   Settings that routinely encounter individuals in withdrawal should
    have written materials available on drug effects and withdrawal from
    specific drugs. This material should also be available for
    non-English-speaking patients.

-   Interventions that assist the client in identifying and managing
    urges to use also may be helpful in retaining the client in
    detoxification and ensuring the initiation of rehabilitation.

**Use Support Systems**

-   The use of client advocates to intervene with clients wishing to
    leave early often is an effective strategy for promoting retention.

-   Visitors should be instructed about the importance of supporting the
    individual in both detoxification and substance abuse treatment.

-   If available and if the patient is stable, he or she can attend
    onsite 12-Step or other support group meetings while receiving
    detoxification services.

**Maintain a Drug-Free Environment**

-   Maintaining a safe and drug-free environment is essential to
    retaining clients in detoxification.

-   Providers should be alert to drug-seeking behaviors.

-   Visiting areas should be easy for staff to monitor.

-   Explain to patients and visitors why substances are not allowed in
    the facility.

**Consider Alternative Approaches and Motivational Enhancement**

-   Although the effectiveness of alternative treatments in
    detoxification has not been validated in well-controlled clinical
    trials, an alternative therapy that brings patients into
    detoxification and keeps them there may have utility beyond the
    therapeutic value it may have.

-   Motivational enhancements are particularly well-suited to promoting
    initiation in rehabilitation and maintenance activities. For more
    information on enhancing motivation for change, see TIP 35,
    *Enhancing Motivation for Change in Substance Abuse Treatment*.

**Foster a Therapeutic Alliance**

-   A relationship between the clinician and patient that is supportive,
    empathic, and nonjudgmental is the hallmark of a strong therapeutic
    alliance.

-   Efforts to establish a therapeutic alliance should begin upon
    admission.

**\
**

**REFERRALS AND LINKAGES**

Once an individual passes through the most severe withdrawal symptoms
and is safe and medically stable, the focus of the psychosocial
intervention shifts toward preparing the patient for substance abuse
treatment. These interventions include

-   Assessment of the patient's characteristics, strengths, and
    vulnerabilities that will influence recommendations for substance
    abuse treatment.

-   Preparing the patient to participate in treatment.

-   Successfully linking the patient to treatment as well as other
    needed services and resources.

**Evaluation of the Patient's Rehabilitation Needs**

*The American Society of Addiction Medicine's Patient Placement
Criteria, Second Edition, Revised* (2001) provides a widely used model
for determining the level of rehabilitation services needed to address
substance-related disorders. The criteria used to determine the most
appropriate level of rehabilitation are based on six dimensions:

1.  Acute Intoxication and/or Withdrawal Potential

2.  Biomedical Conditions and Complications

3.  Emotional, Behavioral, or Cognitive Conditions or Complications

4.  Readiness to Change

5.  Relapse, Continued Use, or Continued Problem Potential

6.  Recovery/Living Environment

Detoxification programs should focus their evaluation on areas that are
essential to make an appropriate linkage to substance abuse treatment.
The following are recommended:

-   Medical conditions and complications

-   Motivation/readiness to change

-   Physical, sensory, or mobility limitations

-   Relapse history and potential

-   Substance abuse/dependence

-   Development and cognitive issues

-   Family and social support

-   Co-occurring psychiatric disorders

-   Dependent children

-   Trauma and violence

-   Treatment history

-   Cultural background

-   Strengths and resources

-   Language

**Providing Linkages to Treatment and Maintenance Activities**

Research indicates that patients are more likely to initiate and remain
in treatment if they believe the services will help them with specific
life problems. The following are strategies that detoxification
personnel can use with their patients to promote the initiation of
treatment:

-   Perform an assessment of urgency for treatment.

-   Reduce time between initial call and appointment.

-   Call to reschedule missed appointments.

-   Provide information about what to expect at the first session.

-   Provide information about confidentiality.

-   Offer tangible incentives such as the prospect of improved relations
    with family and friends and improved self-image.

-   Engage the support of family members.

-   Introduce the client to the counselor who will deliver
    rehabilitation services.

-   Offer services that address basic needs, such as housing,
    employment, and childcare.

**BIOPSYCHOSOCIAL SCREENING AND ASSESSMENT**

This section covers more complex psychosocial and biomedical assessments
that may occur after initial contact as an individual undergoes
detoxification. The following is a list of instruments useful in
characterizing the intensity of specific withdrawal states.

  ----------------------- ----------------------- -----------------------
  **Drug of Dependence**  **Instrument**          **Notes**

  Alcohol                 CIWA-Ar (not valid for  10 items, 2-5 minutes
                          decision-making with    to complete
                          history of serious      
                          alcohol withdrawal or   
                          when benzodiazepine     
                          dependent)              

  Cocaine                 CSSA                    18 items, 10 minutes to
                                                  complete

  Opioids                 SOWS                    16-item questionnaire

  Opioids                 OOWS                    Rater observes patient
                                                  for 10 minutes,
                                                  indicates if any of 13
                                                  manifestations of
                                                  withdrawal are present
  ----------------------- ----------------------- -----------------------

The CIWA-Ar is available for free from CSAT and is reprinted in TIP 24,
*A Guide to Substance Abuse Services for Primary Care Physicians*.
Appendix C of TIP 45 provides further information on how to acquire and
use the CSSA, SOWS, and OOWS.

**Biochemical Markers and Drug Testing**

Biochemical markers are laboratory tests that detect the presence or
absence of alcohol or other substances of abuse. Comprehensive medical
drug testing for specific substances may be able to identify recent use,
quantify the level of recent use, or may be able to quantify recent
cumulative use. Forensic or worksite drug testing should not be equated
to or confused with the more comprehensive range of sensitive tests
available for medical drug testing.

Medical drug testing and testing for biochemical markers are essential
components of a comprehensive clinical assessment.

Common use of biochemical markers and drug tests are:

1.  In the initial screening setting to support or refute other
    information that leads to proper diagnosis, assessment, and
    management.

2.  For forensic purposes.

3.  In detecting secret or hidden use of alcohol and other substances in
    therapeutic settings where abstinence, rehabilitation, and treatment
    are being promoted.

There are several different types of drug tests and biochemical markers:

-   Blood alcohol content

-   Breath alcohol levels

-   Urine drug screens (in addition to alcohol, urine drug screens can
    be effective for detecting benzodiazepines, barbiturates, cocaine,
    amphetamines, opioids, and PCP)

-   Gamma-glutamyltransferase (GGT)

-   Carbohydrate-deficient transferrin

-   Mean corpuscular volume (MCV)

-   Alcohol metabolites

-   Toxicological drug tests for general and specific opiates,
    stimulants, hallucinogens, benzodiazepines, barbiturates, marijuana,
    other controlled substances, and other drugs that are compounded
    with controlled substances (e.g., aspirin and acetaminophen).

**DETOXIFICATION SERVICES FOR SPECIFIC SUBST ANCES OF ABUSE**

**Alcohol Intoxication and Withdrawal**

The following symptoms of alcohol intoxication can vary greatly with the
patient's level of tolerance.

Blood alcohol level is 20-100mg percent

-   Mood and behavioral changes

-   Reduced coordination

-   Impairment of ability to drive a car or operate machinery

Blood alcohol level is 101-200mg percent

-   Reduced coordination of most activities

-   Speech impairment

-   Trouble walking

-   General impairment of thinking and judgment

Blood alcohol level is 201-300mg percent

-   Marked impairment of thinking, memory, and coordination

-   Marked reduction in level of alertness

-   Memory blackouts

-   Nausea and vomiting

Blood alcohol level is 301-400mg percent

-   Worsening of above symptoms with reduction of body temperature and
    blood pressure

-   Excessive sleepiness/comatose

-   Amnesia

-   Nausea and vomiting/aspiration

-   Death

Blood alcohol level is 401-800mg percent

-   Difficulty waking the patient (coma)

-   Serious decreases in pulse, temperature, blood pressure, and rate of
    breathing

-   Urinary and bowel incontinence

-   Death

The signs and symptoms of acute alcohol withdrawal generally start 6 to
24 hours after the patient takes his last drink. Acute withdrawal may
begin when the patient still has significant blood alcohol
concentrations. The signs and symptoms may include the following and are
highly variable:

-   Restlessness, irritability, anxiety, agitation

-   Anorexia, nausea, vomiting

-   Tremor, elevated heart rate, increased blood pressure

-   Insomnia, intense dreaming, nightmares

-   Poor concentration, impaired memory and judgment

-   Increased sensitivity to sound, light, and tactile sensations

-   Hallucinations (auditory, visual, or tactile)

-   Delusions, usually of paranoid or persecutory varieties

-   Grand mal seizures

-   Hyperthermia

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

*Management of alcohol withdrawal without medication*

-   Indications for the management of alcohol withdrawal without
    medication have not been established through scientific studies or
    evidence-based methods.

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

-   Positive aspects of the non-medication approach are that it is
    highly cost-effective and provides inexpensive access to
    detoxification for individuals seeking aid.

*Social detoxification*

Social detoxification programs are short-term, non-medical treatment
service for individuals with substance use disorders. A social
detoxification program offers room, board, and interpersonal support to
intoxicated individuals and individuals in substance use withdrawal.
Social detoxification programs vary widely in services offered, but
there should always be medical surveillance, including monitoring of
vital signs.

The TIP provides several guidelines for social detoxification programs:

-   Such programs should follow local governmental regulations regarding
    licensing and inspection.

-   It is highly desirable that individuals entering social
    detoxification be assessed by primary care practitioners with some
    substance abuse treatment experience.

-   An assessment should determine whether the patient is currently
    intoxicated and the degree of intoxication, the type of withdrawal
    syndrome, severity of the withdrawal, information regarding past
    withdrawals, and the presence of co-occurring psychiatric, medical,
    and surgical conditions that might require specialized care.

-   Particular attention should be paid to individuals who have
    undergone multiple withdrawals in the past and for whom each
    withdrawal appears to be worse than previous ones (the so the called
    "kindling effect"). Patients with a history of severe withdrawals
    are not good candidates for social detoxification.

-   All social detoxification programs should have personnel who are
    familiar with the features of substance use withdrawal, have
    training in basic life support, and have access to an emergency
    medical system that can provide transportation to emergency
    departments.

*Management of alcohol withdrawal with medications*

It is believed that only a minority of patients with alcoholism will go
into significant alcohol withdrawal requiring medication. Identifying
that small minority is sometimes problematic, but there are signs and
symptoms of impending problems that can alert the caretaker to seek
medical attention.

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. If
    there is an opportunity to observe the patient over the next 6 to 8
    hours, then it is possible to delay a decision regarding treatment
    and periodically reevaluate a client of this category.

*Benzodiazepine treatment for alcohol withdrawal*

These drugs remain the medication of choice in treating withdrawal from
alcohol. The early recognition of alcohol withdrawal and prompt
administration of a suitable benzodiazepine will prevent further
withdrawal reaction from proceeding to serious consequences.

-   *Loading dose of a benzodiazepine.* Administration of a metabolized
    benzodiazepine may be carried out every 1 to 2 hours until
    significant clinical improvement occurs or the patient becomes
    sedated. In general, patients with severe withdrawal may receive
    20mg of diazepam or 100mg of chlordiazepoxide every 2 to 3 hours
    until improvement or sedation prevails. The treatment staff should
    closely monitor blood pressure, pulse, and respiratory features.

-   *Symptom-triggered therapy*. Using the CIWA-Ar or similar alcohol
    withdrawal rating scales, medical personnel can be trained to
    recognize symptoms of alcohol withdrawal, make a rating, and based
    on the rating administer benzodiazepines to their patient only when
    signs and symptoms reach a particular threshold. A typical routine
    of administration is as follows: Administer 50mg of chlordizepoxide
    for CIWA-Ar \>9 and reassess in 1 hour. Continue administering 50mg
    chlordizepoxide every hour until CIWA-Ar is \<10.

-   *Gradual, tapering doses.* Once the patient has been stabilized,
    oral benzodiazepines can be administered on a predetermined dosing
    schedule for several days and gradually tapered over time. One
    example of this regimen is that patients might receive 50mg of
    chlordiazepoxide or 10mg diazepam every 6 hours during the first day
    of treatment and 25mg of chlordiazepoxide or 5mg diazepam every 6
    hours on the second and third days.

-   *Single daily dosing protocol.* According to studies, this regimen
    may be attractive in community or social detoxification settings,
    particularly if patients could be monitored between doses.

*Limitations of benzodiazepines in outpatient treatment*

The interaction of benzodiazepines with alcohol can lead to coma and
respiratory suppression, motor incoordination, and abuse. Abuse is
usually in the context of the concurrent use of alcohol, opioids, or
stimulants. There are two other limitations as well:

-   Although benzodiazepines have been studied for 30 years and are
    effective for suppressing alcohol withdrawal symptoms, their ability
    to halt the progressive worsening of each successive alcohol
    withdrawal is in question.

-   Benzodiazepine use to treat outpatients in alcohol withdrawal may
    "prime" or reinstate alcohol use during their administration.

*Other medications*

The following is a list of other medications sometimes used in
detoxification from alcohol:

-   Barbiturates

-   Anticonvulsants

-   Beta blockers/alpha adrenergic agonists

-   Antipsychotics

-   Relapse prevention agents

*Management of delirium and seizures*

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. Death and disability may result
from DTs or seizures without medical care.

For patients with a history of DTs or seizures, early benzodiazepine
treatment is indicated at the first clinical setting. Patients with
severe withdrawal symptoms, multiple past detoxifications (more than
three), and co-occurring unstable medical and psychiatric conditions
should be managed similarly.

**DTs**

-   Giving the patient a benzodiazepine should not be delayed by waiting
    for the return of laboratory studies, transportation problems, or
    the availability of a hospital bed.

-   Once full DTs have developed, they tend to run their course despite
    medication management.

-   Patients presenting in severe DTs should have emergency medical
    transport to a qualified emergency department and generally will
    require hospitalization.

**Seizures**

-   Seizures usually occur within the first 48 hours after cessation or
    reduction of alcohol, with peak incidence around 24 hours.

-   Someone experiencing a seizure is at greater risk for progressing to
    DTs, whereas it is extremely unlikely that a patient already in DTs
    will also then experience a seizure.

-   The occurrence of an alcohol withdrawal seizure happens quickly,
    usually without warning to the individual experiencing the seizure
    or anyone around him.

-   Predicting who will have a seizure during alcohol withdrawal cannot
    be accomplished with any great certainty.

-   Patients having a seizure can be treated with intravenous (IV)
    diazepam or lorazepam and advanced cardiac life support protocol
    procedures.

-   Patients who have had a single witnessed or suspected alcohol
    withdrawal seizure should be immediately given a benzodiazepine,
    preferably with IV administration.

-   Benzodiazepine and/or barbiturate intoxication needs to be treated
    and assessed differently, given the potentially life-threatening
    implications of withdrawal from either substance in combination with
    each other and/or alcohol. (See section titled *Intoxication and
    Withdrawal From Benzodiazepines and Other Sedative-Hypnotics* later
    in this Quick Guide for more information.)

Wernicke-Korsakoff's Syndrome

-   Wernicke-Korsakoff's Syndrome is composed of Wernicke's
    encephalopathy and Korsakoff's psychosis.

-   Wernicke's encephalopathy is an acute neurological disorder
    featuring oculomotor dysfunction (bilateral abducens nerve palsy-eye
    muscle paralysis), ataxia (loss of muscle coordination), confusion,
    and weakness.

-   Korsakoff's psychosis is a chronic neurological condition that
    includes retrograde and antegrade amnesia (profound deficit in new
    learning and remote memory) with confabulation (patients make up
    stories to cover memory gaps).

-   Both syndromes are related to thiamine deficiency.

-   Thiamine initially is given parenterally (in a manner other than
    through the digestive tract, as by intravenous or intramuscular
    injection). Afterward, oral administration is the treatment of
    choice.

-   *Always* give thiamine prior to glucose administration.

**Opioid Intoxication and Withdrawal**

Opioids are highly addicting, and their chronic use leads to withdrawal
symptoms that, although not medically dangerous, can be highly
unpleasant and produce intense discomfort.

*Signs and symptoms of opioid intoxication and withdrawal*

Opioid intoxication signs

-   Slow pulse

-   Low blood pressure

-   Low body temperature

-   Sedation

-   Pinpoint pupils

-   Slowed movement

-   Slurred speech

-   Head nodding

Opioid intoxication symptoms

-   Euphoria

-   Pain-killing effects

-   Calmness

Opioid withdrawal signs

-   Fast pulse

-   High blood pressure

-   High body temperature

-   Insomnia

-   Enlarged pupils

-   Abnormally heightened reflexes

-   Sweating

-   Gooseflesh

-   Increased respiratory rate

-   Tearing (as in crying)

-   Yawning

-   Runny nose

-   Muscle spasms

Opioid withdrawal symptoms

-   Abdominal cramps

-   Nausea

-   Vomiting

-   Diarrhea

-   Bone and muscle pain

-   Anxiety

Medical complications associated with opioid withdrawal can develop and
should be quickly identified and treated. Unlike alcohol and sedative
withdrawal, uncomplicated opioid withdrawal is not life-threatening.

*Management of withdrawal without medication*

It is not recommended that clinicians attempt to manage significant
opioid withdrawal symptoms without the effective detoxification agents
discussed below. Even mild levels of opioid use commonly produce
uncomfortable levels of withdrawal symptoms. Management of withdrawal
without medications can produce needless suffering in a population that
tends to have limited tolerance for physical pain.

*Management of opioid withdrawal with medications*

The management of opioid withdrawal with medication is most commonly
achieved through the use of methadone, buprenorphine, or clonidine.

Methadone

Methadone is a long-acting agonist at the µ-opioid site that displaces
heroin (or other abused opioids) and restabilizes the site, thereby
reversing opioid withdrawal symptoms.

-   If maintained for long enough, this stabilizing effect can reverse
    the immunological and endocrinologic defects caused by long-term
    heroin use.

-   The initial dose requirements of 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.

-   For detailed information on methadone maintenance, readers are
    referred to the forthcoming TIP *Medication-Assisted Treatment for
    Opioid Addiction*.

Clonidine (Catapres)

There are several advantages to treating opioid withdrawal using
clonidine rather than methadone:

-   Clonidine does not produce opioid intoxification and is not
    reinforcing.

-   The FDA does not classify clonidine as having abuse potential,
    though some abuse has been reported.

-   Detoxification with clonidine occurs without opioids.

-   No special licensing is required for the dispensing of this
    medication.

Although clonidine alleviates some symptoms of opioid withdrawal, it
usually is relatively ineffective for insomnia, muscle aches, and drug
craving.

An appropriate protocol for clonidine is 0.1mg administered orally as a
test dose. A dose of 0.2mg might be used initially for patients with
severe signs of opioid withdrawal or for those patients weighing more
than 200 pounds. The sublingual route of administration may also be
used. Clinicians should check the patient's blood pressure prior to
administration and should withhold clonidine if systolic blood pressure
is lower than 90 or diastolic blood pressure is below 60.

Clonidine (0.1 to 0.2mg orally) can be given every 4 to 6 hours on an
as-needed basis. Clonidine detoxification is best conducted in an
inpatient setting, as vital signs and side effects can be monitored more
closely in this environment.

Buprenorphine

-   Buprenorphine is a partial µ-opioid agonist that has recently been
    approved by the FDA in an injectable form as a detoxification agent
    and for opioid maintenance treatment.

-   Buprenorphine is available in an oral form called Subutex; it is
    meant for patients who are starting treatment for drug dependence.

-   Suboxone, another oral form of the buprenorphine, contains
    buprenorphine and naltrexone; it is intended for persons dependent
    on opioids who have already started and are continuing medication
    therapy.

-   An advantage to buprenorphine is safety. Because of the partial
    agonist action, buprenorphine has a ceiling effect with regard to
    overdose potential. Also, it can be administered in a doctor's
    office.

-   For more information on buprenorphine, see TIP 40, *Clinical
    Guidelines for the Use of Buprenorphine in the Treatment of Opioid
    Addiction.*

**Intoxication and Withdrawal From Benzodiazepines and Other
Sedative-Hypnotics**

Patients intoxicated with sedative-hypnotics appear similar to
individuals intoxicated with alcohol: slurred speech, ataxia, and poor
physical coordination are prominent. When benzodiazepines are ingested
alone, intentionally, or accidentally in overdose, they rarely lead to
death by themselves. Unfortunately most individuals who ingest
benzodiazepines also may be using alcohol, other sedative-hypnotics, or
other drugs of abuse, which in combination with benzodiazepines could be
fatal if not managed appropriately.

*General points about withdrawal*

-   Management of benzodiazepines and other sedative-hypnotics in
    overdose is in part supported following principles of advanced
    cardiac life support, with attention to ventilation.

-   Removal of benzodiazepines from the gastrointestinal tract using
    lavage and a cathartic is generally carried out, particularly if the
    overdose is recent.

-   Flumazenil (Romazicon) is a competitive antagonist that acts as a
    benzodiazepine receptor. It can reverse the sedative and overdose
    effects of benzodiazepines but not of alcohol or other
    sedative-hypnotics.

-   Assessing the severity of benzodiazepine and other sedative hypnotic
    abstinence syndrome is based primarily on information from the
    patient, significant others, and physical assessment.

*Management of withdrawal with medication*

-   One strategy that is appropriate is to begin with a slow taper of
    the benzodiazepine that the patient is already taking. This taper
    may be conducted over several weeks or perhaps even months.

-   Switching to another benzodiazepine in a patient who has had a
    serious abuse problem with his primary agent may be therapeutic.

-   Switching to another benzodiazepine with a long-half life can be
    effective; chlorodiazepoxide and clonazepam are recommended.

-   Switching to a long-acting barbiturate like Phenobarbital can be
    effective.

-   A variety of cognitive and behavioral techniques have been proposed
    to assist a medication taper.

-   Anticonvulsants such as carbamazepine and valproate, as well as
    sedating antidepressants such as trazodone and imipramine, have been
    advocated for use in withdrawal.

-   Preparing patients for starting detoxification during a period of
    low external stressors, with patient commitment to tapering and a
    plan to manage underlying anxiety disorders, are also important in
    detoxification.

**Intoxication and Withdrawal From Cocaine, Methamphetamine, and Other
Stimulants**

Cocaine and amphetamines (such as methamphetamine) are the most
frequently abused central nervous system stimulants. Individuals
dependent on stimulants experience profound loss of control over
stimulant intake, presumably in response to the stimulation and
disruption of endogenous reward centers. Alcohol and cocaine together
can result in cardiac arrest secondary to cocoethylene. Patients
intoxicated on both cocaine and ethanol may need to be monitored for
changes in QG interval.

*Stimulant withdrawal symptoms*

-   Depression

-   Hypersomnia or insomnia

-   Fatigue

-   Anxiety

-   Irritability

-   Poor concentration

-   Psychomotor retardation

-   Paranoia

-   Drug craving

While most clinicians believe that alcohol and heroin withdrawal should
be treated aggressively with detoxification, there has been little
emphasis on treating symptoms of stimulant withdrawal. No medication has
been developed for this purpose. The most effective means of treating
stimulant withdrawal involves establishing a period of abstinence form
these agents.

*Medical complications of stimulant withdrawal*

-   Stimulant withdrawal is not usually associated with medical
    complications.

-   While both cocaine and amphetamines (such as methamphetamine) often
    produce depression in users during withdrawal, the period of
    depression experienced by amphetamine users is more prolonged and
    may be more intense.

-   Some patients with recent cocaine use can experience persistent
    cardiac complications, including prolonged QTc interval and
    vulnerability for arrhythmia and myocardial infarction.

-   Seizures may also be a complication of stimulant abuse and can occur
    during detoxification.

*Management of withdrawal with medications*

Although there are no medications proven to treat stimulant withdrawal,
researchers have investigated medications for cocaine detoxification:

-   Disulfiram and Amantadine may help reduce cocaine use in patient
    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 can be prescribed for the depression that often
    accompanies methamphetamine or other amphetamine withdrawal.

**Intoxication and Withdrawal From Inhalants and Solvents**

The term "inhalants" is used to describe a large and varied group of
psychoactive substances that all share common characteristics of being
inhaled for their effects.

*Commonly abused inhalants*

The following is a list of commonly abused inhalants and examples of
each.

Adhesives

-   Airplane glue

-   Special cements

Aerosols

-   Spray paint

-   Hair spray

-   Deodorant/air freshener

-   Analgesic spray

-   Asthma spray

Anesthetics

-   Gaseous

-   Liquid

-   Local

Cleaning agents

-   Dry cleaning

-   Spot remover

-   Degreasers

Solvents and gases

-   Nail polish remover

-   Paint remover

-   Paint thinner

-   Correction fluid and thinner

-   Fuel gas

-   Lighter

-   Fire extinguisher

Food products

-   Whipped cream

-   Whippets

*Withdrawal from inhalants*

-   Dependence on inhalants and subsequent withdrawal symptoms are both
    relatively uncommon phenomena.

-   There are no specific or characteristic withdrawal symptoms that
    would include all drugs in the inhalant class.

-   There are no specific assessment instruments available to measure
    inhalant withdrawal symptoms.

-   Most inhalants produce some neurotoxicity with cognitive, motor, and
    sensory involvement.

-   Damage to internal organs including the heart, lungs, kidneys liver,
    pancreas, and bone marrow has been reported.

*Management of withdrawal*

-   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.

**Detoxification and Withdrawal From Nicotine**

Nicotine addiction in the form of cigarette smoking accounts for
approximately 450,000 deaths/year; or more deaths than AIDS, alcohol,
cocaine, heroin, homicide, suicide, motor vehicle crashes, and fire
combined. Smokers are at increased risk for several medical problems,
including cancer, emphysema, chronic obstructive lung disease, chronic
bronchitis, myocardial infarction, coronary artery diseases,
hypertension, stroke, and peripheral vascular disease.

*Withdrawal symptoms associated with nicotine*

The following are the symptoms of nicotine withdrawal as delineated by
the *Diagnostic and Statistical Manual of Mental Disorders* *4th Text
Revision* (2000):

-   Abrupt cessation of nicotine use, or reduction in the amount of
    nicotine used, followed within 24 hours by four or more of the
    following signs:

    -   Dysphoric or depressed mood

    -   Insomnia

    -   Irritability, frustration, or anger

    -   Anxiety

    -   Difficulty concentrating

    -   Restlessness

    -   Decreased heart rate

    -   Increased appetite or weight gain

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    -   These symptoms cause clinically significant distress or
        impairment in social, occupational, or other important areas of
        functioning.

    -   The symptoms are not due to a general medical condition and are
        not better accounted for by another mental disorder.

For diagnostic considerations based on the DSM-IV-TR, please see Figure
4-9 in TIP 45.

*Assessing severity*

Since 1978, a standard instrument used to measure physical dependence on
nicotine has been the eight-item Fagerstrom Tolerance Questionnaire
(FTQ). A later revision known as the Fagerstrom Test for Nicotine
Dependence (FIND) has been reduced to six questions. The six-question
version appears in Figure 4-10 of TIX 45.

The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) is an
11-question, self-administered test that evaluates the impact of
behaviors and rituals associated with smoking. It was designed to assist
in identifying and quantifying behavioral aspects of smoking that play a
role in maintaining nicotine dependence, which can then help the
clinician develop a cessation strategy. The GN-SBQ appears in Figure
4-11 of TIP 45.

*Medical complications of withdrawal from nicotine*

There are no major medical complications precipitated by nicotine
withdrawal itself. However, patients frequently experience uncomfortable
withdrawal symptoms within a few hours of cessation. Some of these
symptoms---anxiety, irritability, depression, and others---can be
confused as other psychiatric conditions.

During detoxification from nicotine, some medications will have their
metabolism altered, including:

-   Theophylline

-   Caffeine

-   Tacrine

-   Imipramine

-   Haloperidol

-   Pentazocine

-   Propranolol

-   Flecainide

-   Estradiol

*Management of withdrawal without medication*

The U.S. Public Health Service's *Treating Tobacco Use and Dependence:
Clinical Practice Guideline* (2000) is a comprehensive review of smoking
cessation literature. The non-pharmacological interventions it discusses
can be broken down into two categories: self-help interventions and
behavioral interventions.

*Management of withdrawal with medications*

A U.S. Public Health Service panel recommends that all primary care
physicians offer active medication that has been approved for assisting
in smoking cessation to all smokers who want to quit. The following are
different types of medication that can be used with patients who wish to
quit smoking.

*Nicotine Replacement Therapy (NRT)*

Nicotine polacrilex gum was approved by the FDA in 1984. In the 1990s
other NRTs received FDA approval including the nicotine transdermal
patch, the nicotine nasal spray, and the nicotine inhaler. After the
acute withdrawal period, patients are weaned off the medication until
they become nicotine free. It is clear that constituents of tobacco
other than nicotine are responsible for causing cancer, and no ill
effects have been attributed to long-term use of nicotine replacement
therapy.

*Bupropion SR*

Bupropion SR's exact method of action is unknown, but it is not a
nicotine substitute or replacement like the NRTs. The recommended dose
is 150mg daily for 3 days and then 150mg twice daily for 7 to 12 weeks.
Typically patients set their quit date 1 to 2 weeks from the time they
start the medication. This is an ideal time for the patient to focus on
making behavioral changes and enlisting social support to augment the
quit attempt.

*Other non-nicotine pharmacotherapy*

There are several other medications currently being looked at for their
effectiveness in assisting with smoking cessation. They include:

-   The alpha-2 agonist antihypertensive, clonidine

-   The tricyclic antidepressant, nortiptyline

-   The monoamine oxidase inhibitor (MAOI) antidepressant, moclobemide

-   The serotonin 5-HT1A agonist anxiolytic, buspirone

-   The antihypertensive CNS nicotine receptor blocker, mecamylamine

-   Oral dextrose tablets

Although none of these agents have been approved by the FDA for smoking
cessation, clonidine, nortiptyline, and moclobemide have been found to
be effective treatments.

*Combination drug therapies*

NRT products typically provide less than half of the nicotine plasma
levels that cigarette users achieve through smoking. To increase
nicotine levels, several clinical trials have evaluated combinations of
different NRTs. There is moderately strong evidence to conclude that
combining various NRTs is more efficacious than a single form of
nicotine replacement.

**Intoxication and Withdrawal From Anabolic Steroids**

Anabolic steroids are male hormones and subject to abuse as a means of
increasing muscle mass. These agents also can produce aggressive,
manic-like behavior that may include delusions.

*Withdrawal symptoms associated with steroids*

-   Withdrawal symptoms include craving for more steroids, fatigue,
    depression, restlessness, anorexia, insomnia, reduced libido,
    headaches, and nausea.

-   It is not known how commonly this syndrome occurs, but steroid
    withdrawal appears more likely in heavy users.

*Medical complications and management of steroid withdrawal*

-   Due to long duration of action with anabolic steroids, side effects
    that might emerge cannot be quickly reversed by discontinuing
    substance use.

-   Other side effects may require management beyond the simple
    recommendations that steroids be immediately discontinued; there is
    no recommended detoxification protocol---the key medical goal is
    cessation of steroid use.

**Intoxication and Withdrawal From Club Drugs**

Club drugs are illicit drugs used in the settings of nightclubs, dance
clubs, parties, and raves. Use of these drugs among adolescents and
young adults has risen significantly in recent years. Although
withdrawal syndromes have been reported with some of these drugs, this
is not the most common clinical problem. Intoxication and severe
intoxication with overdose are more frequent.

Hallucinogens

-   Hallucinogens are a broad group of substances that can produce
    sensory abnormalities and hallucinations.

-   Hallucinogens are also referred to as psychedelics and
    psychomimetics; they include LSD, mescaline, MDMA, MDA, and DOM.

-   The prominent effects during intoxication are sensory distortions
    with illusions and hallucinations; visual distortions are more
    common than auditory or tactile ones.

-   "Bad trips" involve anxiety including panic attacks, paranoid
    reactions, anger, violence, and impulsivity.

-   Withdrawal syndromes have not been reported with hallucinogens.

-   Acute intoxication and bad trips usually can be managed with
    placement of the individual in a quiet, non-stimulating environment
    with immediate and direct supervision so that the patient does not
    cause harm to himself or to others.

Gamma-hydroxybutyrate (GHB)

-   GHB intoxication may look like alcohol or sedative hypnotic
    intoxication, and case reports of GHB withdrawal have occurred.

-   Management of withdrawal has been with supportive care and
    benzodiazepines such as lorazepam.

Ecstasy

-   Patients using ecstasy (MDMA) or related compounds frequently are
    hyperactive and hyperverbal, reporting heightened tactile and visual
    sensations.

-   Hyperthermia, dehydration, water intoxication with low sodium
    rhabdomyolysis, renal failure, cardiac arrhythmia, and coma have
    been reported.

-   Clinicians are likely to have to manage complications of
    intoxication and overdose but not withdrawal.

Ketamine and PCP (Phencyclidine)

-   Withdrawal symptoms from PCP include depression, drug craving,
    increased appetite, and hypersomnolence.

-   In clinical settings, syndromes of acute intoxication with
    hallucinations, delusions, agitation, and violence are the most
    pressing problems.

-   In clinical settings, ketamine and PCP require management for the
    agitation and psychotic features produced during acute use;
    occasionally oral or parenteral uses of sedating medications such as
    benzodiazepines will be required.

-   Occasionally patients will have such large overdoses that they will
    require airway management and ventilatory support for some hours.

**ORDERING INFORMATION**

**TIP 45**

***Detoxification and Substance Abuse Treatment***

**TIP 45-Related Products**

-   KAP Keys for Clinicians

-   Quick Guide for Administrators

-   Quick Guide for Primary Care Clinicians

**Other Treatment Improvement Protocols that are relevant to this Quick
Guide:**

-   **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**

See the inside back cover for ordering information for all TIPs and
related products.