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## Complete Summary

#### GUIDELINE TITLE

Detoxification and substance abuse treatment: an overview of the
psychosocial and biomedical issues during detoxification.

#### BIBLIOGRAPHIC SOURCE(S)

An overview of psychological and biomedical issues during
detoxification. In: Center for Substance Abuse Treatment (CSAT).
Detoxification and substance abuse treatment. Rockville (MD): Substance
Abuse and Mental Health Services Administration (SAMHSA); 2006 Jan 18.
p. 19-41. (Treatment improvement protocol (TIP); no. 45).

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Substance use disorders

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Infectious Diseases\
Internal Medicine\
Pharmacology\
Psychiatry\
Psychology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers\
Substance Use Disorders Treatment Providers

#### GUIDELINE OBJECTIVE(S)

-   To address the psychosocial and biomedical issues that may affect
    detoxification and ensuing treatment

-   To highlight evaluation procedures for patients undergoing
    detoxification, discuss strategies for engaging and retaining
    patients in detoxification and preparing them for treatment, and
    present an overview for providing linkages to other services

#### TARGET POPULATION

Adult patients undergoing detoxification

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Medical assessment for infectious diseases, co-occurring medical
    conditions, nutritional evaluation, etc.

    -   Assessment for signs and symptoms which require immediate
        medical attention

2.  Psychiatric assessment for co-occurring mental disorders

3.  Considerations for specific patient groups (e.g., adolescents,
    parents with dependent children, victims of domestic violence,
    culturally diverse patients and chronic relapsers)

**Treatment/Management**

1.  Strategies for engaging and maintaining patients in detoxification,
    including:

    -   Patient education

    -   Use of support systems

    -   Maintenance of a drug free environment

    -   Alternative approaches to treatment

    -   Enhancing patient motivation

    -   Fostering a therapeutic alliance

2.  Patient referral and linkage

    -   Assessment of the patient\'s rehabilitation needs

    -   Provision of linkage to treatment and maintenance activities

    -   Provision of access to wraparound services

    -   Minimization of treatment access barriers

    -   Use of case management

    -   Linkage to ongoing psychiatric and follow up medical care

    -   Considerations for individuals with chronic substance dependence

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature search involved careful consideration of all relevant
clinical and health services research findings, practice experience, and
implementation requirements.

Evidence also selected through expert consensus on current best
practices.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Consensus Development Conference)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

After selecting a topic, Center for Substance Abuse Treatment (CSAT)
invites staff from pertinent Federal agencies and national organizations
to be members of a resource panel that recommends specific areas of
focus as well as resources that should be considered in developing the
content for the Treatment Improvement Protocols (TIP). These
recommendations are communicated to a consensus panel composed of
experts on the topic who have been nominated by their peers. This
consensus panel participates in a series of discussions. The information
and recommendations on which they reach consensus form the foundation of
the TIP. The members of each consensus panel represent substance abuse
treatment programs, hospitals, community health centers, counseling
programs, criminal justice and child welfare agencies, and private
practitioners. A panel chair (or co-chairs) ensures that the contents of
the TIP mirror the results of the group\'s collaboration.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A large and diverse group of experts closely reviews the draft document.
Once the changes recommended by these field reviewers have been
incorporated, the Treatment Improvement Protocol (TIP) is prepared for
publication, in print and on line.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: The Substance
Abuse and Mental Health Services Administration (SAMHSA) Consensus Panel
supports the following statement and has taken special care to note that
detoxification is not substance abuse treatment and rehabilitation:

\"Detoxification is a set of interventions aimed at managing acute
intoxication and withdrawal. Supervised detoxification may prevent
potentially life-threatening complications that might appear if the
patient was left untreated. At the same time, detoxification is a form
of palliative care (reducing the intensity of a disorder) for those who
want to become abstinent or who must observe mandatory abstinence as a
result of hospitalization or legal involvement. Finally, for some
patients it represents a point of first contact with the treatment
system and the first step to recovery. Treatment/rehabilitation, on the
other hand, involves a constellation of ongoing therapeutic services
ultimately intended to promote recovery for substance abuse patients.\"

Readers are referred to Chapter 1 \"Overview, Essential Concepts, and
Definitions in Detoxification\" in the full guideline document for
definitions of other relevant terms and detailed examination of the
guiding principles recognized by the Consensus Panel (see \"Availability
of Companion Documents\" field).

Regardless of setting or level of care, the goals of detoxification are
to provide safe and humane withdrawal from substances and to foster the
patient\'s entry into long-term treatment and recovery. Detoxification
presents a unique opportunity to intervene during a period of crisis and
move a client to make changes in the direction of health and recovery.
Hence, a primary goal of the detoxification staff should be to build the
therapeutic alliance and motivate the patient to enter treatment. This
process should begin even as the patient is being medically stabilized.

Psychological dependence, co-occurring psychiatric and medical
conditions, social supports, and environmental conditions critically
influence the probability of successful and sustained abstinence from
substances. Research indicates that addressing psychosocial issues
during detoxification significantly increases the likelihood that the
patient will experience a safe detoxification and go on to participate
in substance abuse treatment. Staff members\' ability to respond to
patients\' needs in a compassionate manner can make the difference
between a return to substance abuse and the beginning of a new (and more
positive) way of life.

+-----------------------------------------------------------------------+
| **Overarching Principles for Care During Detoxification Services**    |
+=======================================================================+
| -   Detoxification services do not offer a \"cure\" for substance use |
|     disorders. They often are a first step toward recovery and the    |
|     \"first door\" through which patients pass to treatment.          |
|                                                                       |
| -   Substance use disorders are treatable, and there is hope for      |
|     recovery.                                                         |
|                                                                       |
| -   Substance use disorders are brain disorders and not evidence of   |
|     moral weaknesses.                                                 |
|                                                                       |
| -   Patients are treated with respect and dignity at all times.       |
|                                                                       |
| -   Patients are treated in a nonjudgmental and supportive manner.    |
|                                                                       |
| -   Services planning is completed in partnership with the patient    |
|     and his or her social support network, including such persons as  |
|     family, significant others, or employers.                         |
|                                                                       |
| -   All health professionals involved in the care of the patient will |
|     maximize opportunities to promote rehabilitation and maintenance  |
|     activities and to link her or him to appropriate substance abuse  |
|     treatment immediately after the detoxification phase.             |
|                                                                       |
| -   Active involvement of the family and other support systems while  |
|     respecting the patient\'s rights to privacy and confidentiality   |
|     is encouraged.                                                    |
|                                                                       |
| -   Patients are treated with due consideration for individual        |
|     background, culture, preferences, sexual orientation, disability  |
|     status, vulnerabilities, and strengths.                           |
+-----------------------------------------------------------------------+

**Evaluating and Addressing Psychosocial and Biomedical Issues**

Patients entering detoxification are undergoing profound personal and
medical crisis. Withdrawal itself can cause or exacerbate current
emotional, psychological, or mental problems. The detoxification staff
needs to be equipped to identify and address potential problems.

**Considerations for Conducting the Initial Evaluation**

An initial evaluation will help detoxification staff foresee any
variables that might complicate a safe and effective withdrawal. The
Table below lists the biomedical and psychosocial domains that can
affect the stabilization of the patient.

+-----------------------------------------------------------------------+
| **Initial Biomedical and Psychosocial Evaluation Domains**            |
+=======================================================================+
| **Biomedical Domains**                                                |
+-----------------------------------------------------------------------+
| -   *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 with neurological exam*\--This will  |
|     ascertain the patient\'s general health and identify any medical  |
|     or psychiatric disorders of immediate concern.                    |
|                                                                       |
| -   *Temperature, pulse, blood pressure*\--These are important        |
|     indicators and should be monitored throughout detoxification.     |
|                                                                       |
| -   *Patterns of substance abuse*\--When did the patient last use?    |
|     What were the substances of abuse? How much of these substances   |
|     was used and how frequently?                                      |
|                                                                       |
| -   *Urine toxicology screen for commonly abused substances*.         |
|                                                                       |
| -   *Past substance abuse treatments or detoxification*\--This should |
|     include the course and number of previous withdrawals, as well as |
|     any complications that may have occurred.                         |
+-----------------------------------------------------------------------+
| **Psychosocial Domains**                                              |
+-----------------------------------------------------------------------+
| -   *Demographic features*\--Gather information on gender, age,       |
|     ethnicity, culture, language, and 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 disabilities*\--Does the client  |
|     have disabilities that require consideration?                     |
+-----------------------------------------------------------------------+

**General Guidelines for Addressing Immediate Medical Concerns**

Health professionals should screen for medical problems that may put the
client at risk for a medical crisis or expose other clients or staff to
contagious diseases. This section outlines important considerations for
both nonmedical and medical staff. Chapter 5, \"Detoxification and
substance abuse treatment: co-occurring medical and psychiatric
conditions,\" in the original guideline document provides a clinical
overview of co-occurring medical conditions and is geared primarily
toward medical personnel.

*Co-Occurring Medical Conditions*

The initial consultation should include an evaluation of the expected
signs, symptoms, and severity of the withdrawal. Detoxification is not
an exact science, but any significant deviation from the expected course
of withdrawal should be observed closely. The Table below provides a
list of signs and symptoms of conditions that require immediate medical
attention. All staff members who work with patients should be aware of
these and seek medical consultation for the patients as necessary.

+-----------------------------------------------------------------------+
| **Symptoms and Signs of Conditions That Require Immediate Medical     |
| Attention**                                                           |
+=======================================================================+
| -   Change in mental status                                           |
|                                                                       |
| -   Increasing anxiety and panic                                      |
|                                                                       |
| -   Hallucinations                                                    |
|                                                                       |
| -   Seizures                                                          |
|                                                                       |
| -   Temperature greater than 100.4 degrees F (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 (i.e., toward the      |
|     mouth of the patient), indicating profound central nervous system |
|     irritability and the potential for seizures                       |
+-----------------------------------------------------------------------+

Seizures are of special concern. Practitioners should interview the
patient and family about seizure disorders and seizure history. In
addition, nonmedical staff should be aware of signs of impending
seizures such as tremors, increased blood pressure, overactive reflexes,
and high temperature and pulse. It is essential that nonmedical staff be
trained in protocols to prevent injury in the event of a seizure.
Competence in carrying out these protocols should be evaluated by a
physician or nurse clinician. For more information on seizures, see the
section titled \"Detoxification and substance abuse treatment: physical
detoxification services for withdrawal from specific substances\" in the
original guideline document.

All staff working with patients should be familiar with medical
disorders that are associated with various addictive substances or
routes of administration. Nonmedical detoxification staff also should be
aware of the medications used in detoxification, medications for common
medical and psychiatric disorders, and signs of common medication
reactions and interactions.

*Infectious Disease*

Standard precautions should be used with all patients to protect the
staff and patients against the transmission of infectious diseases,
including human immunodeficiency virus (HIV) and hepatitis A, B, and C.
All open wounds should be cultured and treated to prevent the spread of
infections. Providers should use HIV/blood and respiratory infection
precautions until HIV and respiratory infectious status are known.
Patients with respiratory infections should be carefully evaluated. The
panel suggests that tuberculin testing be performed or recent test
results obtained on all patients to screen for active tuberculosis. A
chest x-ray is recommended if indicated by the patient\'s history and
physical assessments. Nonmedical detoxification staff should be trained
to watch for the signs of common infectious diseases passed through
casual contact, including infestation with scabies and lice.

**General Guidelines for Addressing Immediate Mental Health Needs**

The following section provides general guidelines for treating patients
who have immediate mental health needs. For more detailed information on
the treatment of patients with co-occurring psychiatric conditions see
the National Guideline Clearinghouse (NGC) summary of Treatment
Improvement Protocol (TIP) 42, [Substance Abuse Treatment for Persons
With Co-Occurring
Disorders](http://www.guideline.gov/summary/summary.aspx?doc_id=6849&nbr=004203).

*Suicide*

During acute intoxication and withdrawal, it is important to provide an
environment that minimizes the opportunities for suicide attempts. As a
precaution, locations not clearly visible to staff should be free of
items that might be used for suicide attempts. Frequent safety checks
should be implemented; the frequency of these checks should be increased
when signs of depression, shame, guilt, helplessness, worthlessness, and
hopelessness are present. When feasible, patients at risk for suicide
should be placed in areas that are easily monitored by staff. Most
important, when interacting with patients at risk for suicide, staff
should avoid harsh confrontation and judgment and instead focus on the
treatable nature of substance use disorders and the rehabilitation
options available. These interactions offer an opportunity to start a
dialog with the patient regarding the impact of substance use on mental
illness and vice versa.

*Anger and Aggression*

As a precaution, all patients who are intoxicated should be considered
potentially violent. Programs should have in place well-developed plans
to promote staff and patient safety, including protocols for response by
local law enforcement agencies or security contractors. Staff working in
detoxification programs should be trained in techniques to de-escalate
anger and aggression. In many cases, aggressive behaviors can be defused
through verbal and environmental means. For the protection of the staff
and the patient, physical restraint should be used as a last resort and
programs should be aware of local laws and regulations pertaining to
physical restraint. The Table below lists some useful ways of managing
patients who are angry and aggressive. Readers may refer to the
standards published by such groups as the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) and the Commission on
Accreditation of Rehabilitation Facilities (CARF) for further guidance.
Additional information is available on the JCAHO Web site
([www.jcaho.org](http://www.jcaho.org/)) and the CARF Web site
([www.carf.org](http://www.carf.org/)). The Substance Abuse and Mental
Health Services Administration (SAMHSA) also has published guidelines on
the use of seclusion and restraint, which call for the reduction and
possible elimination of their use.

+-----------------------------------------------------------------------+
| **Strategies for De-escalating Aggressive Behaviors**                 |
+=======================================================================+
| -   Speak in a soft voice.                                            |
|                                                                       |
| -   Isolate the individual from loud noises or distractions.          |
|                                                                       |
| -   Provide reassurance and avoid confrontation, judgments, or angry  |
|     tones.                                                            |
|                                                                       |
| -   Enlist the assistance of family members or others who have a      |
|     relationship of trust.                                            |
|                                                                       |
| -   Offer medication when appropriate.                                |
|                                                                       |
| -   Separate the individual from others who may encourage or support  |
|     the aggressive behaviors.                                         |
|                                                                       |
| -   Enlist additional staff members to serve as visible backup if the |
|     situation escalates.                                              |
|                                                                       |
| -   Have a clearly developed plan to enlist the support of law        |
|     enforcement or security staff if necessary.                       |
|                                                                       |
| -   Establish clear admission protocols in order to help screen for   |
|     potentially aggressive/violent patients.                          |
|                                                                       |
| -   Determine one\'s own level of comfort during interaction with the |
|     patient and respect personal limits.                              |
|                                                                       |
| -   Ensure that neither the clinician\'s nor the patient\'s exit from |
|     the examination room is blocked.                                  |
+-----------------------------------------------------------------------+

*Co-occurring Mental Disorders*

With the patient\'s consent, a review of the patient\'s mental health
history with the patient and family is useful in identifying
co-occurring psychiatric conditions. Mental health professionals caring
for the client should be consulted. If a pharmacy profile on the patient
is available, it should be copied for review (within the confines of
State and Federal confidentiality laws).

Diagnosis of co-occurring substance-related disorders and mental
conditions is difficult during acute intoxication and withdrawal because
it often is impossible to be precise until the clinical picture allows
for the full assessment of both the effects of substance use and of the
symptoms of mental disorders. As the individual moves from severe to
moderate withdrawal symptoms, attention to differential diagnosis of
substance use disorders and other psychiatric disorders becomes a
priority. The American Psychiatric Association (APA) and the American
Society of Addiction Medicine (ASAM) guidelines recommend a period of 2
to 4 weeks of abstinence before attempting to diagnose a psychiatric
disorder.

**General Guidelines for Addressing Nutritional Concerns**

Malnutrition is a major concern for patients entering detoxification
because the nutrient deficiencies associated with substance abuse can
interfere with or even prolong the detoxification process. Longstanding
irregular eating habits and poor dietary intake only exacerbate the
problem. The detoxification process itself is stressful to the body and
may result in increased nutrient requirements. Proper nutrition during
recovery improves to a significant extent the adverse effects of the
substance abuse.

*Nutritional Evaluation*

An evaluation of nutritional status should be a core component of
detoxification. It should be noted, however, that for patients who abuse
alcohol, the administration of fluids to address dehydration should be
the first step, with nutritional evaluation occurring after the patient
is adequately hydrated.

The nutritional evaluation should consist of laboratory and
anthropometric indices, a detailed nutritional history, and nutrition
counseling. The intervention begins in the initial acute phase of
withdrawal and continues through detoxification and subsequent substance
abuse treatment. If the patient consents, family members or significant
others may be included in the nutritional evaluation and counseling.

Weight is an important consideration in determining the nutritional
status of the person with a substance use disorder. Patients should be
asked whether there have been any recent changes in their weight. While
a patient may appear to be adequately nourished, a skinfold caliper (an
instrument that measures the thickness of a fold of skin with its
underlying layer of fat) can determine body density (the relationship of
the body\'s mass to its volume), though the body mass index may be a
better indicator of nutritional status.

Other questions to ask during the initial evaluation concern appetite,
eating patterns, food preferences, snacking habits, food allergies, food
intolerance, special diets, and foods to be avoided because of cultural
or religious beliefs. A food frequency questionnaire, food diary, or
24-hour food recall may be of use.

Many drug addictions are associated with abnormal glucose (sugar)
metabolism. This abnormality means that the body is unable to maintain a
stable concentration of glucose in the blood. Abnormally high or low
blood sugar levels easily can be confused with the signs and symptoms of
alcohol intoxication or withdrawal; consequently, a check of blood
glucose level is particularly important in patients with a history of
blood sugar abnormalities.

*Nutritional Deficits Associated with Specific Substances*

Detoxification personnel should be familiar with the nutritional
deficits associated with specific substances. Opioids are known to
decrease calcium absorption and to increase cholesterol and body
potassium levels. Magnesium deficiency often is seen in chronic alcohol
dependence. Other nutrient deficiencies seen in alcohol abuse include
protein, fat, zinc, calcium, iron, vitamins A and E, and the
water-soluble vitamins pyridoxine, thiamine, folate, and vitamin B12.
Alcohol also contains calories (7 kcal/gm) that when consumed in
excessive amounts may displace nutrient-dense foods. Cocaine is an
appetite suppressant and may interfere with the absorption of calcium
and vitamin D. Laboratory tests for protein, vitamins, and iron and the
other electrolytes are recommended to determine the extent of liver
function as well as supplementation. Caution should be exercised when
using supplements because of their potential interactions with other
drugs and treatments.

*Addressing Nutritional Deficits*

Detoxification should include efforts to address nutritional deficits
and to begin the patient on a course of improved eating habits. It is
crucial to switch the paradigm from ingesting substances harmful to the
body to taking in foods that heal the body. The regularity of meal
times, taste, and presentation are important considerations.
Attractively arranged, pleasant-tasting food may inspire the patient to
consume vital nutrients and adequate calories. It is important that
during the detoxification process, the patient avoid substituting one
addiction for another. Consuming excessive amounts of caffeine or sugar
can compromise the process and lead to relapse. Patients should be
offered only decaffeinated beverages and healthful snacks instead of
refined carbohydrates such as sugar-based sweets like candy, cookies, or
donuts. Fresh fruits, vegetables, and other whole foods can contribute
to the individual\'s health and wellness.

Gastrointestinal disturbances (i.e., nausea, vomiting, and diarrhea) may
accompany the first phase of detoxification. Such disturbances can
worsen dehydration and may disturb blood chemistry balance, which in
turn can lead to mental status changes, neurological or heart problems,
and other potentially dangerous medical conditions. Patients with
gastrointestinal disturbances may only be able to tolerate clear
liquids. When solid foods are tolerated, balanced meals consisting of
low-fat foods, with an increased intake of protein (meat, dairy
products, legumes), complex carbohydrates (whole grain bread and
cereals), and dietary fiber are recommended. Patients undergoing
detoxification may also experience constipation. Increasing the fiber
content of the diet will help to alleviate this discomfort.

*Considerations for Patients with Special Dietary Requirements*

Patients with special dietary requirements need additional nutrition
therapy. A person with diabetes, for example, should follow the dietary
guidelines of the American Diabetes Association, which emphasizes
individualized meal planning. A patient who is a vegetarian may have
additional nutritional deficiencies, especially if she or he is a vegan
(i.e., a person who avoids eating all foods derived from animals,
including milk products and eggs). If a vegan enters detoxification with
marginal or low nutrient stores, his or her diet should be augmented
with legumes, meat analogs, textured vegetable protein, nuts, and seeds.
Many other medical conditions (e.g., ulcers, heart disease, food
allergies, etc.) may require special diets. At intake, any special
dietary considerations should be noted.

**Considerations for Intoxication and Withdrawal in Adolescents**

Generally, detoxification is the same for adolescents as it is for adult
clients. However, there are a few important and unique considerations
for adolescent patients. For one, adolescents are more likely than
adults to drink large quantities of alcohol in a short period of time,
making it is especially important that detoxification providers be alert
to escalating blood alcohol levels in these patients. Moreover,
adolescents are more likely than adults to use drugs they cannot
identify, to combine multiple substances with alcohol, to ingest
unidentified substances, and to be unwilling to disclose drug use. As a
result, the consensus panel recommends routinely screening adolescent
patients for illicit drug intoxication. It also is important for staff
to be trained in how to assess for the use of phencyclidine (PCP), which
can present with psychosis-like symptoms. Staff should ask the
adolescent directly whether he has used PCP within the 12-hour period
before entering the clinic or treatment center.

Adolescents should be placed in a secure, clean environment with
observation and supportive care. If alcohol, heroin, or other drugs
associated with vomiting are suspected, protecting the individual\'s
airway and positioning the patient on his or her side to avoid
aspiration (inhaling) of stomach contents are critical. In severe cases
of ingestion of respiratory depressants, respiratory support may be
needed. If the individual is severely combative or belligerent, physical
restraint may be needed as a last resort when allowed and appropriate.
In milder cases, observation in a quiet, secure room with compassionate
reassurance may be sufficient. Additionally, adolescents served in adult
settings should be separated from the adult population and observed
closely to ensure that they are not victimized (i.e., verbally,
physically, or sexually) by adult clients. Finally, adolescents in
detoxification settings should always be screened carefully for suicide
potential and co-occurring psychiatric problems.

It sometimes is challenging to establish rapport with adolescents, as
their experience with adults may be marked by adverse consequences.
Asking open-ended questions and using street terminology for drugs and
other expressions commonly used by teenagers can be helpful both in
establishing rapport and in obtaining an accurate substance use history.
For more information on working with adolescents, see [TIP 31, Screening
and Assessing Adolescents for Substance Use
Disorders](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.54841)
and TIP 32, [Treatment of Adolescents With Substance Use
Disorders](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.56031).

**Considerations for Patients Who Are Parents With Dependent Children**

For parents\--especially women\--entering detoxification programs, the
safety of children often is a concern and one of the biggest barriers to
retention. Even if women do not have custody of their children they
often are the ones who continue to care for them. Some children may show
extreme need for their mother while separated from her, and their
demands could trigger unauthorized leave from detoxification. Thus,
ensuring that children have a safe place to stay while their mothers are
in detoxification is of vital importance. Working with women and men to
identify supportive family or friends may identify 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.

**Considerations for Victims of Domestic Violence**

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

If a patient discloses a history of domestic violence, trained staff can
help the victim create a long-term safety plan or make a proper
referral. If a safety plan is made or phone numbers for domestic
violence help are provided, related information should be labeled
carefully so as not to disclose its purpose (e.g., listed as women\'s
health resources) since the abuser may go through all personal
belongings. All printed information about domestic violence also should
be disguised and none should be kept by the patient when she leaves the
safe facility. If the victim needs to press charges or obtain a
restraining order, this should be done from a safe setting (e.g.,
inpatient detoxification). If at all possible, the victim should be
escorted to a safety shelter. It may be important that the abused
person, whether male or female, not be allowed to talk to the abuser
while in detoxification. Parents who are victims of domestic violence
may need help with parenting skills and securing counseling and
childcare. Therefore, it is important for detoxification providers to be
familiar with local childcare resources. For more information see TIP
25, [Substance Abuse Treatment and Domestic
Violence](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.46712).

**Considerations for Culturally Diverse Patients**

In providing psychosocial supports for culturally diverse patients,
cultural sensitivity is of tremendous importance. Clients\' expectations
of detoxification, their feelings about the healthcare system generally,
and their social and community support structures vary according to
their cultural backgrounds. In working with any specific population, the
practitioner should avoid defining the patient in terms of his culture,
since over- or underemphasizing the patient\'s race or ethnicity can be
detrimental. Figure 3-4 in the original guideline document provides
clinicians with some helpful questions to guide their discussions.

**Considerations for Chronic Relapsers**

A patient who recently relapsed after a period of extended abstinence
may feel especially hopeless and vulnerable (an abstinence violation
effect). In this situation, clinicians can acknowledge progress that had
been made prior to relapse and reassure the patient that the internal
gains from past recovery work have not all been lost (despite the
feeling at the moment that they have), perhaps reframing the severity of
emotional pain as an indicator of how important recovery is to the
patient.

**Strategies for Engaging and Retaining Patients in Detoxification**

It is essential to keep patients who enter detoxification from \"falling
through the cracks.\" Successful providers acknowledge and show respect
for the patient\'s pain, needs, and joys, and validate the patient\'s
fears, ambivalence, expectation of recovery, and positive life changes.
It is essential that all clinicians who have contact with patients in
withdrawal continually offer hope and the expectation of recovery. An
atmosphere that conveys comfort, relaxation, cleanliness, availability
of medical attention, and security is beneficial to patients
experiencing the discomforts of the withdrawal process. Throughout the
detoxification experience, detoxification staff should be unified in
their message that detoxification is only the beginning of the substance
abuse 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.
Usually withdrawal includes symptoms that are the opposite of the
effects of the particular drug. This rebound effect can cause anxiety
and concern for patients. Providing information about the common
withdrawal symptoms of the specific drugs of abuse may reduce discomfort
and the likelihood that the individual will leave detoxification
services prematurely (for a list of withdrawal symptoms, see the section
titled \"Detoxification and substance abuse treatment: physical
detoxification services for withdrawal from specific substances\" in the
original guideline document). Settings that routinely encounter
individuals in withdrawal should have written materials available on
drug effects and withdrawal from specific drugs, and have staff who are
well versed in the signs and symptoms of withdrawal. An additional
consideration is providing such information to non-English-speaking
patients and their families.

Interventions that assist the client in identifying and managing urges
to use also may be helpful in retaining the client in detoxification and
ensuring initiation of rehabilitation. These interventions may include
cognitive--behavioral approaches that help the individual identify
thoughts or urges to use, the development of an individualized plan to
resist these urges, and use of medications such as naltrexone to reduce
craving.

**Use Support Systems**

The use of client advocates to intervene with clients wishing to leave
early often can be an effective strategy for promoting retention in
detoxification. 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. These activities reinforce the need for
substance abuse treatment and maintenance activities and may provide a
critical recovery-oriented support system once detoxification services
are completed.

**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, including bringing alcohol or other drugs into the facility.
Visiting areas should be easy for the staff to monitor closely, and
staff may want to search visiting areas and other public areas
periodically to reduce the opportunities for acquiring substances. It is
important to note, however, that personnel should be respectful in their
efforts to maintain a drug-free environment. It is important to explain
to patients (prior to treatment) and visitors why substances are not
allowed in the facility.

**Consider Alternative Approaches**

Alternative approaches such as acupuncture are safe, inexpensive, and
increasingly popular in both detoxification and substance abuse
treatment. Although the effectiveness of alternative treatments in
detoxification and treatment has not been validated in well-controlled
clinical trials, if an alternative therapy brings patients into
detoxification and keeps them there, it may have utility beyond whatever
specific therapeutic value it may have. Other treatments that reside
outside the Western biomedical system, typically grouped together under
the heading of Complementary or Alternative Medicine, also may be useful
for retaining patients. Indeed, given the great cultural diversity in
the United States, other culturally appropriate practices should be
considered.

**Enhancing Motivation**

Motivational enhancements are particularly well-suited to accomplishing
the detoxification services goal of promoting initiation in
rehabilitation and maintenance activities. Use of these techniques in
the detoxification setting increases the likelihood that patients will
seek treatment by helping them understand the adverse consequences of
continued substance use. It also establishes a supportive and
nonjudgmental relationship between the substance abuse counselor and the
patient\--this therapeutic alliance is an important factor in the
patient\'s choice to seek treatment services. TIP 35, [Enhancing
Motivation for Change in Substance Abuse
Treatment](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302),
covers specific interventions and techniques to increase motivation to
change substance-related behaviors. TIP 35 also includes some basic
principles common to motivational interventions:

-   Focus on the patient\'s strengths.

-   Show respect for a patient\'s decisions and autonomy; respect should
    be maintained at all times, even when the patient is intoxicated.

-   Avoid confrontation.

-   Individualize treatment.

-   Do not use labels that depersonalize the patient, such as \"addict\"
    or \"alcoholic.\"

-   Empathize with the patient, making an attempt to understand the
    patient\'s perspective and accept his or her feelings.

-   Accept treatment goals that involve small steps toward ultimate
    goals.

-   Assist the patient in developing an awareness of discrepancies
    between her or his goals or values and current behavior.

-   Listen reflectively to the patient\'s immediate concerns and ask
    open-ended questions.

In addition, the detoxification team can leverage the relationship the
patient has with significant others. Using interventions such as
Community Reinforcement and Family Training (CRAFT), the detoxification
team can help significant others in the patient\'s life capitalize on
moments when the patient is ready for change and assist the patient in
preparing for change in a nonthreatening, nonconfrontational manner. The
consensus panel does not recommend that clinicians use direct
confrontation in helping a person with a substance use disorder begin
the process of detoxification and subsequent substance abuse treatment.
Techniques that involve purposefully confronting patients about their
substance use behavior, such as the Johnson Intervention, where
significant others are taught to confront the individuals using
substances, have been shown to be highly effective when significant
others implement them. However, subsequent studies of clinicians,
groups, and programs that rely on confrontational techniques have
yielded poor outcomes. Moreover, the vast majority of significant others
do not wish to use these techniques, and for that reason these
techniques are not recommended.

Care should be taken to ensure that any significant other who is
involved in motivating the patient for therapy is appropriate for this
task. Only significant others who have been appropriately introduced to
the intervention by a clinician should participate. The presence of a
trained facilitator is recommended, either for coaching or for
facilitating the intervention. It also is important to have the
recommended treatment option readily available so if the patient agrees,
admission can be swift and seamless. Those individuals selected to
intervene should support the patient\'s abstinence from substances of
abuse. Furthermore, if the patient places considerable value on her or
his relationships with these significant others, success is more likely.

**Tailoring Motivational Intervention to Stage of Change**

Perhaps the most well-known and empirically validated model of
\"readiness to change\" that has been applied to substance abuse is the
transtheoretical model, also known as the stages of change model. The
interventions to increase patient motivation for substance abuse
treatment described in TIP 35, [Enhancing Motivation for Change in
Substance Abuse
Treatment](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302),
are based on this model.

According to the model, a client is considered to be at one of five
stages of readiness to change his substance-abusing behavior, each stage
being progressively closer to sustained recovery. Those stages are
precontemplation, contemplation, preparation, action, and maintenance.
The model assumes that individuals may move back and forth between
different stages over time. A corollary to this assumption is that an
individual\'s level of motivation is definitely not a permanent
characteristic. Rather, motivation to change can be influenced by
others, including detoxification treatment staff.

In general, the basic concept is to try to move patients to the next
stage of change. The clinician needs to identify any potential obstacles
that might hinder the patient\'s progress through the stages of change.
The transtheoretical model is illustrated in Figure 3-5 and the details
of each stage are described in the text of the original guideline
document.

**Fostering a Therapeutic Alliance**

The therapeutic alliance refers to the quality of the relationship
between a patient and his care providers and is the \"nonspecific
factor\" that predicts successful therapy outcomes across a variety of
different therapies. A therapeutic alliance should be developed in the
context of an ability to form an alliance to a group of helping
individuals\--such as a healthy support network or therapeutic
community. A clinically appropriate relationship between the clinician
and patient that is supportive, empathic, and nonjudgmental is the
hallmark of a strong therapeutic alliance.

Readiness to change predicts a positive therapeutic alliance. Strong
alliances, in turn, have been associated with positive outcomes in
patients who are dependent on alcohol, as well as patients involved in
methadone maintenance, on such measures as illicit drug use, employment
status, and psychological functioning. In addition, the practitioner\'s
expertise and competence instill confidence in the treatment and
strengthen the therapeutic alliance. Emphasis also should be given to
the alliance with a social support network, which can be a powerful
predictor of whether the patient stays in treatment.

Given the importance of the therapeutic alliance and the fact that
detoxification often is the entry point for patients into substance
abuse treatment services, work on establishing a therapeutic alliance
ideally will begin upon admission. Many of the guidelines listed above
for enhancing motivation apply to establishing this rapport. Some
additional recommendations for developing the therapeutic alliance
include discussing the issue of confidentiality with patients and
acknowledging that the road to recovery is difficult, as well as being
consistent, dependable, trustworthy, and available, even when the
patient is not. The clinician should remain calm and cool even if the
patient becomes noticeably upset. Practitioners should be confident yet
humble and should set limits in a respectful manner without engaging in
a power struggle. See Figure 3-6 in the original guideline document for
a list of characteristics most valuable to a clinician in strengthening
the therapeutic alliance.

**Referrals and Linkages**

Once an individual passes through the most severe of the withdrawal
symptoms and is safe and medically stable, the focus of the psychosocial
interventions shifts toward actively preparing her for substance abuse
treatment and maintenance activities. These interventions include (1)
assessment of the patient\'s characteristics, strengths, and
vulnerabilities that will influence recommendations for substance abuse
treatment; (2) preparing the patient to participate in treatment; and
(3) successfully linking the patient to treatment as well as other
needed services and resources.

Ensuring that patients with substance use disorders enter substance
abuse treatment following detoxification often is difficult. Many
patients believe that once they have eliminated the substance or
substances of abuse from their bodies, they have achieved abstinence.
Moreover, some insurance policies may not cover treatment, or only offer
partial coverage. The patient may have to go through cumbersome channels
to determine if treatment is covered, and if so, how much.

Preparation should focus on eliminating administrative barriers to
entering substance abuse treatment prior to discussing treatment options
with the patient. Discussions with the patient should be consistent with
the patient\'s improving ability to process and assess information in
such a way that the patient appears to be acting with his or her own
interests in mind.

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

To make appropriate recommendations for ongoing treatment and recovery
activities, detoxification staff need to determine the individual
characteristics of clients and their environments that are likely to
influence the level of care, setting, and specialized services needed
for recovery. ASAM\'s *Patient Placement Criteria, Second Edition,
Revised* (PPC-2R) provides one widely used model for determining the
level of services needed to address substance-related disorders. The
levels of treatment services range from community-based early
intervention groups to medically managed intensive inpatient services.
As noted in \"Detoxification and substance abuse treatment: settings,
levels of care, and patient placement,\" providers need to make a
placement decision 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

Due to the limited time patients stay in detoxification settings, it is
challenging for programs to conduct a complete assessment of the
rehabilitation needs of the individual. With this in mind,
detoxification programs should focus on those areas that are essential
to make an appropriate linkage to substance abuse treatment services.
The assessment of the psychosocial needs affecting the rehabilitation
process itself may have to be left to the professionals providing
substance abuse treatment. Other assessment considerations include

-   Special needs, such as co-occurring psychiatric and medical
    conditions that may complicate treatment or limit access to
    available rehabilitation services

-   Pregnancy, physical limitations, and cognitive impairments that
    limit the settings suitable for the individual

-   Support system issues such as family support, domestic violence, and
    isolation that influence recommendations about residential versus
    outpatient settings

-   The needs of dependent children

-   The need for gender-specific treatment

The Table below outlines the areas the consensus panel recommends for
assessment to determine the most appropriate rehabilitation plan.

  -------------------------------------------------------------------------
  **Recommended Areas    
  for Assessment To      
  Determine Appropriate  
  Rehabilitation Plans** 
  ---------------------- --------------------------------------------------
  **Domain**             **Description**

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

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

  Physical, Sensory, or  Physical conditions that may require specially
  Mobility Limitations   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              Frequency, amount, and duration of use; chronicity
  Abuse/Dependence       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      Degree of support from family and significant
  Support                others, substance-free friends, involvement in
                         support groups

  Co-Occurring           Other psychiatric symptoms that are likely to
  Psychiatric Disorders  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          Unique strengths and resources of the client and
  Resources              his or her environment

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

**Settings for Treatment**

Just as with settings for detoxification, settings where substance abuse
treatment is provided often are confused with the level of intensity of
the services. It is increasingly clear that although level of intensity
of services and setting are both critical to successful recovery, they
are two separate dimensions to be considered when linking clients to
treatment. This process has been called \"de-linking\" or \"unbundling\"
and generally involves determining the need for social services
independently from the clinical intensity.

Treatment and maintenance activities are offered in a variety of
settings. These include settings specifically designed to deliver
substance abuse treatment, such as freestanding substance abuse
treatment centers, as well as settings operating for other purposes,
including mental health centers, jails and prisons, and community
corrections facilities. Descriptions of these settings appear in the
section titled \"Setting for Treatment\" in the original guideline
document.

**Provide Linkage to Treatment and Maintenance Activities**

Approximately half of those making an appointment for treatment do not
appear for their first appointment and another 20 percent or more fail
to appear for the second. As patients near completion of detoxification,
whether they take the next step and enter treatment is dependent on a
number of variables.

Research indicates that patients are more likely to initiate and remain
in rehabilitation if they believe the services will help them with
specific life problems. Figure 3-8 in the original guideline document
suggests strategies that detoxification personnel can use with their
patients to promote the initiation of treatment and maintenance
activities.

**Provide Access to Wraparound Services**

Patients are more likely to engage in treatment if they believe the full
array of their problems will be addressed, including those needs
typically addressed by wraparound services (e.g., housing, vocational
assistance, childcare, transportation). Moreover, patients receiving
needed wraparound services remain in substance abuse treatment longer
and improve more than people who do not receive such services.

As the individual passes through acute intoxication and withdrawal, it
is important to ensure that the basic needs of the patient are met after
discharge. These needs include access to a safe, stable, and drug-free
living environment if possible; physical safety; food and clothing;
ongoing health and prenatal care; financial assistance; and childcare.
Ensuring access to these basic needs may be problematic, and staff must
be flexible and creative in finding the means to meet the basic needs of
the patient.

Clearly, services planning should extend beyond the issues of substance
dependence to other areas that may affect compliance with
rehabilitation. Detoxification providers should be familiar with
available resources for legal assistance, dental care, support groups,
interpreters, housing assistance, trauma treatment, recovery-sensitive
parenting groups, spiritual and cultural support, employment assistance,
and other assistance programs for basic needs. Family and other support
systems also can be helpful to the patient in accessing services and
should take part in the services planning as often as possible, always
with the patient\'s consent.

To address the needs of homeless and indigent patients, detoxification
providers should be familiar with emergency shelters, cash assistance,
and food programs in their communities and should have established
referral relationships. Assessing women, teenagers, older adults, and
other vulnerable individuals for victimization by another member of the
household also is important. Patients should be linked with prenatal and
primary health care for domestic violence. Ideally, linkage to these
programs includes more than a phone number; detoxification staff should
assist patients in scheduling initial appointments and arranging for
transportation.

Linkage to primary health and prenatal care as well as to community
resources is essential for individuals with substance use disorders.
Linkages can be an effective mechanism to assist the patient in
accessing these services if they are not available as a part of the
detoxification program. Formalized referral arrangements through
contracts or memoranda of understanding can be useful to specify
organizational obligations.

**Minimize Access Barriers**

An integral part of the process of linking an individual with
rehabilitation and treatment resources is to address access barriers.
Transportation, child care during treatment, the potential for relapse
between detoxification discharge and treatment admission, housing needs,
and safety issues such as possible domestic violence should be addressed
through an individualized plan prior to discharge.

The problem of a patient\'s placement on a waiting list presents a
special barrier to treatment. The solution lies in developing strategies
to maintain motivation for treatment during the waiting period.

For pregnant women and patients with dependent children, the threat of
Child Protective Services removing their children for abuse and neglect
due to drug use can be a barrier to entering a treatment program.

Additionally, interacting with hostile or unfriendly practitioners and
encountering resistance from family, partners, or friends can be
barriers to treatment entry.

Detoxification staff should be knowledgeable about State laws regarding
drug use during pregnancy and definitions of child abuse and neglect in
order to be able to reassure and encourage women to enter treatment.

People who identify as having a physical or cognitive disability also
face special barriers to treatment. The reader is referred to TIP 29,
[Substance Use Disorder Treatment for People With Physical and Cognitive
Disabilities](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.52487),
and TIP 36, [Substance Abuse Treatment for Persons With Child Abuse and
Neglect
Issues](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145),
for more information on these topics.

For racial/ethnic minorities, access barriers can be compounded by
language, cultural, and financial factors. The ability of programs to
develop culturally specific interventions, train staff and interpreters
to respond to the specific needs of these individuals, and be aware of
cultural differences in the manifestation of symptoms is critical to
improving access to care. Supervision of staff and training in
cross-cultural issues is equally important to all programs serving
diverse patient populations.

**Use Case Management**

Case management presents an opportunity to tailor services to individual
client needs and to minimize barriers to these services. Case management
is a set of services managed to assist the client in accessing needed
resources. It is a useful strategy to ensure that access to wraparound
services such as employment, housing, health care, and basic needs are
met along with minimizing barriers to accessing substance abuse
treatment. As outlined in TIP 27, [Comprehensive Case Management for
Substance Abuse
Treatment](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.49769),
the common functions of case management are defined as assessment,
planning, linkage, monitoring, and advocacy. Case managers can
facilitate the critical linkage between detoxification services and
rehabilitation by providing transportation to the rehabilitation
facility, arranging for childcare, or assisting with housing needs.
Additionally, case management is a widely used strategy to integrate
mental health and substance abuse treatment for those with co-occurring
conditions.

**Linkage to Ongoing Psychiatric Services**

Although it is important to make referrals for ongoing psychiatric
attention, the presence of psychological symptoms should not prevent
detoxification staff from referring patients to substance abuse
treatment. Individuals with co-occurring psychiatric conditions appear
to be able to initiate and benefit from substance abuse treatment like
individuals without psychiatric conditions.

Since some psychiatric illnesses may affect drug cravings in patients
who are substance dependent, it is important to ensure that both the
psychiatric condition and the substance use disorder are addressed in
rehabilitation. Individuals who are taking psychotropic medications
should be counseled about the importance of continuing on these
medications. Whenever possible, discharge from the detoxification
services should be coordinated with the patient\'s mental health
provider in the community, and the patient should have an appointment
scheduled at the time of discharge from the detoxification facility.
Detoxification providers should request that the patient sign
appropriate releases of information to provide assessment and other
material to the mental health provider to promote continuity of care.
This should only occur when the patient is medically stabilized and is
in such a state of mind that he or she can make coherent decisions in
this regard (e.g., while intoxicated, patients should not be permitted
to sign releases).

For individuals with serious co-occurring psychiatric conditions,
integrated treatment for substance use disorders and mental illness is
recommended. Case management services as described above may be
especially important for individuals with severe mental illness impeding
their ability to access services on their own. Increasingly, substance
abuse and mental health providers are implementing models using
clinicians trained to deliver both substance abuse and mental health
treatment concurrently. For more information, see the NGC summary of
SAMHSA\'s TIP 42, [Substance Abuse Treatment for Persons With
Co-Occurring
Disorders](http://www.guideline.gov/summary/summary.aspx?doc_id=6849&nbr=4203).

**Linkage to Follow-up Medical Care**

The patient\'s consent should be sought to involve her or his primary
healthcare provider in the coordination of care. Patients with chronic
medical conditions and those in need of follow-up care should have an
appointment made for follow-up medical care before leaving the
detoxification setting.

**Considerations for Individuals With Chronic Substance Dependence**

For individuals with substance abuse problems who detoxify regularly but
have limited periods of abstinence, traditional treatment approaches may
not be effective. In some cases, addressing other needs may provide an
avenue to engage the individual with chronic substance dependence in
treatment. Case management approaches can be successful at addressing
the need for housing, health care, and basic needs even though the
individual is not yet willing to confront the issue of drinking or other
drug use. TIP 27, [Comprehensive Case Management for Substance Abuse
Treatment](http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.49769),
provides additional information about delivery of case management
services to homeless individuals with substance use disorders and those
with other complex problems. Documentation of repetitive inappropriate
use of voluntary detoxification services may help pave the way for civil
commitment to involuntary treatment where this is an option, and, where
detoxification resources are limited, treatment systems need to be
creative in designing care plans for patients seeking frequent
detoxification without evidence of any therapeutic benefit.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated. Recommendations are based on a combination of clinical
experience and research-based evidence.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Research indicates that addressing psychosocial issues during
detoxification significantly increases the likelihood that the patient
will experience a safe detoxification and go on to participate in
substance abuse treatment.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The opinions expressed herein are the views of the consensus panel
members and do not necessarily reflect the official position of Center
for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA), or Department of Health and Human
Services (DHHS). No official support of or endorsement by CSAT, SAMHSA,
or DHHS for these opinions or for particular instruments, software, or
resources described in this document is intended or should be inferred.
The guidelines in this document should not be considered substitutes for
individualized client care and treatment decisions.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Chapter 6, Financing and Organization Issues, in the original guideline
document, covers the challenging financial and organizational aspects of
developing a detoxification program. Careful strategic planning and
assurance of funding from reputable and varied referral sources are
essential for new and existing programs. As a buffer against shrinking
budgets, all programs should consider broadening their funding streams
and referral sources, expanding the range of clients they can serve, and
promptly referring clients for other services not provided on site.
Partnerships can be a critical factor to the financial success of a
program. To operate effectively, administrators and other staff must
thoroughly understand the managed care and community political
environment including its terminology, contracts, negotiations,
payments, appeals, and priority populations. A successful working
relationship with a managed care organization, a health plan, other
purchasers, or with another agency or group of agencies depends on
day-to-day interactions in which staff members serve as informed,
professional advocates for their clients and the program.

Refer to Chapter 6 in the original guideline document for full details
(see \"Companion Documents\" field in this summary).

#### IMPLEMENTATION TOOLS

Patient Resources\
Pocket Guide/Reference Cards

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

An overview of psychological and biomedical issues during
detoxification. In: Center for Substance Abuse Treatment (CSAT).
Detoxification and substance abuse treatment. Rockville (MD): Substance
Abuse and Mental Health Services Administration (SAMHSA); 2006 Jan 18.
p. 19-41. (Treatment improvement protocol (TIP); no. 45).

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006

#### GUIDELINE DEVELOPER(S)

Substance Abuse and Mental Health Services Administration (U.S.) -
Federal Government Agency \[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Treatment Improvement Protocol (TIP) Series 45 Consensus Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Norman S. Miller, MD, FASAM (*Chair*), Professor and
Director of Addiction Medicine, Department of Psychiatry, Michigan State
University, East Lansing, Michigan; Steven S. Kipnis, MD, FACP
(*Co-Chair*), Medical Director, Russell E. Blaisdell Addiction Treatment
Center, New York State Office of Alcoholism and Substance Abuse
Services, Orangeburg, New York

*Workgroup Managers and Co-Managers*: Anne M. Herron, MS, Director,
Division of State and Community Assistance, Center for Substance Abuse
Treatment, Substance Abuse and Mental Health Services Administration
Rockville, Maryland; Ronald J. Hunsicker, D.Min., FACATA,
President/Chief Executive Officer, National Association of Addiction
Treatment Providers, Lancaster, Pennsylvania; Robert J. Malcolm, Jr.,
MD, Professor of Psychiatry, Family Medicine, and Pediatrics, Associate
Dean for Continuing Medical Education, Center for Drug and Alcohol
Programs, Institute of Psychiatry, Medical University of South Carolina,
Charleston, South Carolina; Anthony Radcliffe, MD, FASAM, Chief of
Addiction Medicine, Kaiser Permanente, Southern California Permanente
Medical Group, Fontana, California; Carl Rollynn Sullivan, III, MD,
Professor, Director of Addiction Program, Department of Behavioral
Medicine and Psychiatry, School of Medicine, West Virginia University,
Morgantown, West Virginia; Nancy R. VanDeMark, MSW, Director of Colorado
Social Research Associates, Arapahoe House, Inc., Thornton, Colorado

*Panelists*: Louis E. Baxter, Sr., MD, FASAM, Executive Director,
Physicians Health Program, Medical Society of New Jersey, Lawrenceville,
New Jersey; Kenneth O. Carter, MD, MPH, Dipl.Ac., Psychiatrist,
Acupuncture Detoxification Specialist, Carolinas Medical Center,
Charlotte, North Carolina; Jean Lau Chin, MA, EdD, ABPP, President, CEO
Services; Alameda, California; Charles A. Dackis, MD, Assistant
Professor, Department of Psychiatry, University of Pennsylvania School
of Medicine, Philadelphia, Pennsylvania; Sylvia J. Dennison, MD,
Chief/Medical Director, Division of Addiction Services, Department of
Psychiatry, University of Illinois, Chicago, Illinois; Patricia L.
Mabry, PhD, Health Scientist Administrator/Behavioral Scientist, Office
of Behavioral and Social Sciences Research, Office of the Director,
National Institutes of Health, Bethesda, Maryland; Hendree E. Jones, MA,
PhD, Assistant Professor, CAP Research Director, Department of
Psychiatry and Behavioral Sciences, Johns Hopkins University Center,
Baltimore, Maryland; Frances J. Joy, RN, CD, CASAC, Manager, Alcohol and
Drug Abuse Unit, State of Missouri Department of Mental Health, Fulton
State Hospital, Fulton, Missouri

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [National Clearinghouse for
Alcohol and Drug Information (NCADI) Web
site.](http://store.health.org/catalog/productDetails.aspx?ProductID=17398)

Print copies: Available from the National Clearinghouse for Alcohol and
Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20852.
Publications may be ordered from [NCADI\'s Web
site](http://ncadistore.samhsa.gov/catalog/) or by calling (800)
729-6686 (United States only).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Executive summary. Detoxification and substance abuse treatment. p.
    xiii-xvii. (Treatment improvement protocol (TIP); no. 45).

-   Overview, essential concepts, and definitions in detoxification.
    Detoxification and substance abuse treatment. p. 1-6. (Treatment
    improvement protocol (TIP); no. 45).

-   Financing and organizational issues. Detoxification and substance
    abuse treatment. p. 135-156. (Treatment improvement protocol (TIP);
    no. 45).

Electronic copies: Available from the [National Clearinghouse for
Alcohol and Drug Information (NCADI) Web
site](http://store.health.org/catalog/productDetails.aspx?ProductID=17398).

Print copies: Available from the National Clearinghouse for Alcohol and
Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20852.
Publications may be ordered from [NCADI\'s Web
site](http://store.health.org/catalog/SC_Itemlist.aspx) or by calling
(800) 729-6686 (United States only).

The following are also available:

-   Detoxification and Substance Abuse Treatment Quick Guide for
    Clinicians. See the related QualityTool summary on the [Health Care
    Innovations Exchange Web
    site](http://www.innovations.ahrq.gov/content.aspx?id=1990).

-   Detoxification and Substance Abuse Treatment Quick Guide for
    Administrators. See the related QualityTool summary on the [Health
    Care Innovations Exchange Web
    site](http://www.innovations.ahrq.gov/content.aspx?id=2003).

-   Detoxification and Substance Abuse Treatment Quick Guide for
    Physicians.

-   KAP KEYS for Clinicians based on TIP 45, Detoxification and
    Substance Abuse Treatment.

Electronic copies: Available from the [National Clearinghouse for
Alcohol and Drug Information (NCADI) Web
site](http://store.health.org/catalog/productDetails.aspx?ProductID=17398).

Print copies: Available from the National Clearinghouse for Alcohol and
Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20852.
Publications may be ordered from [NCADI\'s Web
site](http://ncadistore.samhsa.gov/catalog/) or by calling (800)
729-6686 (United States only).

#### PATIENT RESOURCES

The following is in development:

-   What happens now? A guide to help you after detoxification.

Electronic copies: Available from the [National Clearinghouse for
Alcohol and Drug Information (NCADI) Web
site.](http://ncadistore.samhsa.gov/catalog/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on June 29, 2006. The information
was verified by the guideline developer on July 25, 2006.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008