A Treatment 

Improvement 

Protocol

TIP

45

Detoxification and

Substance Abuse Treatment
         

           

     

   

Detoxification and
 

Substance Abuse
 

Treatment
 

A Treatment 

Improvement 

Protocol
 

TIP
 45
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, MD 20857
Acknowledgments

This publication was produced under the

Knowledge Application Program (KAP) contract numbers 270-99-7072 and 270-04-7049

with the Substance Abuse and Mental Health

Services Administration (SAMHSA), U.S.

Department of Health and Human Services

(HHS). Andrea Kopstein, Ph.D., M.P.H, Karl

D. White, Ed.D, and Christina Currier served

as Government Project Officers.

Disclaimer

The views, opinions, and content expressed

herein are those of the consensus panel and do

not necessarily reflect the views, opinions, or

policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS

for these opinions or for particular instruments, software, or resources is intended or

should be inferred.

Public Domain Notice

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission from SAMHSA.

Citation of the source is appreciated. However,

this publication may not be reproduced or distributed for a fee without the specific, written

authorization of the Office of Communications,

SAMHSA, HHS.

Electronic Access and Copies

of Publication

This publication may be ordered from or downloaded from SAMHSA’s Publications Ordering 

Web page at http://store.samhsa.gov. Or, please 

call SAMHSA at 1-877-SAMHSA-7 (1-877-726-

4727) (English and Español).

Recommended Citation

Center for Substance Abuse Treatment.

Detoxification and Substance Abuse

Treatment. Treatment Improvement Protocol

(TIP) Series, No. 45. HHS Publication No.

(SMA) 15-4131. Rockville, MD: Center for

Substance Abuse Treatment, 2006.

Originating Office

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental

Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 15-4131

Printed 2006

Revised 2008, 2012, 2013, and 2015

ii Acknowledgments
Contents
 

What Is a TIP?........................................................................................................vii
 

Consensus Panel ......................................................................................................ix
 

KAP Expert Panel and Federal Government Participants................................................xi
 

Foreword ..............................................................................................................xiii
 

Executive Summary .................................................................................................xv
 

Chapter 1—Overview, Essential Concepts, and Definitions in Detoxification........................1
 

Purpose of the TIP.....................................................................................................1
 

Audience ..................................................................................................................2
 

Scope ......................................................................................................................2
 

History of Detoxification Services...................................................................................2
 

Definitions................................................................................................................3
 

Guiding Principles in Detoxification and Substance Abuse Treatment .....................................7
 

Challenges to Providing Effective Detoxification ................................................................8
 

Chapter 2—Settings, Levels of Care, and Patient Placement...........................................11
 

Role of Various Settings in the Delivery of Services...........................................................11
 

Other Concerns Regarding Levels of Care and Placement...................................................20
 

Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification .......23
 

Evaluating and Addressing Psychosocial and Biomedical Issues ...........................................24
 

Strategies for Engaging and Retaining Patients in Detoxification ..........................................33
 

Referrals and Linkages ..............................................................................................38
 

Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .......47
 

Psychosocial and Biomedical Screening and Assessment.....................................................47
 

Alcohol Intoxication and Withdrawal.............................................................................52
 

Opioids ..................................................................................................................66
 

Benzodiazepines and Other Sedative­Hypnotics ...............................................................74
 

Stimulants...............................................................................................................76
 

Inhalants/Solvents.....................................................................................................82
 

Nicotine..................................................................................................................84
 

Marijuana and Other Drugs Containing THC ..................................................................95
 

Anabolic Steroids......................................................................................................96
 

Club Drugs..............................................................................................................97
 

Management of Polydrug Abuse: An Integrated Approach.................................................101
 

Alternative Approaches ............................................................................................103
 

Considerations for Specific Populations........................................................................105
 

iii
Chapter 5—Co­Occurring Medical and Psychiatric Conditions.......................................121
 

General Principles of Care for Patients With Co­Occurring Medical Conditions .....................122
 

Treatment of Co­Occurring Psychiatric Conditions..........................................................136
 

Standard of Care for Co­Occurring Psychiatric Conditions ...............................................138
 

Chapter 6—Financing and Organizational Issues.........................................................145
 

Preparing and Developing a Program...........................................................................145
 

Working in Today’s Managed Care Environment.............................................................157
 

Preparing for the Future...........................................................................................168
 

Appendix A—Bibliography......................................................................................169
 

Appendix B—Common Drug Intoxication Signs and Withdrawal Symptoms .....................223
 

Appendix C—Screening and Assessment Instruments ...................................................225
 

Section I: Screening and Assessment for Alcohol Abuse ....................................................225
 

Section II: Screening and Assessment for Alcohol and Other Drug Abuse..............................228
 

Appendix D—Resource Panel..................................................................................231
 

Appendix E—Field Reviewers..................................................................................233
 

Index ..................................................................................................................237
 

SAMHSA TIPs and Publications...............................................................................243
 

Figures
 

Figure 1­1 DSM­IV­TR Definitions of Terms .....................................................................6
 

Figure 1­2 Guiding Principles Recognized by the Consensus Panel .........................................7
 

Figure 2­1 Issues To Consider in Determining Whether Inpatient or Outpatient 

Detoxification Is Preferred .......................................................................................21
 

Figure 3­1 Initial Biomedical and Psychosocial Evaluation Domains......................................25
 

Figure 3­2 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26
 

Figure 3­3 Strategies for De­escalating Aggressive Behaviors ...............................................28
 

Figure 3­4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural 

Framework...........................................................................................................32
 

Figure 3­5 The Transtheoretical Model (Stages of Change) ..................................................36
 

Figure 3­6 Clinician’s Characteristics Most Important to the Therapeutic Alliance....................38
 

Figure 3­7 Recommended Areas for Assessment To Determine Appropriate 

Rehabilitation Plans...............................................................................................40
 

Figure 3­8 Strategies To Promote Initiation of Treatment and Maintenance Activities................42
 

Figure 4­1 Assessment Instruments for Dependence and Withdrawal From Alcohol and
 

Specific Illicit Drugs................................................................................................49
 

Figure 4­2 Symptoms of Alcohol Intoxication...................................................................53
 

Figure 4­3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61
 

Figure 4­4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67
 

Figure 4­5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents........................77
 

iv Contents
Figure 4­6 Other Sedative­Hypnotics and Their Phenobarbital Withdrawal Equivalents............78
 

Figure 4­7 Stimulant Withdrawal Symptoms....................................................................79
 

Figure 4­8 Commonly Abused Inhalants/Solvents..............................................................83
 

Figure 4­9 DSM­IV­TR on Nicotine Withdrawal ...............................................................86
 

Figure 4­10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87
 

Figure 4­11 The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ) ........................88
 

Figure 4­12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With 

Other Psychiatric Conditions ....................................................................................89
 

Figure 4­13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications......90
 

Figure 4­14 The “5 A’s” for Brief Intervention .................................................................91
 

Figure 4­15 Some Definitions Regarding Disabilities ........................................................111
 

Figure 4­16 Impairment and Disability Chart.................................................................112
 

Figure 4­17 Locating Expert Assistance.........................................................................114
 

Figure 6­1 Financial Arrangements for Providers............................................................162
 

Contents v
What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Center for

Substance Abuse Treatment (CSAT), part of the Substance Abuse and

Mental Health Services Administration (SAMHSA) within the U.S.

Department of Health and Human Services (HHS). Each TIP involves the

development of topic-specific best-practice guidelines for the prevention

and treatment of substance use and mental disorders. TIPs draw on the

experience and knowledge of clinical, research, and administrative experts

of various forms of treatment and prevention. TIPs are distributed to

facilities and individuals across the country. Published TIPs can be

accessed via the Internet at http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for

the practices it recommends, SAMHSA recognizes that behavioral health is

continually evolving, and research frequently lags behind the innovations

pioneered in the field. A major goal of each TIP is to convey "front-line"

information quickly but responsibly. If research supports a particular

approach, citations are provided. When no citation is provided, the information is based on the collective clinical knowledge and experience of the

consensus panel. 

vii
ix

Consensus Panel

Chair

Norman S. Miller, M.D., FASAM

Professor and Director of Addiction Medicine

Department of Psychiatry 

Michigan State University

East Lansing, Michigan

Co-Chair

Steven S. Kipnis, M.D., FACP

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, M.S.

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., M.D.

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, M.D., FASAM

Chief of Addiction Medicine

Kaiser Permanente

Southern California Permanente Medical

Group

Fontana, California

Carl Rollynn Sullivan, III, M.D.

Professor 

Director of Addiction Program 

Department of Behavioral Medicine and

Psychiatry 

School of Medicine 

West Virginia University 

Morgantown, West Virginia

Nancy R. VanDeMark, M.S.W.

Director of Colorado Social Research

Associates

Arapahoe House, Inc.

Thornton, Colorado

Panelists 

Louis E. Baxter, Sr., M.D., FASAM 

Executive Director 

Physicians Health Program 

Medical Society of New Jersey

Lawrenceville, New Jersey

Kenneth O. Carter, M.D., M.P.H., Dipl.Ac.

Psychiatrist

Acupuncture Detoxification Specialist 

Carolinas Medical Center 

Charlotte, North Carolina

Jean Lau Chin, M.A., Ed.D., ABPP

President 

CEO Services

Alameda, California

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.
     

   

     

         

     

   

       

     

   

       

   

         

     

     

         

   

     

       

     

   

           

         

             

     

Charles A. Dackis, M.D.

Assistant Professor

Department of Psychiatry

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania

Sylvia J. Dennison, M.D.

Chief/Medical Director

Division of Addiction Services

Department of Psychiatry

University of Illinois

Chicago, Illinois

Patricia L. Mabry, Ph.D.

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, M.A., Ph.D.

Assistant Professor

CAP Research Director

Department of Psychiatry and Behavioral

Sciences

Johns Hopkins University Center

Baltimore, Maryland

Frances J. Joy, R.N., CD, CASAC

Manager

Alcohol and Drug Abuse Unit

State of Missouri Department of Mental Health

Fulton State Hospital

Fulton, Missouri

x Consensus Panel
xi

KAP Expert Panel and Federal

Government Participants

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC,

CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, Ohio 

Deion Cash

Executive Director

Community Treatment & Correction 

Center, Inc.

Canton, Ohio

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, Colorado 

Carlo C. DiClemente, Ph.D.

Chair

Department of Psychology

University of Maryland Baltimore County

Baltimore, Maryland 

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief 

Services Research Branch

National Institute on Drug Abuse

Bethesda, Maryland

Michael Galer, D.B.A., M.B.A., M.F.A.

Independent Consultant

Westminster, Massachusetts

Renata J. Henry, M.Ed.

Director

Division of Substance Abuse and 

Mental Health

Delaware Health and Social Services

New Castle, Delaware 

Joel Hochberg, M.A.

President

Asher & Partners

Los Angeles, California

Jack Hollis, Ph.D.

Associate Director

Center for Health Research

Kaiser Permanente

Portland, Oregon 

Mary Beth Johnson, M.S.W.

Director

Addiction Technology Transfer Center

National Office

University of Missouri—Kansas City

Kansas City, Missouri 

Eduardo Lopez, B.S.

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.
       

     

   

   

   

     

     

   

   

     

     

         

   

      

   

   

   

    

       

     

         

    

     

   

         

       

    

   

   

   

       

   

     

         

     

   

     

     

Diane Miller

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse

and Alcoholism

Kensington, Maryland

Harry B. Montoya, M.A.

President/Chief Executive Officer

Hands Across Cultures

Espanola, New Mexico

Richard K. Ries, M.D.

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Harborview Medical Center

Seattle, Washington

Gloria M. Rodriguez, D.S.W.

Research Scientist

Division of Addiction Services

New Jersey Department of Health

and Senior Services

Trenton, New Jersey

Everett Rogers, Ph.D.

Center for Communications Programs

Johns Hopkins University

Baltimore, Maryland

Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst

Agency for Healthcare Research & Quality

Rockville, Maryland

Nedra Klein Weinreich, M.S.

President

Weinreich Communications

Canoga Park, California

Clarissa Wittenberg

Director

Office of Communications and Public Liaison

National Institute of Mental Health

Kensington, Maryland

Consulting Members

Paul Purnell, M.A.

Social Solutions, L.L.C.

Potomac, Maryland

Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development

Washington, DC

Thomas W. Valente, Ph.D.

Director, Master of Public Health Program

Department of Preventive Medicine

School of Medicine

University of Southern California

Alhambra, California

Patricia A. Wright, Ed.D.

Independent Consultant

Baltimore, Maryland

xii Expert Panel
xiii

Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human

Services that leads public health efforts to advance the behavioral health

of the nation. SAMHSA’s mission is to reduce the impact of substance

abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance abuse and mental illness on

America's communities by providing evidence-based and best practice

guidance to clinicians, program administrators, and payers. TIPs are the

result of careful consideration of all relevant clinical and health services

research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program

administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. Field

reviewers then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs panelists and reviewers

bring to this highly participatory process have helped bridge the gap

between the promise of research and the needs of practicing clinicians and

administrators to serve, in the most scientifically sound and effective ways,

people in need of behavioral health services. We are grateful to all who

have joined with us to contribute to advances in the behavioral health

field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Daryl W. Kade

Acting Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration
                         

                   

       

               

               

                 

   

               

   

               

                 

               

     

                 

                 

             

Executive Summary
 

This Treatment Improvement Protocol (TIP) is a revision of TIP 19,

Detoxification From Alcohol and Other Drugs (Center for Substance

Abuse Treatment 1995d). It provides clinicians with updated information and expands on the issues commonly encountered in the delivery of

detoxification services. Like its predecessor, this TIP was created by a

panel of experts (the consensus panel) with diverse experience in detoxification services—physicians, psychologists, counselors, nurses, and

social workers, all with particular expertise to share. 

This diverse group agreed to the following principles, which served as a

basis for the TIP:

1. Detoxification, in and of itself, does not constitute complete substance abuse treatment. 

2. The detoxification process consists of three essential components,

which should be available to all people seeking treatment:

•Evaluation 

•Stabilization 

•Fostering patient readiness for and entry into substance abuse

treatment

3.	 Detoxification can take place in a wide variety of settings and at a number of levels of intensity within these settings. Placement should be

appropriate to the patient’s needs.

4.	 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 substance abuse treatment

providers after detoxification.

5.	 Ultimately, insurance coverage for the full range of detoxification services is cost­effective.

6.	 Patients seeking detoxification services have diverse cultural and ethnic

backgrounds as well as unique health needs and life situations.

Programs offering detoxification should be equipped to tailor treatment

to their client populations.

7.	 A successful detoxification process can be measured, in part, by

whether an individual who is substance dependent enters and

remains in some form of substance abuse treatment/rehabilitation

after detoxification.

Among the issues covered in this TIP is the importance of detoxification

as one component in the continuum of healthcare services for substance­related disorders. The TIP reinforces the urgent need for nonxv
     

     

     

   

       

     

traditional settings—emergency rooms, medi­        

cal and surgical wards in hospitals, acute care

clinics, and others—to be prepared to participate in the process of getting the patient who

is in need of detoxification services into treatment as quickly as possible. Furthermore, it

promotes the latest strategies for retaining

individuals in detoxification while also

encouraging the development of the therapeutic alliance to promote the patient’s entrance

into substance abuse treatment. The TIP also

includes suggestions on addressing psychosocial issues that may impact detoxification

treatment, such as providing culturally

appropriate services to the patient population.

Matching patients to appropriate care represents a challenge to detoxification programs.

Given the wide variety of settings and the

unique needs of the individual patient, establishing criteria that take into account all the

possible needs of patients receiving detoxification and treatment services is an extraordinarily complex task. Addiction medicine has

sought to develop an efficient system of care

that matches patients’ clinical needs with the

appropriate care setting in the least restrictive and most cost­effective manner. Patient

placement criteria, such as those published

by the American Society of Addiction

Medicine (ASAM) in the Patient Placement

Criteria, Second Edition, Revised, represent

an effort to define how care settings may be

matched to patient needs and special characteristics. These criteria—the five “Adult

Detoxification” placement levels—define the

most broadly accepted standard of care for

detoxification services. The five levels of care

are

1.	 Level I­D: Ambulatory Detoxification

Without Extended Onsite Monitoring

2.	 Level II­D: Ambulatory Detoxification With

Extended Onsite Monitoring

3.	 Level II.2­D: Clinically Managed Residential

Detoxification

4.	 Level III.7­D: Medically Monitored

Inpatient Detoxification

5.	 Level IV­D: Medically Managed Intensive

Inpatient Detoxification

ASAM criteria are being adopted extensively

on the basis of their face validity, though

their outcome validity has yet to be clinically

proven. The ASAM guidelines are to be

regarded as a work in progress, as their

authors readily admit. They are an important

set of guidelines that are of great help to clinicians. For administrators, the standards published by such groups as the Joint

Commission on Accreditation of Healthcare

Organizations and the Commission on

Accreditation of Rehabilitation Facilities provide guidance for overall program operations. 

Placement will depend in part on the substance of abuse. The consensus panel suggests

that for alcohol, sedative­hypnotic, and opioid withdrawal syndromes, hospitalization (or

some form of 24­hour medical care) is often

the preferred setting for detoxification, based

on principles of safety and humanitarian concerns. When hospitalization cannot be provided, then a setting that provides a high level

of nursing and medical backup 24 hours a

day, 7 days a week is desirable.

A further challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients

often leave detoxification without followup to

the treatment needed to achieve long­term

abstinence. Each year at least 300,000

patients with substance use disorders or acute

intoxication obtain inpatient detoxification in

general hospitals, while additional numbers

obtain detoxification in other settings. Only

20 percent of people discharged from acute

care hospitals receive substance abuse treatment during that hospitalization. Only 15

percent of people who are admitted to a

detoxification program through an emergency

room and then discharged go on to receive

treatment.

The consensus panel recognizes that medically assisted withdrawal is not always necessary

or desirable. A nonmedical approach can be

highly cost­effective and provide inexpensive

xvi Executive Summary
           

     

           

       

             

             

           

           

         

             

           

         

access to treatment for individuals seeking

aid. Young individuals in good health, with no

history of previous withdrawal reactions, may

be well served by management of withdrawal

without medication. However, personnel

supervising in this setting should be trained to

identify life­threatening symptoms and solicit

help through the emergency medical system as

needed. 

The consensus panel also agreed on several

guidelines for nonmedical detoxification programs. Such programs should follow local governmental regulations regarding their licensing

and inspection. In addition, it is desirable that

all such programs have an alcohol and drugfree environment as well as personnel who are

familiar with the features of substance use

withdrawal syndromes, have training in basic

life support, and have access to an emergency

medical system that can transport patients to

emergency departments and other sites for clinical care.

A major clinical question for detoxification is

the appropriateness of the use of medication

in the management of an individual in withdrawal. This can be a difficult matter because

protocols have not been firmly established

through scientific studies or evidence­based

methods. Furthermore, the course of withdrawal is unpredictable and currently available techniques of screening and assessment

do not predict who will experience life­threatening complications. 

Although it is the philosophy of some treatment facilities to discontinue all medications,

this course of action is not always in the best

interest of the patient. Abrupt cessation of

psychotherapeutic medications may cause

severe withdrawal symptoms or the re­emergence of a psychiatric disorder. As a general

rule, therapeutic doses of medication should

be continued through any withdrawal if the

patient has been taking the medication as prescribed. Decisions about discontinuing the

medication should be deferred until after the

individual has completed detoxification. If,

however, the patient has been abusing the

medication or the psychiatric condition was

clearly caused by substance use, then the

rationale for discontinuing the medication is

strengthened. Finally, practitioners should

consider withholding medication that lowers

the seizure threshold (e.g., bupropion, conventional antipsychotics) during the acute

alcohol withdrawal period or at least prescribing a loading dose or scheduled taper of

benzodiazepine.

Further studies are needed to confirm the

clinical experience that psychiatric symptoms

(including anxiety, depression, and personality disorders) respond to specific treatment of

the addiction. For example, cognitive–behavioral techniques employed in the 12­Step

treatment approach have been effective in the

management of anxiety and depression associated with addiction. Although challenging,

treatment of both addiction and co­occurring

psychiatric conditions has proven cost­effective in some studies.

This TIP also provides medical information

on detoxification protocols for specific substances as well as considerations for individuals with co­occurring medical conditions

including mental disorders. While the TIP is

not intended to take the place of medical

texts, it provides the practitioner with an

overview of common medical complications

seen in individuals who use substances.

Disorders of several systems are discussed in

some detail: gastrointestinal (including the

gastrointestinal tract, liver, and pancreas),

cardiovascular system, hematologic (blood)

abnormalities, pulmonary (lung) diseases, diseases of the central and peripheral nervous

system, infectious diseases, and special miscellaneous disorders. The TIP presents a cursory overview of special conditions, modifications in protocols, and the use of detoxification medications in patients with co­occurring

medical conditions or mental disorders.

Overall treatment of specific conditions is not

addressed unless modification of such treatment is needed.

Executive Summary xvii
The setting in which detoxification occurs is

also influenced by the existence of co­occurring medical disorders. It is highly desirable

that individuals undergoing detoxification be

assessed by primary care practitioners (i.e.,

physicians, physician assistants, nurse practitioners) with some experience in substance

abuse treatment. Such an assessment should

determine whether the patient is currently

intoxicated and the degree of intoxication; the

type and severity of the withdrawal syndrome; information regarding past withdrawals; and the presence of co­occurring

psychiatric, medical, and surgical conditions

that might require specialized care.

Particular attention should be paid to those

individuals who have undergone multiple

withdrawals in the past and for whom each

withdrawal appears worse than previous

ones. Subjects with a history of severe withdrawals, multiple withdrawals, delirium

tremens (a potentially fatal syndrome associated with alcohol withdrawal), or seizures are

not good candidates for detoxification programs in nonmedical settings.

The setting in which detoxification is carried

out should be appropriate for the medical

and psychological conditions present and

should be adequate to provide the degree of

monitoring needed to ensure safety (e.g.,

oximetry [a measurement of the amount of

oxygen present in the blood], greater frequency of taking vital signs, etc.). Acute, lifethreatening conditions need to be addressed

concurrently with the withdrawal process and

intensive care unit monitoring may be indicated. Detoxification staff providing support

should be familiar with the signs and symptoms of common co­occurring medical disorders. Likewise, personnel at medical facilities

(e.g., emergency rooms, physicians’ offices)

should be aware of the signs of withdrawal

and how it affects the treatment of the presenting medical conditions. 

This TIP will also bring clinicians and administrators up to date on administrative issues

related to detoxification, including how the

services themselves can be paid for. It is

unusual in a clinical treatment improvement

protocol to discuss issues related to how clinical services are reimbursed. In the field of

substance abuse and detoxification services,

however, reimbursement issues have become

so intertwined with the delivery of services

that the consensus panel deemed it necessary

to address the conflicts and misunderstandings that sometimes arise between the care

systems and the reimbursement systems. 

Third­party payors sometimes prefer to manage payment for detoxification separately

from other phases of substance abuse treatment, thus treating detoxification as if it

occurred in isolation from that treatment.

This “unbundling” of services can result in

the separation of services into scattered segments. In other instances, reimbursement and

utilization policies dictate that only detoxification can be authorized. This detoxification

often does not cover the nonmedical counseling that is an integral part of substance abuse

treatment. 

Finally, identifying and maintaining funding

sources is a major issue in detoxification.

Substance abuse treatment in the United

States is financed through a diverse mix of

public and private sources, with substantially

more being spent by the public sector. The

existence of diverse funding streams in substance abuse treatment funding presents both

management challenges and opportunities for

program independence and stability.

However, a program with only one major

funding source is financially and clinically

vulnerable to changes in its major source’s

budget and priorities. This situation should

be avoided. The TIP suggests ways to diversify funding sources to create a steady stream

of resources that can withstand the loss of one

particular funding source. 

This TIP also makes recommendations for

fostering relationships with reimbursement

organizations, such as managed care organizations (MCOs). These positive working relationships are vital to successfully link the

patient to the needed services.  For example,

xviii Executive Summary
the MCO may use a wide variety of specific

criteria and protocols to determine whether

or not services may be authorized for substance abuse, typically including the ASAM

patient placement criteria and other level of

care or diagnosis­based criteria sets.

Successfully addressing the needs of the staff

at MCOs that are responsible for authorizing

the care provided to patients is a critical element in maintaining a relationship with an

MCO and the program’s clinical and financial

viability. To do so, staff should understand

what MCO staff do, be well trained in conducting professional relationships over the

telephone, be familiar with the criteria and

protocols used by the MCOs with which the

program has contracts, and have easy access

to the abundance of clinical and service information required by an MCO in order to help

them complete a review and authorize services. Maintaining thorough, clear, and accurate records is essential to this process.

Detoxification staff also should be familiar

with each MCO’s appeal or exceptions process

for those occasions when the outcome of a

first­level review is unsatisfactory. 

Regardless of their role in providing detoxification services, all personnel should keep in

mind that patients undergoing detoxification

are in the midst of a personal and medical

crisis. For many patients, this crisis represents a window of opportunity to acknowledge

their substance abuse problem and become

willing to seek treatment. Physicians, nurses,

substance abuse counselors, and administrators are in a unique position, not only to

ensure a safe and humane withdrawal from

substances of dependency, but also to foster

the path for the patient’s entry into substance

abuse treatment. This TIP suggests ways for

clinicians and programs to prepare the

patient for treatment while addressing the

complex psychosocial and medical variables

involved in detoxification.

Executive Summary xix
                     

                   

                   

               

                   

         

       

             

           

                     

                   

           

             

In This
 

Chapter...
 

Purpose of the TIP
 

Audience
 

Scope 

History of Detoxification
 

Services 

Definitions 

Guiding Principles in
 

Detoxification and
 

Substance Abuse
 

Treatment
 

Challenges to Providing
 

Effective Detoxification 

1  Overview, Essential

Concepts, and

Definitions in

Detoxification

Chapter 1 provides a brief historical overview of changes in the perceptions and provision of detoxification services. It also introduces the core

concepts of the detoxification field, discusses the primary goals of detoxification services, clarifies the distinction between detoxification and treatment, and highlights some of the broader issues involved with providing

detoxification within systems of care.

Purpose of the TIP

This TIP is a revision of TIP 19, Detoxification From Alcohol and

Other Drugs (Center for Substance Abuse Treatment [CSAT] 1995d).

Significant changes in the area of detoxification services since the publication of TIP 19 include

•Refinement of patient placement procedures

•Increased knowledge of the physiology of withdrawal

•Pharmacological advances in the management of withdrawal

•Changes in the role of detoxification in the continuum of services for

patients with substance use disorders, and new issues in the management

of detoxification services within comprehensive systems of care

•Emerging issues regarding specific populations (e.g., women, cultural

minorities, adolescents)

1
           

       

         

       

           

         

       

             

         

           

         

         

     

       

         

       

         

             

         

         

       

       

     

             

         

           

                 

         

         

             

   

             

           

           

         

       

This TIP provides clinicians with up­to­date

information in these areas. It also expands on

the administrative, legal, and ethical issues

commonly encountered in the delivery of

detoxification services and suggests performance measures for detoxification programs.

Like its predecessor, this TIP was created by

a panel of experts with diverse experience in

detoxification services—physicians, psychologists, counselors, nurses, and social workers,

all with particular expertise to share. 

Audience

The primary audiences for this TIP include

substance abuse treatment counselors; administrators of detoxification programs; Single State

Agency directors; psychiatrists and other

physicians working in the field; primary care

providers such as physicians, nurse practitioners, physician assistants, nurses, psychologists,

and other clinical staff members; staff of managed care and insurance carriers; policymakers; and others involved in planning, evaluating, and delivering services for detoxifying

patients from substances of abuse. Secondary

audiences include public safety/police and

criminal justice personnel, educational institutions, those involved with assisting workers

(e.g., Employee Assistance Programs), shelters/feeding programs, and managed care organizations. The TIP also should prove useful to

providers of other services in comprehensive

systems of care (vocational counseling, occupational therapy, and public housing/assisted living), administrators, and payors (public, private, and managed care).

Scope

Among other issues covered in this TIP is the

importance of detoxification as one component in the continuum of healthcare services

for substance­related disorders. The TIP

reinforces the urgent need for nontraditional

settings—such as emergency rooms, medical

and surgical wards in hospitals, acute care

clinics, and others that do not traditionally

provide detoxification services—to be prepared to participate in the process of getting

the patient who is in need of detoxification

into a program as quickly as possible to

potentially avoid the myriad possible negative

consequences associated with substance abuse

(e.g., physiological and psychological disturbances/disorders, criminal involvement,

unemployment, etc.). Furthermore, it promotes the latest strategies for retaining individuals in detoxification while also encouraging the development of the therapeutic

alliance to promote the patient’s entrance into

substance abuse treatment. This includes suggestions on addressing psychosocial issues

that may affect detoxification services.

This TIP provides medical information on

detoxification protocols for specific substances, as well as considerations for individuals with co­occurring medical conditions

including mental disorders. While the TIP is

not intended to take the place of medical

texts, it provides the practitioner with an

overview of medical considerations. 

This TIP will also bring clinicians and administrators up­to­date on important aspects of

detoxification, including how the services are to

be paid for. It is unusual in a clinical treatment

improvement protocol to discuss issues related

to how clinical services are reimbursed.

However, in the field of substance abuse and

detoxification services, reimbursement issues

have become so intertwined with the delivery of

services that the consensus panel deemed it

necessary to address the conflicts and misunderstandings that sometimes arise between the

care systems and the reimbursement systems.

History of

Detoxification Services

Prior to the 1970s, public intoxication was

treated as a criminal offense. People arrested

for it were held in the “drunk tanks” of local

jails where they underwent withdrawal with

little or no medical intervention (Abbott et al.

2 Chapter 1
1995; Sadd and Young 1987). Shifts in the

medical field, in perceptions of addiction, and

in social policy changed the way that people

with dependency on drugs, including alcohol,

were viewed and treated. Two notable events

were particularly instrumental in changing

attitudes. In 1958, the American Medical

Association (AMA) took the official position

that alcoholism is a disease. This declaration

suggested that alcoholism was a medical problem requiring medical intervention. In 1971,

the National Conference of Commissioners on

Uniform State Laws adopted the Uniform

Alcoholism and Intoxication Treatment Act,

which recommended that “alcoholics not be

subjected to criminal prosecution because of

their consumption of alcoholic beverages but

rather should be afforded a continuum of

treatment in order that they may lead normal

lives as productive members of society”

(Keller and Rosenberg 1973, p. 2). While this

recommendation did not carry the weight of

law, it made a major change in the legal implications of addiction. With these changes came

more humane treatment of people with addictions.

Several methods of detoxification have evolved

that reflect a more humanitarian view of people

with substance use disorders. In the “medical

model,” detoxification is characterized by the

use of physician and nursing staff and the

administration of medication to assist people

through withdrawal safely (Sadd and Young

1987). The “social model” rejects the use of

medication and the need for routine medical

care, relying instead on a supportive nonhospital environment to ease the passage through

withdrawal (Sadd and Young 1987). Today, it is

rare to find a “pure” detoxification model. For

example, some social model programs use medication to ease withdrawal but generally employ

nonmedical staff to monitor withdrawal and

conduct triage (i.e., sorting patients according

to the severity of their disorders). Likewise,

medical programs generally have some components to address social/personal aspects of

addiction.

Just as the treatment and the conceptualization of addiction have changed, so too have

the patterns of substance use and the accompanying detoxification needs. The popularity

of cocaine, heroin, and other substances has

led to the need for different kinds of detoxification services. At

the same time, public

health officials have

increased invest­ The AMA’s

position is that substance dependence

is a disease, and it

encourages physicians and other

clinicians, health

organizations, and

policymakers to

base all their activities on this premise.

ments in detoxification services and

substance abuse

treatment, especially

after 1985, as a

means to inhibit the

spread of HIV infection and AIDS

among people who

inject drugs. More

recently, people with

substance use disorders are more likely

to abuse more than

one drug simultaneously (i.e., polydrug

abuse) (Office of

Applied Studies

2005).

The AMA continues

to maintain its position that substance
 

dependence is a disease, and it encourages physicians and other clinicians, health
 

organizations, and policymakers to base all
 

their activities on this premise (AMA 2002).
 

As treatment regimens have become more
 

sophisticated and polydrug abuse more common, detoxification has evolved into a compassionate science. 

Definitions 

Few clear definitions of detoxification and

related concepts are in general use at this

time. Criminal justice, health care, substance

abuse, mental health, and many other sysOverview, Essential Concepts, and Definitions in Detoxification 3
tems all define detoxification differently. This

TIP offers a clear and uniform set of definitions for the various components of detoxification and substance abuse treatment that

may prove useful to the field of detoxification. 

Detoxification

Detoxification is a set 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 caused by the abuse of substances. The

acute medical management of life­threatening

intoxication and related medical problems

generally is not included within the term

detoxification and is not covered in detail in

this TIP. 

The Washington Circle Group (WCG), a body

of experts organized to improve the quality

and effectiveness of substance abuse prevention and treatment, defines detoxification as

“a medical intervention that manages an individual safely through the process of acute

withdrawal” (McCorry et al. 2000a, p. 9).

The WCG makes an important distinction,

however, in noting that “a detoxification program is not designed to resolve the longstanding psychological, social, and behavioral

problems associated with alcohol and drug

abuse” (McCorry et al. 2000a, p. 9). The consensus panel supports this statement and has

taken special care to note that detoxification

is not substance abuse treatment and rehabilitation. For further explanation, see the text

box below. 

The consensus panel built on existing definitions of detoxification as a broad process with

three essential components that may take

place concurrently or as a series of steps: 

• Evaluation entails testing for the presence

of substances of abuse in the bloodstream,

measuring their concentration, and screening for co­occurring mental and physical

conditions. Evaluation also includes a comprehensive assessment of the patient’s medical and psychological conditions and social

situation to help determine the appropriate

level of treatment following detoxification.

Essentially, the evaluation serves as the

basis for the initial substance abuse treatment plan once the patient has been withdrawn successfully.

• Stabilization includes the medical and psychosocial processes of assisting the patient

through acute intoxication and withdrawal

to the attainment of a medically stable, fully

supported, substance­free state. This often

is done with the assistance of medications,

though in some approaches to detoxification

no medication is used. Stabilization

includes familiarizing patients with what to

expect in the treatment milieu and their

role in treatment and recovery. During this

time practitioners also seek the involvement

of the patient’s family, employers, and

Detoxification as Distinct From Substance 

Abuse Treatment

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised

detoxification may prevent potentially life­threatening complications that might appear if the patient

were 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. 

4 Chapter 1
     

other significant people when appropriate

and with release of confidentiality.

• Fostering the patient’s entry into treatment

involves preparing the patient for entry into

substance abuse treatment by stressing the

importance of following through with the

complete substance abuse treatment continuum of care. For patients who have demonstrated a pattern of completing detoxification services and then failing to engage in

substance abuse treatment, a written treatment contract may encourage entrance into

a continuum of substance abuse treatment

and care. This contract, which is not legally

binding, is voluntarily signed by patients

when they are stable enough to do so at the

beginning of treatment. In it, the patient

agrees to participate in a continuing care

plan, with details and contacts established

prior to the completion of detoxification. 

All three components (evaluation, stabilization, and fostering a patient’s entry into

treatment) involve treating the patient with

compassion and understanding. Patients

undergoing detoxification need to know that

someone cares about them, respects them as

individuals, and has hope for their future.

Actions taken during detoxification will

demonstrate to the patient that the provider’s

recommendations can be trusted and followed. 

Other Relevant Terms

As defined by the Diagnostic and Statistical

Manual of Mental Disorders, 4th edition,

Text Revision (DSM­IV­TR) (American

Psychiatric Association [APA] 2000), a substance­related disorder is a “disorder related

to the taking of a drug of abuse (including

alcohol), to the side effects of a medication,

and to toxin exposure” (APA 2000, p. 191).

The term substance “can refer to a drug of

abuse, a medication, or a toxin” (APA 2000,

p. 191). In this TIP, the term substance refers

to alcohol as well as other drugs of abuse.

Substance­related disorders are divided into

two groups: substance use disorders and substance­induced disorders. According to the

DSM­IV­TR, substance use disorders include

both “substance dependence” and “substance

abuse.” Substance dependence refers to “a

cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance­related problems. There is

a pattern of repeated self­administration that

can result in tolerance, withdrawal, and compulsive drug­taking behavior” (APA 2000, p.

192). Substance abuse refers to “a maladaptive pattern of substance use manifested by

recurrent and significant adverse consequences related to the repeated use of substances” (APA 2000, p. 198). It should be

noted that for purposes of this TIP, the term

“substance abuse” is sometimes used to

denote both substance abuse and substance

dependence as they are defined by the DSMIV­TR. 

This TIP also uses the DSM­IV­TR definitions

for substance intoxication and substance

withdrawal. Substance intoxication is “the

development of a reversible substance­specific

syndrome due to the recent ingestion of (or

exposure to) a substance” whereas substance

withdrawal is “the development of a substance­specific maladaptive behavioral

change, with physiological and cognitive concomitants, that is due to the cessation of, or

reduction in, heavy and prolonged substance

use” (APA 2000, pp. 199, 201). Figure 1­1 

(p. 6) defines these and other relevant terms.

Treatment/rehabilitation includes an ongoing,

continual assessment of the patient’s physical,

psychological, and social status, as well as an

analysis of environmental risk factors that

may be contributing to substance use and the

identification of immediate relapse triggers as

well as prevention strategies for coping with

them. It also includes the delivery of primary

medical care and psychiatric care, if necessary, to help the patient abstain from substance use and minimize the physical harm

caused by it. Ultimately, the goal of treatment/rehabilitation is to attain a higher level

of social functioning by reducing risk factors,

Overview, Essential Concepts, and Definitions in Detoxification 5
               

                   

                     

         

       

                 

               

             

       

       

   

           

                 

           

               

             

     

           

                     

     

         

                     

       

   

Figure 1­1

DSM­IV­TR Definitions of Terms

Term Definition

Substance A drug of abuse, a medication, or a toxin.

Substance­related disorders Disorders related to the taking of a drug of abuse (including

alcohol), to the side effects of a medication, and to toxin exposure.

Substance abuse (in this TIP, also

sometimes used to denote “substance

dependence”)

A maladaptive (i.e., harmful to a person’s life) pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances.

Substance dependence (in this TIP,

“substance abuse” is sometimes used

to include “dependence”)

A cluster of cognitive, behavioral, and physiological symptoms

indicating that the individual is continuing use of the substance

despite significant substance­related problems. A person experiencing substance dependence shows a pattern of repeated selfadministration that usually results in tolerance, withdrawal, and

compulsive drug­taking behavior.

Substance intoxication The development of a reversible substance­specific syndrome as

the result of the recent ingestion of (or exposure to) a substance.

Substance withdrawal The development of a substance­specific maladaptive behavioral

change, usually with uncomfortable physiological and cognitive

consequences, that is the result of a cessation of, or reduction in,

heavy and prolonged substance use.

Source: APA 2000.

enhancing protective factors, and thus

decreasing the possibility of relapse.

Maintenance includes the continuation of

counseling and support specified in the treatment plan, refinement and strengthening of

strategies to avoid relapse, and engagement in

ongoing relapse prevention, aftercare, and/or

domiciliary care (Lehman et al. 2000). 

As a final note, in this TIP persons in need of

detoxification services and subsequent substance abuse treatment are referred to as

patients to emphasize that these persons are

coming into contact with physicians, nurses,

physician assistants, and medical social workers in a medical setting in which the patient

often is physically ill from the effects of withdrawal from specific substances. In some

social setting detoxification programs, the

terms “client” or “consumer” may be used in

place of “patient.” 

6 Chapter 1
           

         

             

           

         

               

     

                               

   

                   

                       

         

                                   

                 

                     

                       

Guiding Principles in empirically measurable and agreed upon by all

Detoxification and

Substance Abuse
 

Treatment
 

parties. The consensus panel developed guidelines (listed in Figure 1­2) that serve as the

foundation for the TIP.

The consensus panel recognizes that the successful delivery of detoxification services is
 

dependent on standards that are to some extent
 

Figure 1­2

Guiding Principles Recognized by the Consensus Panel

1.	 Detoxification does not constitute substance abuse treatment but is one part of a continuum of care for

substance­related disorders.

2.	 The detoxification process consists of the following three sequential and essential components:

•Evaluation 

•Stabilization 

•Fostering patient readiness for and entry into treatment

A detoxification process that does not incorporate all three critical components is considered incomplete

and inadequate by the consensus panel.

3.	 Detoxification can take place in a wide variety of settings and at a number of levels of intensity within

these settings. Placement should be appropriate to the patient’s needs.

4.	 Persons seeking detoxification should have access to the components of the detoxification process

described above, no matter what the setting or the level of treatment intensity.

5. All persons requiring treatment for substance use disorders should receive treatment of the same

quality and appropriate thoroughness and should be put into contact with a substance abuse treatment program after detoxification, if they are not going to be engaged in a treatment service provided

by the same program that provided them with detoxification services. There can be “no wrong door

to treatment” for substance use disorders (CSAT 2000a). 

6. Ultimately, insurance coverage for the full range of detoxification services is cost­effective. If reimbursement systems do not provide payment for the complete detoxification process, patients may be

released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical complications ultimately drive up the overall cost of health care.

7. Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as

unique health needs and life situations. Organizations that provide detoxification services need to

ensure that they have standard practices in place to address cultural diversity. It also is essential that

care providers possess the special clinical skills necessary to provide culturally competent comprehensive assessments. Detoxification program administrators have a duty to ensure that appropriate

training is available to staff. (For more information on cultural competency training and specific

competencies that clinicians need to be “culturally competent” see the forthcoming TIP Improving

Cultural Competence in Substance Abuse Treatment [SAMHSA in development a]).

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.

Overview, Essential Concepts, and Definitions in Detoxification 7
Challenges to

Providing Effective

Detoxification

It is an important challenge for detoxification

service providers to find the most effective

way to foster a patient’s recovery. Effective

detoxification includes not only the medical

stabilization of the patient and the safe and

humane withdrawal from drugs, including

alcohol, but also entry into treatment.

Successfully linking detoxification with substance abuse treatment reduces the “revolving

door” phenomenon of repeated withdrawals,

saves money in the medium and long run, and

delivers the sound and humane level of care

patients need (Kertesz et al. 2003). Studies

show that detoxification and its linkage to the

appropriate levels of treatment lead to

increased recovery and decreased use of

detoxification and treatment services in the

future. In addition, recovery leads to reductions in crime, general healthcare costs, and

expensive acute medical and surgical treatments consequent to untreated substance

abuse (Abbot et al. 1998; Aszalos et al. 1999).

While detoxification is not treatment per se,

its effectiveness can be measured, in part, by

the patient’s continued abstinence. 

Another challenge to providing effective

detoxification occurs when programs try to

develop linkages to treatment services. A

study (Mark et al. 2002) conducted for the

Substance Abuse and Mental Health Services

Administration highlights the pitfalls of the

service delivery system. According to the

authors, each year at least 300,000 patients

with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals while additional numbers

obtain detoxification in other settings. Only

about one­fifth of people discharged from

acute care hospitals for detoxification receive

substance abuse treatment during that hospitalization. Moreover, only 15 percent of people who are admitted through an emergency

room for detoxification and then discharged

receive any substance abuse treatment.

Finally the average length of stay for people

undergoing detoxification and treatment in

1997 was only 7.7 days (Mark et al. 2002).

Given that “research has shown that patients

who receive continuing care have better outcomes in terms of drug abstinence and readmission rates than those who do not receive

continuing care,” the report authors conclude

that there is a pronounced need for better

linkage between detoxification services and

the treatment services that are essential for

full recovery (Mark et al. 2002, p. 3). 

Reimbursement systems can present another

challenge to providing effective detoxification

services (Galanter et al. 2000). Third­party

payors sometimes prefer to manage payment

for detoxification separately from other phases of addiction treatment, thus treating detoxification as if it occurred in isolation from

addiction treatment. This “unbundling” of

services has promoted the separation of all

services into somewhat scattered segments

(Kasser et al. 2000). In other instances, some

reimbursement and utilization policies dictate

that only “detoxification” currently can be

authorized, and “detoxification” for that policy or insurer does not cover the nonmedical

counseling that is an integral part of substance abuse treatment. Many treatment programs have found substance abuse counselors

to be of special help with resistant patients,

especially for patients with severe underlying

shame over the fact that their substance use is

out of control. Yet some payors will not reimburse for nonmedical services such as those

provided by these counselors, and therefore

the use of such staff by a detoxification or

treatment service may be impossible, in spite

of the fact that they are widely perceived as

useful for patients.

Payors are gradually beginning to understand

that detoxification is only one component of a

comprehensive treatment strategy. Patient

placement criteria, such as those published

by the American Society of Addiction

Medicine (ASAM) in the Patient Placement

Criteria, Second Edition, Revised (ASAM

2001), have come to the fore as clinicians and

8 Chapter 1
insurers try to reach agreements on the level

of treatment required by a given patient, as

well as the medically appropriate setting in

which the treatment services are to be delivered. Accordingly, the TIP offers suggestions

for resolving conflicts as well as clearly defining terms used in patient placement and treatment settings as a step toward clearer understanding among interested parties.

Overview, Essential Concepts, and Definitions in Detoxification 9
                   

               

                 

                 

             

                     

                   

                 

                     

                   

                     

               

     

               

                 

                   

           

                   

                     

In This
 Chapter...
 

Role of Various
 

Settings in the
 

Delivery of Services
 

Other Concerns
 

Regarding Levels of
 

Care and Placement
 

2 Settings, Levels of

Care, and Patient
 

Placement

Establishing criteria that take into account all the possible needs of

patients receiving detoxification and treatment services is an extraordinarily complex task. This chapter discusses the criteria for placing

patients in the appropriate treatment settings and offering the required

intensity of services (i.e., level of care).

Role of Various Settings in the

Delivery of Services

Addiction medicine has sought to develop an efficient system of care that

matches patients’ clinical needs with the appropriate care setting in the

least restrictive and most cost­effective manner. (For an explanation of

least restrictive care, see the text box, p. 12.) Challenges to effective

placement matching for clients arise from a number of factors:

•Deficits in the full range of care settings and levels of care

•Limitations imposed by third­party payors (e.g., strict adherence to

standardized admission criteria)

•Clinicians’ lack of authority (and sometimes sufficient knowledge) to

determine the most appropriate care setting and level of care

•Insurance that does not have a substance use disorder benefit available

as part of its patient coverage

•Absence of any health insurance at all (Gastfriend et al. 2000)

No clear solution or formula to meet these challenges has emerged.

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Least Restrictive Care

Least restrictive refers to patients’ civil rights and their right to choice of care. There are four specific themes of historical and clinical importance:

1.	 Patients should be treated in those settings that least interfere with their civil rights and freedom to

participate in society.

2.	 Patients should be able to disagree with clinician recommendations for care. While this includes the

right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as

long as considerations of dangerousness and mental competency are satisfied). It implies a patient’s

right to seek a higher or different level of care than that which the clinician has planned.

3.	 Patients should be informed participants in defining their care plan. Such planning should be done

in collaboration with their healthcare providers.

4.	 Careful consideration of State laws and agency policies is required for patients who are unable to

act in their own self­interests. Because the legal complexities of this issue will vary from State to

State the TIP cannot provide definitive guidance here, but providers need to consider whether or

not the person is “gravely” incapacitated, suicidal, or homicidal; likely to commit grave bodily

injury; or, in some States, likely to cause injury to property. In such cases, State law and/or case

law may hold providers responsible if they do not commit the patient to care, but in other cases

programs may be open to lawsuits for forcibly holding a patient.

In spite of the impediments, some progress has

been made in developing comprehensive

patient placement criteria. Because the choice

of a treatment setting and intensity of treatment (level of care) are so important, the

American Society of Addiction Medicine

(ASAM) created the Patient Placement

Criteria, Second Edition, Revised (PPC­2R) a

consensus­based clinical tool for matching

patients to the appropriate setting and level of

care. The ASAM PPC­2R represents an effort

to define how care settings may be matched to

patient needs and special characteristics. These

criteria currently define the most broadly

accepted standard of care for the treatment of

substance use disorders. ASAM criteria are

intended to provide flexible clinical guidelines;

these criteria may not be appropriate for particular patients or specific care settings.

The PPC­2R identifies six “assessment dimensions to be evaluated in making placement

decisions” (ASAM 2001, p. 4). They are as

follows:

1.	 Acute Intoxication and/or Withdrawal

Potential

2.	 Biomedical Conditions and Complications

3.	 Emotional, Behavioral, or Cognitive

Conditions and Complications

4.	 Readiness to Change

5.	 Relapse, Continued Use, or Continued

Problem Potential

6.	 Recovery/Living Environment

The ASAM PPC­2R describes both the settings

in which services may take place and the intensity of services (i.e., level of care) that patients

may receive in particular settings. It is important to reiterate, however, that the ASAM

PPC­2R criteria do not characterize all the

details that may be essential to the success of

treatment (Gastfriend et al. 2000). Moreover,

traditional assumptions that certain treatment

can be delivered only in a particular setting

may not be applicable or valuable to patients.

Clinical judgment and consideration of the

patient’s particular situation are required for

appropriate detoxification and treatment.

In addition to the general placement criteria

for treatment for substance­related disorders,

ASAM also has developed a second set of place12 Chapter 2
           

           

         

         

       

ment criteria, which are more important for

the purposes of this TIP—the five “Adult

Detoxification” placement levels of care within

Dimension 1 (ASAM 2001). These “Adult

Detoxification” levels of care are

1.	 Level I­D: 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 II­D: 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.2­D: Clinically Managed

Residential Detoxification (e.g., nonmedical 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 24­hour support.

4.	 Level III.7­D: Medically Monitored

Inpatient Detoxification (e.g., freestanding

detoxification center). Unlike Level

III.2.D, this level provides 24­hour medically supervised detoxification services.

5.	 Level IV­D: Medically Managed Intensive

Inpatient Detoxification (e.g., psychiatric

hospital inpatient center). This level provides 24­hour care in an acute care inpatient settings.

As described by the ASAM PPC­2R, the

domain of detoxification refers not only to the

reduction of the physiological and psychological features of withdrawal syndromes, but

also to the process of interrupting the momentum of compulsive use in persons diagnosed

with substance dependence (ASAM 2001).

Because of the force of this momentum and

the inherent difficulties in overcoming it even

when there is no clear withdrawal syndrome,

this phase of treatment frequently requires a

greater intensity of services initially to establish participation in treatment activities and

patient role induction. That is, this phase

should increase the patient’s readiness for

and commitment to substance abuse treatment and foster a solid therapeutic alliance

between the patient and care provider. 

It is important to note that ASAM PPC­2R

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 (Center for

Substance Abuse Treatment [CSAT] 1995h). 

Because this TIP is geared to audiences that

may or may not be familiar with the ASAM

PPC­2R levels of care, this section discusses

the services and staffing specific to the care

settings that are familiar to a broad audience. 

Physician’s Office

It has been estimated that nearly one half of

the patients who visit a primary care provider

have some type of problem related to substance use (Miller and Gold 1998). Indeed,

because the physician may be the first point

of contact for these people, initiation of treatment often begins in the family physician’s

office (Prater et al. 1999). Physicians should

use prudence in determining which patients

may undergo detoxification safely on an outpatient basis. As a general rule, outpatient

treatment is just as effective as inpatient

treatment for patients with mild to moderate

withdrawal symptoms (Hayashida 1998).

For physicians treating patients with substance use disorders, preparing the patient to

enter treatment and developing a therapeutic

alliance between patient and clinician should

begin as soon as possible. This includes providing the patient and his family with information on the detoxification process and subsequent substance abuse treatment, in addition to providing medical care or referrals if

necessary. Staffing should include certified

interpreters for the deaf and other language

Settings, Levels of Care, and Patient Placement 13
           

           

   

     

       

           

   

interpreters if the program is serving patients

in need of those services. Physicians should

be able to accommodate frequent followup

visits during the management of acute withdrawal. Medications should be dispensed in

limited amounts.

Level of care 

Ambulatory detoxification without

extended onsite monitoring

This level of detoxification (ASAM’s Level ID) is an organized outpatient service, which

may be delivered in an office setting, healthcare or addiction treatment facility, or in a

patient’s home by trained clinicians who provide medically supervised evaluation, detoxification, and referral services according to a

predetermined schedule. Such services are

provided in regularly scheduled sessions.

These services should be delivered under a

defined set of policies and procedures or medical protocols (ASAM 2001). Ambulatory

detoxification is considered appropriate only

when a positive and helpful social support

network is available to the patient. In this

level of care, outpatient detoxification services should be designed to treat the patient’s

level of clinical severity, to achieve safe and

comfortable withdrawal from mood­altering

drugs, and to effectively facilitate the

patient’s transition into treatment and recovery.

Ambulatory detoxification with

extended onsite monitoring

Essential to this level of care—and distinguishing it from Ambulatory Detoxification

Without Extended Onsite Monitoring—is the

availability of appropriately credentialed and

licensed nurses (such as registered nurses

[RNs] or licensed practical nurses [LPNs])

who monitor patients over a period of several

hours each day of service (ASAM 2001).

Otherwise, this level of detoxification

(ASAM’s Level II­D) also is an organized outpatient service. Like Level I­D, in this level of

care detoxification services are provided in

regularly scheduled sessions and delivered

under a defined set of policies and procedures

or medical protocols. Outpatient services are

designed to treat the patient’s level of clinical

severity and to achieve safe and comfortable

withdrawal from mood­altering drugs, including alcohol, and to effectively facilitate the

patient’s entry into ongoing treatment and

recovery (ASAM 2001).

Staffing

Although they need not be present in the

treatment setting at all times, physicians and

nurses are essential to office­based detoxification. In States where physician assistants,

nurse practitioners, or advance practice clinical nurse specialists are licensed as physician

extenders, they may perform the duties ordinarily carried out by a physician (ASAM

2001).

Because detoxification is conducted on an

outpatient basis in these settings, it is important for medical and nursing personnel to be

readily available to evaluate and confirm that

detoxification in the less supervised setting is

safe. All clinicians who assess and treat

patients should be able to obtain and interpret information regarding the needs of these

persons, and all should be knowledgeable

about the biomedical and psychosocial dimensions of alcohol and illicit drug dependence.

Requisite skills and knowledge base include

the following:

•Understanding how to interpret the signs and

symptoms of alcohol and other drug intoxication and withdrawal

•Understanding the appropriate treatment

and monitoring of these conditions

•The ability to facilitate the individual’s entry

into treatment

It is essential that medical consultation is

readily available in emergencies. It is desirable that medical staff link patients to treatment services, although this may be an unreasonable expectation that cannot be met in a

busy office setting. Linkage to treatment services may be provided by the physician or by

14 Chapter 2
designated counselors, psychologists, social

workers, and acupuncturists who are available either onsite or through the healthcare

system (ASAM 2001).

Freestanding Urgent Care

Center or Emergency

Department

There are several distinctions between urgent

care facilities and emergency rooms (ERs).

Urgent care often is used by patients who

cannot or do not want to wait until they see

their doctor in his or her office, whereas

emergency rooms are utilized more often by

patients who perceive themselves to be in a

crisis situation. Unlike emergency departments, which are required to operate 24

hours a day, freestanding urgent care centers

usually have specific hours of operation.

Staffing for urgent care centers generally is

more limited than for an ER. Standard

staffing includes only a physician, an RN, a

technician, and a secretary. Despite these distinctions, in actual practice there is considerable overlap between the two—the ER will see

medical problems that could be handled by

visits to offices, and urgent care facilities will

handle some cases of emergency medicine. 

A freestanding urgent care center or emergency department reasonably can be expected to

provide assessment and acute biomedical

(including psychiatric) care. However, these

settings often are unable to provide satisfactory psychosocial stabilization or complete

biomedical stabilization (which includes both

the initiation and taper of medications used in

the treatment of substance withdrawal syndromes). Appropriate triage and successful

linkage to ongoing detoxification services is

essential. The ongoing detoxification services

may be provided in an inpatient, residential,

or outpatient setting. Patients with more than

moderate biomedical or psychosocial complications are more likely to require treatment

in an inpatient setting. Care in these settings

can be quite costly and should be accessed

only when there are serious concerns about a

patient’s safety.

A timely and accurate assessment in an emergency department is of the highest importance. This will permit the rapid transfer of

the patient to a setting where complete care

can be provided.

Ideally, personnel in

the emergency Although they

need not be

present in the

treatment setting

at all times,

physicians and

nurses are

essential to

office­based

detoxification.

department will have

at least a small

amount of experience and expertise in

identifying critically

ill substance­using

patients who may be

about to experience

or are already experiencing withdrawal

symptoms. Three

essential rules apply

to emergency departments and their handling of intoxicated

patients and patients

who have begun to

experience withdrawal:

•Emergency departments and their

clinicians should

never simply

administer medications to intoxicated persons

and then send them home.

•No intoxicated patient should ever be allowed

to leave a hospital setting. All such persons

should be referred to the appropriate detoxification setting if possible, although there are

legal restrictions that forbid holding persons

against their will under certain conditions

(Armenian et al. 1999).

•A clear distinction must be made between

acute intoxication on the one hand and withdrawal on the other. Acute intoxication, it

must be remembered, creates special issues

and challenges that need to be addressed.

The risk of suicidality in patients who present in a state of intoxication needs to be

Settings, Levels of Care, and Patient Placement 15
carefully assessed. Because of their volatility

and often risky behavior, patients who are

intoxicated, as well as those patients who

have begun to experience withdrawal, merit

special attention. For more on treating intoxicated patients, see chapter 3.

Level of care 

Care is provided to

Inpatient

detoxification

provides 24­hour

supervision,	 

observation, and

support for

patients who are

intoxicated or

experiencing

withdrawal.	 

patients whose withdrawal signs and

symptoms are sufficiently severe to

require primary

medical and nursing

care services. The

services are delivered under a

defined set of physician­managed procedures or medical

protocols. Both settings provide medically directed assessment and acute care
 

that includes the initiation of detoxification for substance

use withdrawal.

Neither setting is

likely to offer satisfactory biomedical

stabilization or 24­

hour observation. Generally speaking, triage to

inpatient care can easily be facilitated from

either setting.

Freestanding urgent care centers and emergency departments are outpatient settings

that are uniquely designed to address the

needs of patients in biomedical crisis. For

patients with substance use disorders, care in

these settings is not complete until successful

linkage is made to treatment that is focused

specifically on the substance use disorder. To

accomplish this, a comprehensive assessment,

taking into account psychosocial as well as

biomedical issues, is recommended wherever

possible. 

Appreciation of the value of multidimensional

patient assessment is central to the clinician’s

ability to decide which triage (linkage) options

are least restrictive and most cost­effective

for a given patient. 

Staffing

Both emergency departments and freestanding

urgent care units are staffed by physicians.

The same rules regarding who may provide

care apply here as they did in the discussion of

staffing of office­based detoxification (ASAM

2001). An RN or other licensed and credentialed nurse is available for primary nursing

care and observation. Psychologists, social

workers, addiction counselors, and acupuncturists usually are not available in these settings. The physician or attending nurse usually

facilitates linkage to substance abuse treatment.

Freestanding Substance Abuse

Treatment or Mental Health

Facility

Freestanding substance abuse treatment facilities may or may not be equipped to provide

adequate assessment and treatment of cooccurring psychiatric conditions and biopsychosocial problems, as the range of services

varies considerably from one facility to another. Inpatient mental health facilities, on the

other hand, are able generally to provide treatment for substance use disorders and co­occurring psychiatric conditions. Nonetheless, like

substance abuse treatment facilities, the range

of available services varies from one mental

health facility to another.

General guidelines for considering patient

placement in either of these settings are provided below; however, it should be emphasized that a clear understanding of the specific services that a given setting provides is

16 Chapter 2
   

     

         

             

             

         

             

           

             

           

           

         

       

         

             

       

             

           

       

       

             

           

           

       

         

             

       

           

             

         

       

           

               

           

           

         

             

         

           

     

           

         

indispensable to identifying the least restrictive and most cost­effective treatment option

that may be available. Concern for safety is

of primary importance, and the final decision

regarding placement always rests with the

treating physician.

Level of care

Medically Monitored Inpatient

Detoxification

Inpatient detoxification provides 24­hour

supervision, observation, and support for

patients who are intoxicated or experiencing

withdrawal. Since this level of care is relatively

more restrictive and more costly than a residential treatment option, the treatment mission

in this setting should be clearly focused and

limited in scope. Primary emphasis should be

placed on ensuring that the patient is medically

stable (including the initiation and tapering of

medications used for the treatment of substance use withdrawal); assessing for adequate

biopsychosocial stability, quickly intervening to

establish this adequately; and facilitating effective linkage to and engagement in other appropriate inpatient and outpatient services.

Inpatient settings provide medically managed

intensive inpatient detoxification. At this level

of care, physicians are available 24 hours per

day by telephone. A physician should be

available to assess the patient within 24 hours

of admission (or sooner, if medically necessary) and should be available to provide

onsite monitoring of care and further evaluation on a daily basis. An RN or other qualified nursing specialist should be present to

administer an initial assessment. A nurse will

be responsible for overseeing the monitoring

of the patient’s progress and medication

administration on an hourly basis, if needed.

Appropriately licensed and credentialed staff

should be available to administer medications

in accordance with physician orders. 

Clinically Managed Residential

Detoxification

Residential settings vary greatly in the level of

care that they provide. Those with intensive

medical supervision involving physicians, nurse

practitioners, physician assistants, and nurses

can handle all but the most demanding complications of intoxication and withdrawal. On the

other hand, some residential settings have minimally intensive medical oversight. Residential

detoxification in settings with limited medical

oversight often is referred to as “social detoxification.” (Though the “social detoxification”

model is not limited to residential facilities.)

Facilities with lower levels of care should have

clear procedures in place for implementing and

pursuing appropriate medical referral and

linkage, especially in the case of emergencies.

For example, a patient who is in danger of

seizures or delirium tremens needs to be

referred to the appropriate medical facility for

acute care of presenting symptoms, possibly

medicated, and then returned to a social detoxification setting for continuing monitoring and

observation. The establishment of this kind of

collaborative relationship between institutions

provides a good example of a cost­effective way

to provide adequate care to patients.

Residential detoxification programs provide

24­hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. They are characterized

by an emphasis on peer and social support

(ASAM 2001). Standards published by such

groups as the Joint Commission on

Accreditation of Healthcare Organizations

(JCAHO) and the Commission on

Accreditation of Rehabilitation Facilities

(CARF) provide further information on quality measures for residential detoxification. 

Settings, Levels of Care, and Patient Placement 17
   

         

           

         

           

     

           

         

             

             

           

             

             

     

           

       

             

     

         

           

         

           

             

             

         

         

             

             

                 

             

       

             

               

           

               

   

Staffing

Inpatient detoxification programs employ

licensed, certified, or registered clinicians who

provide a planned regimen of 24­hour, professionally directed evaluation, care, and treatment services for patients and their families.

An interdisciplinary team of appropriately

trained clinicians (such as physicians, RNs and

LPNs, counselors, social workers, and psychologists) should be available to assess and treat

the patient and to obtain and interpret information regarding the patient’s needs. The number and disciplines of team members should be

appropriate to the range and severity of the

patient’s problems (ASAM 2001).

Residential detoxification programs are

staffed by appropriately credentialed personnel who are trained and competent to implement physician­approved protocols for

patient observation and supervision. These

persons also are responsible for determining

the appropriate level of care and facilitating

the patient’s transition to ongoing care.

Medical evaluation and consultation should

be available 24 hours a day, in accordance

with treatment/transfer practice guidelines.

All clinicians who assess and treat patients

should be able to obtain and interpret information regarding the needs of these persons

and should be knowledgeable about the

biomedical and psychosocial dimensions of

alcohol and other drug dependence. Such

knowledge includes awareness of the signs

and symptoms of alcohol and other drug

intoxication and withdrawal, as well as the

appropriate treatment and monitoring of

those conditions and how to facilitate the

individual’s entry into ongoing care. Staff

should ensure that patients are taking medications according to their physician’s orders

and legal requirements (ASAM 2001).

Some residential detoxification programs are

staffed to supervise self­administered medications for the management of withdrawal. All

such programs should rely on established

clinical protocols to identify patients who

have biomedical needs that exceed the capacity of the facility and to identify which programs will likely have a need for transferring

such patients to more appropriate treatment

settings.

Intensive Outpatient and

Partial Hospitalization

Programs

An intensive outpatient program (IOP) or partial hospitalization program (PHP) is appropriate for patients with mild to moderate withdrawal symptoms. Thorough psychosocial

assessment and intervention should be available in addition to biomedical assessment and

stabilization. Many of these programs have

close clinical and/or administrative ties to hospital centers. When needed, triage to a higher

level of care should be easy to accomplish.

Outpatient treatment should be delivered in

conjunction with all components of detoxification.

Level of care 

This level of detoxification is an organized outpatient service that requires patients to be present onsite for several hours a day. It is thus

similar to a physician’s office in that ambulatory detoxification with extended onsite monitoring is provided. Unlike the physician’s office, in

the IOP and PHP it is standard practice to

have a multidisciplinary team available to provide or facilitate linkage to a range of medically

supervised evaluation, detoxification, and

referral services.

Detoxification services also are provided in

regularly scheduled sessions and delivered

under a defined set of policies and procedures

or medical protocols. These outpatient services are designed to treat the patient’s level

of clinical severity, to achieve safe and comfortable withdrawal from mood­altering drugs

(including alcohol), and to effectively facili18 Chapter 2
tate the patient’s engagement in ongoing treatment and recovery (ASAM 2001).

A partial hospitalization program may occupy

the same setting (i.e., physical space) as an

acute care inpatient treatment program.

Although occupying the same space, the levels

of care provided by these two programs are

distinct yet complementary. Acute care inpatient programs provide detoxification services

to patients in danger of severe withdrawal

and who therefore need the highest level of

medically managed intensive care, including

access to life support equipment and 24­hour

medical support. In contrast, partial hospitalization programs provide services to patients

with mild to moderate symptoms of withdrawal that are not likely to be severe or lifethreatening and that do not require 24­hour

medical support. The transition from an

acute care inpatient program to either a partial hospitalization or intensive outpatient

program sometimes is referred to as a “stepdown.” Typically, whether these programs

share space and staff with an acute care inpatient program or are physically distinct from

a hospital structure, they have close clinical

and/or administrative ties to hospital centers.

Collaborative working relationships are indispensable in pursuing the goal of providing

patients with the most appropriate level of

care in the most cost­effective setting.

Staffing

IOPs and PHPs should be staffed by physicians who are available daily as active members of an interdisciplinary team of appropriately trained professionals and who medically

manage the care of the patient. An RN or

other licensed and credentialed nurse should

be available for primary nursing care and

observation during the treatment day.

Addiction counselors or licensed or registered

addiction clinicians should be available to

administer planned interventions according to

the assessed needs of the patient. The multidisciplinary professionals (such as physicians,

nurses, counselors, social workers, psychologists, and acupuncturists) should be available

as an interdisciplinary team to assess and

care for the patient with a substance­related

disorder, as well as patients with both a substance use disorder and a co­occurring

biomedical, emotional, or behavioral condition. Successful linkage to treatment for the

substance use disorder (in addition to

biomedical stabilization) is central to the mission of an intensive

outpatient or partial

hospitalization program (ASAM 2001). Successful linkage

to treatment for

the substance use

disorder (in

addition to

biomedical

stabilization) is

central to the

mission of an

intensive outpatient or partial

hospitalization

program.

For more information, see the TIP

Substance Abuse:

Clinical Issues in

Intensive Outpatient

Treatment [SAMHSA

in development d].

Acute Care

Inpatient

Settings

There are several

types of acute care

inpatient settings.

They include

•Acute care general

hospitals

•Acute care addiction treatment units

in acute care general hospitals

•Acute care psychiatric hospitals

•Other appropriately

licensed chemical

dependency specialty hospitals

These settings share the ready availability of

acute care medical and nursing staff, life support equipment, and ready access to the full

resources of an acute care general hospital or

its psychiatric unit. This level of care provides

medically managed intensive inpatient detoxification (ASAM 2001).

Settings, Levels of Care, and Patient Placement 19
           

       

           

   

         

           

           

           

           

               

           

       

     

           

               

     

       

               

               

               

           

         

           

             

       

             

     

         

       

             

           

       

     

     

                   

               

           

             

       

         

             

         

           

           

           

       

         

           

       

             

         

             

               

           

           

   

Level of care

Acute inpatient care is an organized service

that provides medically monitored inpatient

detoxification that is delivered by medical and

nursing professionals. Medically supervised

evaluation and withdrawal management in a

permanent facility with inpatient beds is provided for patients whose withdrawal signs and

symptoms are sufficiently severe to require 24­

hour inpatient care. Services should be delivered under a set of policies and procedures or

clinical protocols designated and approved by a

qualified physician (ASAM 2001).

Staffing

Acute care inpatient detoxification programs

typically are staffed by physicians who are

available 24 hours a day as active members of

an interdisciplinary team of appropriately

trained professionals and who medically manage the care of the patient. In some States,

these duties may be performed by an RN or

physician assistant. An RN or LPN, as usual, is

available for primary nursing care and observation 24 hours a day. Facility­approved addiction counselors or licensed or registered addiction clinicians should be available 8 hours a

day to administer planned interventions

according to the assessed needs of the patient.

An interdisciplinary team of appropriately

trained clinicians (such as physicians, nurses,

counselors, social workers, and psychologists)

should be available to assess and treat the

patient with a substance­related disorder, or a

patient with co­occurring substance use,

biomedical, psychological, or behavioral conditions (ASAM 2001).

Other Concerns

Regarding Levels of

Care and Placement

In part because of the need to keep costs to a

minimum and in part as the result of research

in the field, outpatient detoxification is becoming the standard for treatment of symptoms of

withdrawal from substance dependence in

many locales. Most alcohol treatment programs

have found that more than 90 percent of

patients with withdrawal symptoms can be

treated as outpatients (Abbott et al. 1995).

Careful screening of these patients is essential

to reserve for inpatient treatment those clients

with possibly complicated withdrawal; for

example, patients with subacute medical or

psychiatric conditions (that in and of themselves would not require hospitalization) and

those in danger of seizures or delirium tremens

should receive inpatient care. Inpatient addiction treatment programs will vary in the level

of acute medical or psychiatric care that can be

provided. Figure 2­1 presents an overview of

issues to consider in deciding between inpatient

and outpatient detoxification.

ASAM criteria are being adopted extensively

on the basis of their “face validity,” though

their outcome validity has yet to be clinically

proven. Early studies of more versus less

restrictive and intensive treatment settings on

randomized samples generally have failed to

show group differences, and studies continue

to show this pattern (Gastfriend et al. 2000).

Whether patients undergoing detoxification

will have better results as outpatients rather

than as inpatients remains to be established

(Hayashida 1998). 

Another consideration is that ASAM placement guidelines are not always the best guide

to placing a patient in the proper setting at

the proper level. For example, what is the

clinician to do with the patient who qualifies

for outpatient treatment according to the

ASAM guidelines but is homeless in sub­zero

temperatures? No provision is made for such

cases. The ASAM guidelines are to be regarded as a “work in progress,” as their authors

readily admit (ASAM 2001, p. 19).

Nevertheless, they are an important set of

guidelines that are of great help to clinicians.

For administrators, the standards published

20 Chapter 2
Figure 2­1

Issues To Consider in Determining Whether Inpatient or Outpatient

Detoxification Is Preferred

Considerations Indications

Ability to arrive at clinic on a daily basis Necessary if outpatient detoxification is to be carried out

History of previous delirium tremens or withdrawal seizuresContraindication to outpatient detoxification:

recurrence likely; specific situation may suggest

that an attempt at outpatient detoxification is possible

No capacity for informed consent Protective environment (inpatient) indicated

Suicidal/homicidal/psychotic condition Protective environment (inpatient) indicated

Able/willing to follow treatment recommendations Protective environment (inpatient) indicated if

unable to follow recommendations

Co­occurring medical conditions Unstable medical conditions such as diabetes,

hypertension, or pregnancy: all relatively strong

contraindications to outpatient detoxification

Supportive person to assist Not essential but advisable for outpatient detoxification

Source: Consensus Panelist Sylvia Dennison, M.D.

by such groups as JCAHO and CARF offer

guidance for overall program operations. 

It has become clear that detoxification

involves much more than simply medically

withdrawing a patient from alcohol or other

drugs. Detoxification, whether done on an

inpatient, residential, or outpatient basis, frequently is the initial therapeutic encounter

between patient and clinician. Irrespective of

the substance involved, a detoxification

episode should provide an opportunity for

biomedical (including psychiatric) assessment, referral for appropriate services, and

linkage to treatment services. Chapter 3 provides an overview of the psychosocial and

biomedical issues relevant to detoxification,

strategies to engage the patient, and an

overview of providing adequate linkage to follow up treatment and services. 

Settings, Levels of Care, and Patient Placement 21
                 

             

             

                 

                   

In This
 Chapter...
 

Evaluating and
 

Addressing
 

Psychosocial and
 

Biomedical Issues
 

Strategies for
 

Engaging and
 

Retaining Patients
 

in Detoxification
 

Referrals and
 

Linkages
 

3 An Overview of

Psychosocial and

Biomedical Issues

During Detoxification 

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 long­term 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 (Onken et al. 1997). 

Psychological dependence, co­occurring 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. 

This chapter addresses the psychosocial and biomedical issues that may

affect detoxification and ensuing treatment. It highlights evaluation procedures for patients undergoing detoxification, discusses strategies for

engaging and retaining patients in detoxification and preparing them for

treatment, and presents an overview for providing linkages to other

services.

23
       

       

           

         

           

         

   

   

         

           

             

       

             

           

               

               

         

         

                   

               

         

         

             

         

     

           

           

           

           

           

             

                               

                     

                   

                     

                 

               

                             

               

                             

                             

     

                           

   

                       

         

Overarching Principles for Care During 

Detoxification Services

•Detoxification services do not offer a “cure” for substance use disorders. They often are a first step

toward recovery and the “first door” through which patients pass to treatment.

•Substance use disorders are treatable, and there is hope for recovery.

•Substance use disorders are brain disorders and not evidence of moral weaknesses.

•Patients are treated with respect and dignity at all times.

•Patients are treated in a nonjudgmental and supportive manner.

•Services planning is completed in partnership with the patient and his or her social support network,

including such persons as family, significant others, or employers.

•All health professionals involved in the care of the patient will maximize opportunities to promote 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. Figure 3­1

lists the biomedical and psychosocial domains

that can affect the stabilization of the patient.

The following sections include some general

guidelines and important considerations to

follow when providing detoxification services.

General Guidelines for

Addressing Immediate

Medical Concerns

Because substance abuse affects all systems of

the body and is associated with lack of selfcare, it is not unusual for detoxification to be

complicated by medical problems. 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 provides a clinical overview of

co­occurring medical conditions and is geared

primarily toward medical personnel.

Co­occurring 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. Figure 3­2 (p. 26) provides

24 Chapter 3
Figure 3­1 

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?

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.

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,

An Overview of Psychosocial and Biomedical Issues During Detoxification  25
       

             

             

             

         

             

         

     

           

             

       

                 

             

           

         

         

         

         

           

             

         

             

Figure 3­2

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° 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

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 chapter 4.

All staff working with patients should be

familiar with medical disorders that are associated with various addictive substances or

routes of administration. Alcoholism has multiple organ effects involving the liver, pancreas, central nervous system, cardiovascular

system, and endocrine system. Cocaine produces many of its medical complications

through vasoconstriction (i.e., narrowing of

the blood vessels), including myocardial

infarction (heart attack), stroke, renal disease, spontaneous abortion, and even bowel

infarction (death of tissue). Cocaine also can

cause seizures and cardiac arrhythmia (irregular heartbeat). A heroin overdose can lead

to a fatal respiratory depression. Intravenous

drug use is particularly likely to increase the

risk of infectious complications, including

HIV, viral hepatitis, abscesses, and sepsis (the

spreading of infection from its original site in

the body). Intrapulmonary (within the lungs)

administration can cause lung disorders

(Dackis and Gold 1991). 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 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 x­ray is recommended if indicated by the

26 Chapter 3
       

     

               

         

         

   

             

           

             

         

         

           

           

             

           

               

           

           

           

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 cooccurring psychiatric conditions see TIP 42,

Substance Abuse Treatment for Persons With

Co­Occurring Disorders (Center for

Substance Abuse Treatment [CSAT] 2005c).

Suicide

Those who are users of multiple illicit substance are more likely to experience psychiatric

disorders, and the risk is highest among those

who use both opiates and benzodiazepines

and/or alcohol (Marsden et al. 2000).

Depression is more common among those who

abuse a combination of these substances, and

women are at higher risk than men. Among

those patients who are positive for depression,

the risk of suicide is high. Marsden and colleagues’ 2000 study of 1,075 clients entering

treatment showed that 29 percent reported suicidal ideation in the past 3 months.

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

Alcohol, cocaine, amphetamine, and hallucinogen intoxication may be associated with

increased risk of violence. Symptoms associated with this increased risk for violence

include hallucinations, paranoia, anxiety, and

depression. As a precaution, all patients who

are intoxicated should be considered potentially violent (Miller et al. 1994). Programs

should have in place well­developed 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 de­escalate anger and

aggression. In many cases, aggressive behaviors can be defused through verbal and environmental means (Reilly and Shopshire

2002). 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. Figure 3­3 (p. 28) 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. 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 (SAMHSA 2002).

An Overview of Psychosocial and Biomedical Issues During Detoxification  27
             

           

           

       

             

               

             

           

   

         

       

               

             

                 

             

           

       

           

         

         

           

       

                 

           

         

           

     

       

             

           

         

         

         

                 

       

           

           

           

             

           

           

           

           

       

       

Figure 3­3 

Strategies for De­escalating 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.

Co­occurring 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 co­occurring

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 co­occurring substance­related

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 (First

et al. 2002). 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 (APA 2000; ASAM 2001).

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 (Nazrul Islam et al. 2001).

Longstanding irregular eating habits and poor

dietary intake only exacerbate the problem

(Pelican et al. 1994). 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 (Nazrul Islam et al. 2001).

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.

28 Chapter 3
         

       

       

           

               

       

         

           

             

   

           

             

           

               

             

           

         

             

       

             

             

               

         

           

                 

           

             

               

           

             

         

       

             

           

           

             

         

     

             

           

             

               

         

           

             

       

               

               

           

           

           

           

               

       

           

         

           

           

         

       

         

           

           

         

             

           

         

           

             

             

             

         

             

             

         

         

   

         

             

               

           

               

           

             

     

The nutritional evaluation should consist of

laboratory and anthropometric indices, a

detailed nutritional history, and nutrition

counseling (Simko et al. 1995). 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. Substance abuse may

result in a reduction in food intake and disruption in the patient’s metabolism that may in

turn have caused an eating disorder, weight

loss, and malnutrition. Conversely, weight gain

may be related to inactivity and an excessive

intake of highly refined carbohydrates (Zador

et al. 1996). 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 (Simko et al. 1995).

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

24­hour 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. Hypoglycemia (low levels of blood sugar) in the person

with a substance use disorder may lead to drastic mood changes. When blood glucose levels

drop below a certain threshold, these patients

usually feel depressed, anxious, or moody and

may experience cravings for their drug of

choice.

Nutritional deficits 

associated with specific 

substances

As noted, the abuse of drugs can interfere with

nutrient utilization and storage. 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 water­soluble vitamins

pyridoxine, thiamine, folate, and vitamin B12

(Nazrul Islam et al. 2001). Alcohol also contains calories (7 kcal/gm) that when consumed

in excessive amounts may displace nutrientdense 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 (Fontaine et al. 2001). 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 (Nebelkopf 1981, 1987,

1988). The regularity of meal times, taste, and

presentation are important considerations.

An Overview of Psychosocial and Biomedical Issues During Detoxification  29
   

             

             

         

         

         

             

           

         

         

           

           

           

       

         

           

       

     

       

               

       

                   

           

             

         

             

         

           

         

           

       

   

   

         

               

           

         

             

               

           

           

           

             

           

         

             

           

       

         

                 

                 

       

           

             

           

Attractively arranged, pleasant­tasting 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 sugar­based

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 low­fat foods, with an increased intake of

protein (meat, dairy products, legumes), complex carbohydrates (whole grain bread and

cereals), and dietary fiber are recommended

(Duyff 1996). 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 (American Diabetes Association

2004). 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 (Westermeyer 1997). 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 PCP, which can

present with psychosis­like symptoms. Staff

should ask the adolescent directly whether he

has used PCP within the 12­hour 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

30 Chapter 3
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

co­occurring psychiatric problems.

It sometimes is challenging to establish rapport with adolescents, as their experience

with adults may be marked by adverse consequences. Asking open­ended 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

(CSAT 1999d), and TIP 32, Treatment of

Adolescents With Substance Use Disorders

(CSAT 1999f).

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

While both men and women are victims of
 

domestic abuse, women’s substance use is associated with increased risk of intimate partner
 

violence (Cunradi et al. 2002). 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
 Ensuring that

children have a

safe place to stay

while their

mothers are in

detoxificaton is of

vital importance.

violence, trained

staff can help the

victim create a longterm 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

An Overview of Psychosocial and Biomedical Issues During Detoxification  31
   

         

           

   

       

         

       

       

           

           

             

             

             

information see TIP 25, Substance Abuse

Treatment and Domestic Violence (CSAT

1997b). 

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 (Clark et al. 1998). Figure 3­4 proFigure 3­4

Questions To Guide Practitioners To Better Understand the Patient’s

Cultural Framework

•What language do you prefer we use? 

•Therapists and clients sometimes have different ideas about diseases, can you tell me more about

your idea of why you are in detoxification now?

•Do you require assistance for daily living activities (such as personal hygiene, shopping, paying bills,

etc.)?

•What do you call your present condition/situation (as it relates to substance use)? How does your

family view your present condition/situation (as it relates to substance use)? 

•What is the role of alcohol or drugs in your family?

•How does your community view your present condition/situation (as it relates to substance use)? Or

what is the role of alcohol or drugs in your community?

•How has your present condition/situation (as it relates to substance use) altered your status in the

community?

•What experiences have you had with the healthcare system?

•Do you think your substance use is a problem for you?

•What do you think caused your present condition/situation (as it relates to substance use)?

•Why do you think it started?

•What is going on in your body?

•How has your present condition/situation (as it relates to substance use) altered your life?

•How have you tried to solve the problem(s) associated with substance use in the past? Was it helpful?

What worked/didn’t work?

•Why are you coming now? 

•Are you on any herbal medications or special foods for this problem? 

•What concerns or fears do you have about your present condition/situation (as it relates to substance

use)?

•What concerns or fears do you have about this treatment?

Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.

32 Chapter 3
           

     

   

             

         

         

           

         

             

           

                 

           

             

             

               

         

         

           

           

       

             

             

         

           

         

         

         

         

   

           

           

           

       

           

       

           

           

             

       

                 

             

           

         

               

           

         

             

         

           

           

             

             

         

     

       

   

             

               

         

       

           

           

               

               

         

       

           

vides 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”

(Kertesz et al. 2003). 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 chapter

4). 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–English­speaking

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 (Anton 1999;

Miller and Gold 1994).

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 12­Step or

other support group meetings while receiving

detoxification services. These activities reinforce the need for substance abuse treatment

An Overview of Psychosocial and Biomedical Issues During Detoxification  33
         

     

     

   

       

         

         

         

         

           

           

         

             

         

       

         

           

       

           

             

       

     

       

           

         

               

         

         

         

         

           

         

     

           

           

       

         

       

and maintenance activities and may provide a

critical recovery­oriented support system once

detoxification services are completed.

Maintain a Drug­Free

Environment

Maintaining a safe and drug­free environment

is essential to retaining clients in detoxification. Providers should be alert to drug­seeking 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 drug­free 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 well­controlled

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

(Trachtenberg 2000). 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

well­suited 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

(Miller and Rollnick 2002). TIP 35,

Enhancing Motivation for Change in

Substance Abuse Treatment (CSAT 1999c),

covers specific interventions and techniques

to increase motivation to change substancerelated behaviors. TIP 35 also includes some

basic principles common to motivational

interventions (CSAT 1999c, p. xvii): 

•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 open­ended 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) (Miller et al. 1999), the

detoxification team can help significant others

in the patient’s life capitalize on moments

when the patient is ready for change and

34 Chapter 3
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

(Liepman 1993), 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 (Miller et al. 1995). Moreover, the

vast majority of significant others do not wish

to use these techniques, and for that reason

these techniques are not recommended (Miller

et al. 1999). 

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

(Longabaugh et al. 1993). 

Tailoring Motivational

Intervention to Stage of

Change

Perhaps the most well­known 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 (DiClemente and

Prochaska 1998). The interventions to

increase patient motivation for substance

abuse treatment described in TIP 35,

Enhancing Motivation for Change in

Substance Abuse

Treatment (CSAT

1999c) 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 substance­abusing 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

Clinicians,

groups, and

programs that

rely on

confrontational

techniques have

yielded poor

outcomes.

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 3­5 

(p. 36) and the details of each stage are

described in the text below. 

An Overview of Psychosocial and Biomedical Issues During Detoxification  35
Figure 3­5 

The Transtheoretical Model (Stages of Change)

Source: DiClemente and Prochaska 1998.

In the precontemplation stage, the individual

is not considering any change in substanceusing behavior in the foreseeable future.

Typically, a patient in this stage either is

unaware that his substance use is a problem

or is unwilling or too discouraged to make a

change. Often, a person in the precontemplation stage has not experienced serious consequences from substance use. During the precontemplation stage, the clinician should be

attentive for and seize upon any ambivalence

expressed by the patient toward substancerelated behaviors. Such ambivalence may be

more likely to emerge during initial detoxification, before the patient has returned to a

relative zone of comfort and greater denial.

For patients who are determined to remain in

the precontemplation stage, the main goal is

to get the patient to begin to consider changing. To accomplish this, the clinician might

express concern, listen to the patient’s per36 Chapter 3
   

             

             

           

         

         

         

               

               

           

       

         

           

             

   

spective, and keep the door open for further

communication regarding treatment options.

In the contemplation stage, the individual has

some awareness that substance use presents a

problem. In this stage, the patient may

express a desire or willingness to change, but

has no definite plans to do so in the near

future, which generally is considered to be

the next 2 to 6 months. Whether it is explicitly stated or not, it is thought that most individuals in this stage are ambivalent about

changing. That is, side­by­side with any

desire to change is a desire to continue the

current behavior. For patients in the contemplation stage, clinicians are advised to use

“decisional balancing strategies” to help the

patient move to the action stage (Carey et al.

1999). In this approach, the clinician helps

the patient to consider the positive and negative aspects of her substance abuse and has

the patient weigh them against each other

with the expectation that the scale of balance

tips in favor of adopting new behavior.

Psychoeducation on the interaction of substance abuse with other problems, including

health, legal, employment, parenting, and

mental illness, can be part of this procedure.

Helping the patient understand that ambivalent feelings about changing substance use

behaviors are normal and expected can be

particularly useful at this stage.

In the preparation stage, the patient is aware

that his substance use presents a significant

problem and desires change. Moreover, the

patient has made a conscious decision to commit himself to a behavior change. This stage is

defined as one in which the individual prepares for the upcoming change in specific

ways, such as deciding whether a formal

treatment program is needed and, if so, which

one. This stage is characterized by goal setting and making commitments to stop using,

such as informing coworkers, friends, and

family of treatment plans. For patients in the

preparation stage, clinicians should elicit the

patient’s goals and strategies for change and

be on the alert for signs that the patient is

ready to move into the action stage. It is critical that the clinician respond quickly to any

requests for treatment to capitalize on this

motivation before it wanes. One of the most

critically important roles the clinician can

play in this stage is to assist the patient in

developing a plan of action or a behavioral

contract, taking into account the individual

needs of the patient. As part of this process

the clinician should help the patient enlist

social support. Exploring the patient’s expectations regarding treatment and her role in it

is important. Finally, because of the commonly experienced difficulty in accessing treatment, the clinician should discuss with the

patient ways of maintaining motivation for

change during a possible wait for entry into a

treatment program, should the patient be

placed, for example, on a waiting list.

In the action stage, the patient is taking

active steps to change substance use behaviors. This includes making modifications to

his habits and environment, such as not

spending time in places or with people associated with drug taking behavior. These

changes may even continue to be made 3 to 6

months after substance abuse has ceased.

In the maintenance stage, the patient is working to maintain the changes initiated in the

action phase. 

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 (Horvath and

Luborsky 1993). 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.

An Overview of Psychosocial and Biomedical Issues During Detoxification  37
           

             

             

       

           

     

           

         

   

           

         

               

     

Readiness to change predicts a positive therapeutic alliance (Connors et al. 2000). Strong

alliances, in turn, have been associated with

positive outcomes in patients who are dependent on alcohol (Connors et al. 1997), 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 (Luborsky 2000).

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. Newman (1997)

makes some additional recommendations for

developing the therapeutic alliance, such as

discussing the issue of confidentiality with

patients and acknowledging that the road to

recovery is difficult. He also advises 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 3­6 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.

Figure 3­6

Clinician’s Characteristics Most Important to the Therapeutic Alliance

•Is supportive, empathic, and nonjudgmental

•Knows which patients can be engaged and which should be referred to another treatment provider

•Can establish rapport with any client

•Remembers to discuss confidentiality issues

•Acknowledges challenges on the road to recovery

•Is consistent, trustworthy, and reliable

•Remains calm and cool even when a client is upset

•Is confident but humble

•Sets limits without engaging in a power struggle

•Recognizes the client’s progress toward a goal

•Encourages self­expression on the part of the client

38 Chapter 3
     

   

     

     

     

   

     

       

               

             

           

             

       

             

         

           

       

               

       

       

           

           

               

           

           

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

(PPC­2R) (ASAM 2001) provides one widely

used model for determining the level of services needed to address substance­related disorders. The levels of treatment services range

from community­based early intervention

groups to medically managed intensive inpatient services. As noted in chapter 2,

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 co­occurring 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 gender­specific treatment (for

more information see the forthcoming TIPs

Substance Abuse Treatment: Addressing

the Specific Needs of Women [SAMHSA in

development e] and Substance Abuse

Treatment: Men’s Issues [SAMHSA in

development g]).

Figure 3­7 (p. 40) outlines the areas the consensus panel recommends for assessment to determine the most appropriate rehabilitation plan.

Appendix C lists a variety of instruments useful in characterizing the addiction and related

disorders (for example, the Addiction

Severity Index [ASI]), measuring motivational willingness to change (Stages of Change

Readiness and Treatment Eagerness Scale

[SOCRATES] and University of Rhode Island

Change Assessment [URICA]), and evaluating

co­occurring psychiatric conditions and social

An Overview of Psychosocial and Biomedical Issues During Detoxification  39
                   

         

                     

             

                     

                     

             

                   

     

                 

     

                   

     

                     

               

               

                   

         

                 

             

                       

               

             

           

                   

               

               

                         

                       

       

Figure 3­7 

Recommended Areas for Assessment To Determine Appropriate

Rehabilitation Plans

Domain Description

Medical Conditions and

Complications

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

Motivation/Readiness to

Change

Degree to which the client acknowledges that substance use behaviors are a

problem and is willing to confront them honestly

Physical, Sensory, or

Mobility Limitations

Physical conditions that may require specially designed facilities or staffing

Relapse History and

Potential

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

Substance

Abuse/Dependence

Frequency, amount, and duration of use; chronicity of problems; indicators of

abuse or dependence

Developmental and

Cognitive Issues

Ability to participate in confrontational treatment settings, and benefit from

cognitive interventions and group therapy

Family and Social

Support

Degree of support from family and significant others, substance­free friends,

involvement in support groups

Co­Occurring Psychiatric

Disorders

Other psychiatric symptoms that are likely to complicate the treatment of the

substance use disorder and require treatment themselves, concerns about

safety in certain settings (note that assessment for co­occurring 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, cooccurring posttraumatic stress disorder or trauma history that might complicate rehabilitation

Treatment History Prior successful and unsuccessful rehabilitation experiences that might influence decision about type of setting indicated

Cultural Background Cultural identity, issues, and strengths that might influence the decision to

seek culturally specific rehabilitation programs, culturally driven strengths or

obstacles that might dictate level of care or setting

Strengths and Resources Unique strengths and resources of the client and his or her environment

Language Language or speech issues that make it difficult to communicate or require an

interpreter familiar with substance abuse

40 Chapter 3
   

and family factors. Administering these

instruments requires varying degrees of

sophistication on the part of the clinician. All

instruments should be considered for their

cultural, linguistic, level of cognitive comprehension, and developmental appropriateness

for each patient. For further information on

patient placement see TIP 13, The Role and

Current Status of Patient Placement Criteria

in the Treatment of Substance Use Disorders

(CSAT 1995h).

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 “delinking” or “unbundling” and generally

involves determining the need for social services independently from the clinical intensity

(Gastfriend and McLellan 1997; McGee and

Mee­Lee 1997). 

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 below:

•Inpatient programs for treatment of substance abuse generally are delivered in hospitals and freestanding clinics and provide

24­hour nursing care in addition to intensive treatment for substance­related problems.

•Residential treatment programs normally

provide 24­hour supervision by nonmedical

staff and the availability of medical staff

may be limited. These programs deliver

highly intensive substance abuse counseling

and clients may participate in the upkeep of

facilities. Peer support is critical to the

treatment delivered. As a general rule,

patients will stay at a residential treatment

facility for 7 to 30 days.

•Therapeutic communities (TCs) usually

have 24­hour supervision by nonmedical

staff or clients who have sustained recovery. They tend to provide highly intensive

counseling services and rely on peer support and confrontation to shape behaviors

of clients. The TC is based on concepts of

self­help. Residence in a TC is longer than a

patient’s stay in a residential program—

patients usually stay for a period of at least

30 days and often 6 months to a year. In

some special situations, such as a criminal

justice setting, TC residence can last 2

years or more.

•Transitional residential programs and

halfway houses ordinarily have 24­hour

supervision from nonmedical staff or clients

who have sustained recovery. Patients in

these programs often are working and participate in counseling and peer support during the evening and weekend hours. 

•Partial hospitalization and day treatment

programs use a combination of medical and

nonmedical staff to deliver a high intensity

of counseling services during daytime

hours. Patients return home in the

evenings.

•Intensive outpatient programs usually are

delivered by nonmedical staff in a clinic

location. Patients receive 6 to 9 hours of

counseling services each week in two or

three contacts. 

•Traditional outpatient services typically are

delivered by counselors in a clinic or office

setting and provide fewer hours of services

than the “intensive outpatient” programs.

•Recovery maintenance activities are not

treatment but are highly valuable for ongoing sobriety maintenance. They include 12­

Step and other support groups aimed at

maintaining the gains accomplished in treatAn Overview of Psychosocial and Biomedical Issues During Detoxification  41
     

     

             

               

ment settings. Oxford House establishments

and other “clean and sober” living environments are among the resources that clinicians should explore and perhaps incorporate in maintenance activities.

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

appointment (Gottheil et al. 1997; Parker

2002). As patients near completion of detoxification, whether they take the next step and

enter treatment is dependent on a number of

variables. Patients who are employed, are

motivated beyond the precontemplation stage,

and have family and social support, as well as

those with co­occurring psychiatric conditions, are more likely to initiate treatment.

Conversely, those who have severe drug

dependence and those who are older are less

likely to follow through and enter treatment

(Kirchner et al. 2000; Weisner et al. 2001).

Women are more likely to initiate treatment

after detoxification than men, and individuals

who have health insurance that features a

behavioral health carve­out and lower costsharing requirements are more likely to enter

treatment than those who do not (Mark et al.

2003b). Kleinman and associates (2002) followed 279 opioid­ and cocaine­dependent

patients who had been in detoxification programs to determine how many had entered

substance abuse treatment 30 days after leaving the detoxification program. They found

that those who were on parole, homeless, or

who had been using drugs for less than 20

years were more likely than others to have

entered treatment. 

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 (Fiorentine et al. 1999).

Figure 3­8 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

Figure 3­8

Strategies To Promote Initiation of Treatment and 

Maintenance Activities

•Perform 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.

•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.

Source: Carroll 1997; Fehr et al. 1991.

42 Chapter 3
           

         

     

       

     

       

           

             

     

   

               

       

         

       

         

       

           

         

         

will be addressed, including those needs typically addressed by wraparound services (e.g.,

housing, vocational assistance, childcare,

transportation) (Fiorentine et al. 1999).

Moreover, patients receiving needed

wraparound services remain in substance

abuse treatment longer and improve more than

people who do not receive such services (Hser

et al. 1999).

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 drug­free 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, recovery­sensitive 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 (D’Aunno 1997).

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. 

An Overview of Psychosocial and Biomedical Issues During Detoxification  43
   

   

             

         

       

         

       

       

             

         

           

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 (CSAT 1998g) and TIP 36,

Substance Abuse Treatment for Persons With

Child Abuse and Neglect Issues (CSAT

2000d), 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 cross­cultural issues is equally important to all programs serving diverse patient

populations. The forthcoming TIP Improving

Cultural Competence in Substance Abuse

Treatment (SAMHSA in development a) contains more information on this topic.

Use Case Management

Case management presents an opportunity to

tailor services to individual client needs and

to minimize barriers to these services

(Gastfriend and McLellan 1997). 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 (CSAT 1998a),

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 co­occurring conditions (Drake

and Mueser 2000).

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

co­occurring psychiatric conditions appear to

be able to initiate and benefit from substance

abuse treatment like individuals without psychiatric conditions (Joe et al. 1995).

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

(Anton 1999). 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 co­occurring 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

44 Chapter 3
     

           

           

           

             

         

           

       

   

   

mental health providers are implementing

models using clinicians trained to deliver both

substance abuse and mental health treatment

concurrently (Drake and Mueser 2000). For

more information, see TIP 42, Substance

Abuse Treatment for Persons With CoOccurring Disorders (CSAT 2005c).

Linkage to Followup

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

followup care should have an appointment

made for followup medical care before leaving

the detoxification setting (Luborsky et al.

1997).

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 (Cox et al. 1998). TIP

27, Comprehensive Case Management for

Substance Abuse Treatment (CSAT 1998a),

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.

An Overview of Psychosocial and Biomedical Issues During Detoxification  45
               

                   

                   

               

                   

               

               

         

               

                   

           

                     

     

                     

                 

               

                       

               

                 

                 

In This
 

Chapter...
 

Psychosocial and
 

Biomedical
 

Screening and
 

Assessment
 

Alcohol
 

Intoxication and
 

Withdrawal
 

Opioids
 

Benzodiazepines
 

and Other
 

SedativeHypnotics
 

Stimulants
 

Inhalants/Solvents
 

Nicotine
 

Marijuana and
 

Other Drugs
 

Containing THC
 

Anabolic Steroids
 

Club Drugs
 

Management of
 

Polydrug Abuse:
 

An Integrated
 

Approach
 

Alternative
 

Approaches
 

Considerations for
 

Specific
 

Populations
 

4 Physical

Detoxification

Services for

Withdrawal From
 

Specific Substances

This chapter highlights specific treatment regimens for specific substances and provides guidance on the medical, nursing, and social services aspects of these treatments. It also includes considerations for specific populations. Although it is written principally for healthcare professionals, some professionals without medical training may find it of use.

To accommodate a broad audience, the chapter includes definitions for

technical terms that may be unfamiliar to some readers—for example,

“the patient was afebrile (without fever).”

Psychosocial and Biomedical

Screening and Assessment

This section covers more complex psychosocial and biomedical assessments that may occur after initial contact as an individual undergoes

detoxification. Psychosocial and biomedical screening and services are

closely associated: neither is likely to succeed without the other, as the

case study below illustrates.

Although the medical issues in this case indicate that the patient could

successfully be managed as an outpatient, careful assessment of psychosocial and biomedical aspects of the patient’s condition, including

lack of transportation, the risk of violence, and his inability to carry out

routine medical instructions, strongly indicated that the patient remain

in a 24­hour supervised setting such as a residential detoxification or

treatment program. For an illustration of some of the fundamental

47
           

             

         

           

         

             

   

           

         

         

       

     

           

                   

             

       

               

               

             

       

           

               

         

     

                             

                               

                             

                         

                             

                       

                               

                                 

                       

Case Study

A 44­year­old Caucasian male with a fifth­grade education presented to an emergency clinic in mild alcohol

withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia;

blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical

Institute Withdrawal Assessment for Alcohol (CIWA­Ar) (see below) score = 12, indicating mild withdrawal.

A treatment plan was recommended that called for an outpatient 3­day fixed­dose taper of lorazepam (a

benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return

daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that

there was no reliable transportation to the clinic, there had been domestic violence on the parts of both

spouses, and the patient’s ability to carry out routine medical instructions was questionable.

aspects of the patient’s health and psychosocial

status that should be covered in screening and

assessment, see Figure 3­1, p. 25.

Figure 4­1 lists several instruments useful in

characterizing the intensity of specific withdrawal states (see appendix C for more information on these instruments and how to obtain

them).

Biochemical Markers and

Their Use

This section focuses on biochemical laboratory tests that detect the presence or absence of

alcohol or another substance of abuse, may

be able to quantify the level of present use, or

may be able to quantify cumulative use over

the past few weeks. Tests in all of these areas

are reasonably well developed and validated

for alcohol. This is not the case for most

other substances of abuse. Biochemical markers are not adequate screening or assessment

instruments alone, but rather are used to

support a more comprehensive clinical assessment. Common uses of these biochemical

markers 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 (e.g., evaluating a

driver after an automobile accident). 

3. In detecting occult (secretive or hidden)

use of alcohol and other substances in

therapeutic settings where abstinence,

rehabilitation, and treatment are being

promoted.

Clinicians also can use the presentation of

information from biochemical markers to

patients as an effective tool in motivational

enhancement. For example, information

regarding liver transaminases (specific kinds

of enzymes that perform chemical reactions

within the liver) helps provide the patient

with objective information on the level of

recent alcohol use and potential acute hepatic

damage. This may help the patient move from

contemplating treatment to actually beginning

treatment. For a more detailed discussion of

biological markers in substance abuse, see

Javors and colleagues (1997).

Blood alcohol content

Blood alcohol content (BAC) can be determined

by highly sensitive laboratory procedures that

generally are available in most emergency

departments, hospitals, and clinical chemistry

laboratories. Alcohol elimination undergoes,

for the most part, zero­order kinetics (decreasing a set amount per unit of time rather than a

set percentage), so the concept of half­life is not

really accurate. However, first­order kinetics

and half­life do occur when BAC is low (i.e.,

below 10mg percent), and the half­life is on the

order of about 15 minutes at that point.

Though disappearance rates of 15mg percent

per hour are probably average for moderate

drinkers, higher values were seen in a group of

Swedish drivers apprehended for driving while

intoxicated (19mg/dL/hr) (Jones and Andersson

48 Chapter 4
           

   

       

         

       

       

Figure 4­1 

Assessment Instruments for Dependence and Withdrawal From Alcohol

and Specific Illicit Drugs

Drug of Dependence Instrument Reference Notes

Alcohol CIWA­Ar Sullivan et

al. 1989

10 items that take 2 to 5 minutes to complete; scores 0–67, with 10 or greater as

clinically significant; requires training to

administer

Cocaine Cocaine Selective

Severity

Assessment (CSSA)

Kampman et

al. 1998

18 items that take 10 minutes to complete; high scores correlated with poor

outcome

Opioids Subjective Opiate

Withdrawal Scale

(SOWS)

Handelsman

et al. 1987

16­item questionnaire; using a scale of

0–4, respondents rate to what extent

they are currently experiencing each of

16 characteristics; higher scores indicate

more severe withdrawal

Objective Opiate

Withdrawal Scale

(OOWS)

Handelsman

et al. 1987

Rater observes patient for about 10 minutes and indicates if any of 13 manifestations of withdrawal are present; scores

can range from 0 to 13, with higher

scores indicating more severe withdrawal; staff must be familiar with withdrawal signs

1996). The rate of metabolism of alcohol

increases with dependence—some alcoholics

can metabolize 20–25mg/dL/hr (Jones and

Andersson 1996), and Jones and Sternebring

(1992) have found that alcohol­dependent

patients may metabolize 22mg/dL/hr during

detoxification.

When knowledge of BAC is combined with

clinical information, the healthcare provider

can make some predictions regarding the

acuteness of withdrawal. For example, in an

individual whose blood alcohol level is 200mg

percent but who is already showing tremulousness (shakiness of the hands), brisk

reflexes, tachycardia (rapid heart rate),

diaphoresis (excessive sweating), and perhaps

a CIWA­Ar score in the moderate or high

range (about 15 or higher), the clinician can

reasonably predict that the withdrawal will be

relatively severe. As noted, however, the rate

of metabolism of alcohol increases with

dependence. The diagnosis of alcohol intoxication is a clinical diagnosis and not based

simply on a BAC. A person with a BAC of

200mg percent could be in withdrawal, intoxicated (showing related signs and symptoms),

or showing no signs and symptoms of either

intoxication or withdrawal. A BAC above

100mg percent does not necessarily indicate

clinical intoxication. Like all laboratory procedures, the blood alcohol levels test has limitations. Usually, patient permission must be

obtained prior to testing, the testing itself can

be expensive, and forensic testing may be

subject to specific legal procedures. 

Physical Detoxification Services for Withdrawal From Specific Substances 49
             

           

           

         

           

         

             

         

             

             

         

           

     

       

           

             

             

               

         

           

           

         

           

           

             

           

             

         

       

       

               

         

         

   

     

   

           

             

             

         

               

     

         

         

       

         

               

           

       

           

       

           

           

         

             

             

           

         

             

             

           

   

               

                             

                                 

                             

             

Reading Blood Alcohol Concentrations

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. This

figure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BAC

of .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.

Source: Center for Substance Abuse Treatment (CSAT) 1995a.

Breath alcohol levels

Although the initial cost of small breath alcohol

instruments may be relatively high, the recurring costs (of disposable mouthpieces and periodic recalibration) are low. The technique is

less invasive than blood testing and health

providers can follow breath alcohol levels

repeatedly at low expense during the course of

assessment and detoxification. The detection of

rapidly rising, high levels of alcohol over a

short period of time may indicate alcohol poisoning overdose. Breath alcohol levels provide

useful guidance in determining whether to hospitalize these patients.

Limitations on breath alcohol determinations

are that patient cooperation is required and

that some patients with lung diseases are not

able to muster a sufficient tidal volume (forceful breath) to give an accurate reading to the

machine. On occasion, patients whose breath

alcohol levels indicate recent alcohol use will

assert that they have recently gargled with

mouthwash that contained alcohol. Having the

patient rinse his mouth with water several

times and then making another breath alcohol

determination in 15 to 30 minutes usually will

resolve whether the patient’s assertion is valid.

Urine drug screens

Urine drug screens vary widely in their methods of detection, sensitivity and specificity,

expense, and availability. The healthcare

provider assessing patients for detoxification

should be familiar with the type of assay (test

measurement) being used; some examples are

enzyme multiple assay techniques, thin layer

chromatography, high performance liquid

chromatography, urine alcohol concentration,

and gas chromatography­mass spectrometry.

Informed clinicians also should be aware of

which drugs are screened for by the laboratory

they use, the relative time window of detection

(a substance’s metabolic half­life, or approximately how long a drug can be detected once

ingested), and whether cross­reactivity with

other interfering substances may alter outcomes. Many laboratories perform more specific confirmation testing on positive screening

tests, which can largely eliminate false­positives. It is important to clarify which type of

test result is being reported. Interfering and

cross­reactive substances leading to false­positive tests frequently are discussed in bulletins

and publications periodically published by the

National Institute on Drug Abuse (NIDA) and

the Centers for Disease Control and Prevention

(CDC). Usually, the senior laboratory supervisor has up­to­date information in this area and

often can be consulted via e­mail or telephone

in an emergency. Limitations of urine drug

screening include consent and privacy issues,

expense, the inability to screen for some drugs

of abuse, and the inability of urine drug

screens to provide information on the current

level of intoxication.

Urine testing should at a minimum test for the

presence of

•Benzodiazepines

•Barbiturates

•Cocaine

•Amphetamines

•Opioids

•PCP

50 Chapter 4
               

           

           

       

         

                 

                 

             

           

           

   

             

               

               

           

           

               

               

             

                 

           

               

           

             

               

           

               

                 

           

               

           

               

               

             

           

         

           

               

             

           

             

               

           

         

           

             

             

                 

             

           

               

           

           

           

             

             

       

It also should be noted that current testing for

opioids primarily refers to “organic” drugs that

are derived from opium (i.e., heroin, codeine,

and morphine). Synthetic opioids like

hydrocodone and methadone are not detected

by the usual tests; this is true of oxycodone as

well. If the use of these drugs is suspected, special tests can be ordered. Most important, each

program should tailor its urine screening tests

to reflect the substance use patterns prevalent

in the community.

Gamma­glutamyltransferase

(GGT)

GGT has been measured in serum (the portion

of the blood that has neither red nor white

blood cells) for many years as a marker for

liver damage. More recently, GGT has been

advocated as a measure of cumulative alcohol

use (Dackis 2001). Sensitivity of the test is in

the 60 to 70 percent range and specificity (its

ability not to misidentify or confuse alcohol use

with other disorders) is in the 40 to 50 percent

range. In general, both sensitivity and specificity are lower in females than males. GGT does

correlate with alcohol intake but often requires

heavy drinking (more than six drinks per day)

to elevate it, and only about half of individuals

will show elevations. The half­life of elevated

serum GGT after the onset of abstinence is said

to be 2 to 3 weeks with alcoholic liver disease.

Chlorpromazine, phenobarbital, and

acetaminophen can all raise serum GGT levels.

GGT is limited by its expense and its relatively low specificity, which sometimes leads to

false­positive evaluations. GGT is helpful as a

motivational enhancer in patients with a high

degree of denial during detoxification.

Evidence of liver damage, as measured by the

GGT, provides patients with objective feedback concerning the consequences of their

alcohol use and thus plays a very important

role in enhancing motivation.

Hepatitis is a general term that refers to

inflammation of the liver with damage to liver

cells (hepatocytes). Hepatitis may be due to

viruses (such as in hepatitis A, B, C) or

insults to the liver from toxins (such as chemicals, alcohol, prescribed or over­the­counter

medications). In any form of hepatitis, GGT

may be elevated, indicating damage to liver

cells. Therefore, GGT elevation does not

automatically mean liver damage from alcohol

use, although this is certainly one of the most

common reasons for elevated GGT levels in

patients hospitalized in North America. The

use of GGT levels along with carbohydratedeficient transferrin (CDT) levels is a relatively sensitive and specific indicator of alcohol use. The CDT test is discussed below.

Carbohydrate­deficient 

transferrin

CDT has been developed over the past 20 years

as a marker of cumulative alcohol consumption

but is just now becoming widely available as a

clinical tool. Sensitivities appear to be in the 70

to 80 percent range, and specificities of greater

than 90 percent have been found. Sensitivity

and specificity are somewhat lower among

females than males. Most therapeutic drugs or

drugs of abuse do not appear to affect CDT

levels. When CDT and GGT levels are combined, sensitivity and specificity rise to more

than 90 percent (Anton 2001). CDT testing is

limited by its relatively high cost, lack of clinical availability in some laboratories, and falsepositive results in abstaining individuals who

have endstage liver disease from causes other

than alcohol use (DiMartini et al. 2001).

Mean corpuscular 

volume (MCV)

Erythrocyte (red blood cell) size is measured in

a Coulter counter and often is part of a complete blood count; therefore, it is widely available to clinicians. Sensitivity and specificity are

in the 30 to 50 percent range. Hence, caution

should be exercised when interpreting an elevated MCV in relation to drinking behavior.

This lab test should be considered complementary to other biological markers that are more

specific and sensitive, such as GGT or CDT.

Advanced age, nutritional status, cigarette

Physical Detoxification Services for Withdrawal From Specific Substances 51
         

             

   

         

           

           

       

           

         

         

               

       

           

           

           

           

           

           

             

           

     

         

               

                 

             

       

             

             

     

               

             

               

             

           

             

           

               

               

         

         

       

         

             

             

             

       

         

           

   

           

             

                 

                 

               

           

         

   

             

               

           

             

         

       

     

         

       

   

     

     

           

       

         

           

         

             

         

         

             

smoking, and co­occurring disease states without the presence of alcoholism may make test

results abnormal.

Alcohol Intoxication

and Withdrawal

Intoxication Signs and

Symptoms

The clinical presentation of intoxication from

alcohol varies widely depending in part on

blood alcohol level and level of previously

developed tolerance. At alcohol concentrations

between 20mg percent and 80mg percent, loss

of muscular coordination, changes in mood,

personality alteration, and [increases in motor

activity] begin. At levels from 80 to 200mg percent, more progressive neurologic impairment

occurs with ataxia (inability to coordinate muscular activity) and slurring of speech being

prominent. A variety of cognitive functions also

are impaired. At blood alcohol levels between

200 and 300mg percent nausea and vomiting

may occur, which along with sedation may

place patients at grave risk for aspiration of

stomach contents. At levels greater than 300mg

percent, hypothermia (low body temperature)

with impairment of level of consciousness is

likely except in all but the most tolerant individuals. Coma begins to be seen at levels of 400

to 600mg percent, but this is variable, again

depending on tolerance. Although exceptions

are found, BACs between 600 and 800mg percent are fatal. At this point, respiratory, cardiovascular, and body temperature controls

fail. See Figure 4­2 for more symptoms of alcohol intoxication.

Since the elimination rate of alcohol from the

body generally is 10 to 30mg percent per hour,

the goals for the treatment of alcohol intoxication are to preserve respiration and cardiovascular function until alcohol levels fall into a

safe range. Patients who are severely intoxicated and comatose as the result of alcohol use

should be managed in the same manner as all

comatose patients, with particular care taken

in monitoring vital functions, protecting respiration, and observing aspiration, hypoglycemia, and thiamin deficiency. Screening for

other drugs that may contribute to the coma,

as well as other sources of coma induction,

should be done. Agitation is best managed with

interpersonal and nursing approaches rather

than additional medications, which may only

complicate and delay the elimination of the

alcohol.

Withdrawal Signs and

Symptoms

Hippocrates, writing around 400 B.C., gave us

our first written clinical picture of alcohol withdrawal when he wrote that if the patient is “in

the prime of life and if from drinking he has

trembling hands,” it may well be the case that

the patient is showing withdrawal signs and

symptoms. To this day, alcohol withdrawal

remains underrecognized and undertreated.

The signs and symptoms of acute alcohol withdrawal generally start 6 to 24 hours after the

patient takes his last drink. Alcohol withdrawal

may begin when the patient still has significant

blood alcohol concentrations. The signs and

symptoms may include the following:

•Restlessness, irritability, anxiety, agitation

•Anorexia (lack of appetite), nausea, vomiting

•Tremor (shakiness), 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 (grand mal seizures represent a severe, generalized, abnormal electrical discharge of the major portions of the

brain, resulting in loss of consciousness, brief

cessation of breathing, and muscle rigidity

followed by muscle jerking; a brief period of

52 Chapter 4
             

     

   

         

         

       

           

         

         

   

         

       

       

         

             

           

     

                 

Figure 4­2

Symptoms of Alcohol Intoxication*

Blood Alcohol Level Clinical Picture

20–100mg percent •Mood and behavioral changes

•Reduced coordination

•Impairment of ability to drive a car or operate machinery

101–200mg percent •Reduced coordination of most activities

•Speech impairment

•Trouble walking

•General impairment of thinking and judgment

201–300mg percent •Marked impairment of thinking, memory, and coordination

•Marked reduction in level of alertness

•Memory blackouts

•Nausea and vomiting

301–400mg percent •Worsening of above symptoms with reduction of body temperature and blood

pressure

•Excessive sleepiness

•Amnesia

401–800mg percent •Difficulty waking the patient (coma)

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

•Urinary and bowel incontinence

•Death

*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood

alcohol level).

Source: Consensus Panelist Robert Malcolm, M.D.

sleep, awakening later with some mild to even

severe confusion, generally occurs)

•Hyperthermia (high fever)

•Delirium with disorientation with regard to

time, place, person, and situation; fluctuation in level of consciousness

For a discussion of seizures and delirium,

including delirium tremens, see below under

the heading Management of Delirium and

Seizures (p. 63).

Mild alcohol withdrawal generally consists of

anxiety, irritability, difficulty sleeping, and

decreased appetite. Severe alcohol withdrawal

usually is characterized by obvious trembling

of the hands and arms, sweating, elevation of

pulse (above 100) and blood pressure (greater

Physical Detoxification Services for Withdrawal From Specific Substances 53
         

           

           

           

             

           

               

           

               

           

         

         

         

             

       

         

         

           

           

         

       

         

     

         

     

         

         

             

     

         

     

     

           

     

than 140/90), nausea (sometimes with vomiting), and hypersensitivity to noises (which seem

louder than usual) and light (which appears

brighter than usual). Brief periods of hearing

and seeing things that are not present (auditory

and visual hallucinations) also may occur. A

fever greater than 101° F also may be seen,

though care should be taken to determine

whether the fever is the result of an infection.

Seizures and true delirium tremens, as discussed elsewhere, represent the most extreme

forms of severe alcohol withdrawal. Moderate

alcohol withdrawal is defined more vaguely,

but represents some features of both mild and

severe withdrawal.

The course of these symptoms is extremely

variable. An individual may progress partially through some of the symptoms noted above

and then have a slow improvement. Other

individuals may have mild to moderate symptoms with almost abrupt resolution. Yet

another group may present with a grand mal

seizure or with hallucinations. Some people

with alcohol dependence, regardless of their

pattern of drinking or the extent of drinking,

appear to develop minor symptoms or show

no symptoms of withdrawal. Infrequent binge

drinkers seem less likely to have withdrawal

symptoms than individuals who are heavy

regular users of alcohol who then abruptly

cease their alcohol use, but this is not well

substantiated. As previously discussed in the

assessment section, the use of a standardized

clinical rating instrument for withdrawal such

as the CIWA­Ar is valuable because it guides

the clinician through multiple domains of

alcohol withdrawal and allows for semi­quantitative assessment of nausea, tremor, autonomic hyperactivity, anxiety, agitation, perceptual disturbances, headache, and disorientation. Age, general health, nutritional factors, and possible co­occurring medical or

psychiatric conditions all appear to play a

role in increasing the severity of the symptoms of alcohol withdrawal. 

The most useful clinical factors to assess the

likelihood and the extent of a current withdrawal is the patient’s last withdrawal and

the number of previous withdrawals (treated

or untreated) experienced, with three or four

being a particularly significant number for

the appearance of severe withdrawal reactions unless adequate medical care is provided. This assumption that this phenomenon

will manifest itself, which has been referred

to as the “kindling hypothesis,” is well­established in the research literature (Booth and

Blow 1993; Wojnar et al. 1999).

Uncomplicated or mild to moderate withdrawal is characterized by restlessness, irritability, anorexia (lack of appetite), tremor

(shakiness), insomnia, impaired cognitive

functions, and mild perceptual changes.

Complicated or severe medical withdrawal

has one or more elements of delirium, hallucinations, delusions, seizures, and disturbances

of body temperature, pulse, and blood pressure.

Medical Complications of

Alcohol Withdrawal: Possible

Fatal Outcomes

Seizures; delirium tremens (severe delirium

with trembling); and dysregulation of body

temperature, pulse, and blood pressure are

outcomes in severe alcohol dependence that can

lead to fatal consequences. Other medical complications of alcohol withdrawal include infections, hypoglycemia, gastrointestinal (GI)

bleeding, undetected trauma, hepatic failure,

cardiomyopathy (dilation of the heart with

ineffective pumping), pancreatitis (inflammation of the pancreas), and encephalopathy

(generalized impaired brain functioning). The

suspicion of impending complications or their

appearance will require hospitalization of the

client and possible intensive care unit level of

management. Consultation with internists specializing in infectious disease, pulmonary care,

and hepatology; surgeons; neurologists; psychiatrists; anesthesiologists; and other specialists

also may be warranted, depending on the

nature of the complications.

54 Chapter 4
Management of Withdrawal

Without Medication

The management of an individual in alcohol

withdrawal without medication is a difficult

matter because the indications for this have not

been established firmly through scientific studies or any evidence­based methods.

Furthermore, the course of alcohol withdrawal

is unpredictable and currently available techniques of screening and assessment do not

allow us to predict with confidence who will or

will not experience life­threatening complications. Severe alcohol withdrawal may be associated with seizures due to relative impairment of

gamma­aminobutyric acid (GABA) and relative

over­activity of N­methyl­D­aspartate systems

(a subtype of the excitatory glutamate receptor

system) (Moak and Anton 1996). The failure to

treat incipient convulsions is a deviation from

the established general standard of care.

Positive aspects of the nonmedication

approach are that it is highly cost­effective

and provides inexpensive access to detoxification for individuals seeking aid. Observation

is generally better than no treatment, but

people in moderate to severe withdrawal will

be best served at a higher level of care. Young

individuals in good health, with no history of

previous withdrawal reactions, may be well

served by management of withdrawal without

medication. However, personnel supervising

in this setting should possess assessment abilities and be able to summon help through the

emergency medical system. Methods of withdrawal management without medication

include frequent interpersonal support, provision of adequate fluids and food, attention

to hygiene, adequate sleep, and the maintenance of a no­alcohol/no­drug environment. 

Social Detoxification

Social detoxification programs are defined as

short­term, nonmedical treatment services 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. The consensus panel has found
 

that in actual practice, social detoxification
 

programs vary greatly in their approach and
 

scope. Some programs offer some medical and
 

nursing onsite supervision, while others provide access to medical
 

and nursing evaluation through clinics, For alcohol,
 

sedative­hypnotic,

and opioid withdrawal syndromes,

hospitalization (or

some form of

24­hour medical

care) is generally the

preferred setting for

detoxification, based

on principles of

safety and humanitarian concerns.
 

urgent care programs, and emergency departments.

Some social detoxification programs only

offer basic room and

board for a “cold

turkey” detoxification, while other programs offer supervised use of medications. Sometimes

medications are prescribed at the onset of

withdrawal by healthcare professionals in

an outpatient setting,

while the staff in the

social detoxification

program supervises

the administration of

these medications.
 

Whatever the particular situation might

be, there should
 

always be medical

surveillance, including monitoring of
 

vital signs, as part of every social detoxification
 

program.
 

The consensus panel agrees that for alcohol,
 

sedative­hypnotic, and opioid withdrawal syndromes, hospitalization (or some form of 24­

hour medical care) is generally the preferred
 

setting for detoxification, based on principles of
 

safety and humanitarian concerns. When hospitalization cannot be provided, a setting that
 

provides a high level of nursing and medical
 

backup 24 hours a day, 7 days a week is desirable. The panel readily acknowledges that
 

social detoxification programs are, for some
 

Physical Detoxification Services for Withdrawal From Specific Substances 55
communities, the only available resources for

uninsured, homeless individuals. Social detoxification is preferable to detoxification in unsupervised settings such as the street, shelters, or

jails. The panel also notes that in some large

urban areas, social detoxification programs

have longstanding, excellent reputations of providing high­quality supervision and nurturance

for their clients.

Social detoxification

programs are orga­ For a substantial

group of

individuals,

substance use

withdrawal

syndromes do not

lead to fatal

outcomes or even

significant	 

morbidity.

nized and funded by

a variety of sources,

including faith­based

organizations, community charities,

and municipal and

other local governments.

The genesis of social

detoxification is

complex. Often,

these programs grew

out of community

needs when no other

alternatives were

available. Early

reports (Whitfield et

al. 1978) indicated

that many individuals in alcohol withdrawal could be

managed successfully without medications in a social detoxification

setting. Subsequent reviews that have revisited

the topic (Lapham et al. 1996) have reached

similar conclusions. Critical analysis of these

reports by the consensus panel indicates that

some of the scientific issues were oversimplified

and misleading. A number of these studies, in

fact, excluded many seriously ill clients from

their surveys prior to referral to social detoxification. Some of these surveys had a very high

staff­to­client ratio during social detoxification,

thus providing an unusually high level of psychological support. This level of staffing is not

frequently found today in social detoxification

programs.

The consensus panel acknowledges that, for a

substantial group of individuals, substance

use withdrawal syndromes do not lead to fatal

outcomes or even significant morbidity.

Determining which individuals will have

benign outcomes often is difficult, and in fact

this determination prior to social detoxification referral frequently is not made. Some

incorrect beliefs have sprung up in the context of social detoxification: Individuals

undergoing opioid withdrawal often are considered to require hospitalization to alleviate

suffering, while individuals undergoing alcohol withdrawal sometimes are, for a variety of

reasons, denied hospital­level treatment for

detoxification, even though alcohol withdrawal produces suffering and may have fatal consequences.

The consensus panel agreed on several guidelines for social detoxification programs:

•Such programs should follow local governmental regulations regarding their licensing

and inspection. 

•It is highly desirable that individuals entering

social detoxification be assessed by primary

care practitioners (physicians, physician

assistants, nurse practitioners) with some

experience in substance abuse treatment.

•Such an assessment should determine

whether the patient currently is intoxicated

and the degree of intoxication, the type of

withdrawal syndrome, severity of the withdrawal, information regarding past withdrawals, and the presence of co­occurring

psychiatric, medical, and surgical conditions

that might well require specialized care (see

chapter 3, Figure 3­1, p. 25).

•Particular attention should be paid to those

individuals who have undergone multiple

withdrawals in the past and for whom each

withdrawal appears to be worse than previous ones—this is the so­called “kindling

effect” (Ballenger and Post 1978; Booth and

Blow 1993; Malcolm et al. 2000; Shaw et al.

1998; Wojnar et al. 1999; Worner 1996).

Subjects with a history of severe withdrawals, multiple withdrawals, delirium

56 Chapter 4
           

       

       

         

             

         

           

             

           

         

   

               

           

               

             

               

       

       

           

           

             

tremens, or seizures are not good candidates

for social detoxification programs.

•All social detoxification programs should

have an alcohol­ and drug­free environment,

have personnel who are familiar with the features of substance use withdrawal syndromes, have training in basic life support,

and have access to an emergency medical system that can provide transportation to emergency departments and other sites of clinical

care.

Management of Withdrawal

With Medications

Over the last 15 years several reviews and position papers (Fuller and Gordis 1994; Lejoyeux

et al. 1998; Mayo­Smith 1997; Nutt et al. 1989;

Shaw 1995) have asserted that only a minority

of patients with alcoholism will in fact go into

significant alcohol withdrawal requiring medications. Identifying that significant minority

sometimes is problematic, but there are signs

and symptoms of impending problems that can

alert the caretaker to seek medical attention.

Deciding on whether to use medical management for the treatment of alcohol withdrawal

requires that patients be separated into three

groups. The first and most obvious group

comprises those clients who have had a previous history of the most extreme forms of withdrawal, that of seizures and/or delirium. This

group is discussed in more detail below, but

in general, the medication treatment of this

group in early abstinence, whether or not

they have had the initiation of withdrawal

symptoms, should proceed as quickly as possible. 

The second group of patients requiring immediate medication treatment includes those

patients who are already in withdrawal and

demonstrating moderate symptoms of withdrawal. 

The third group of patients includes those

who may still be intoxicated and therefore

have not had time to develop withdrawal

symptoms or who have, at the time of admission, been abstinent for a few hours and have

not developed signs or symptoms of withdrawal. A decision regarding medication for this

group should be in part based on age, number of years of alcohol dependence, and the

number of previously treated or untreated

severe withdrawals (three or four appears to

be a significant threshold in predicting future

serious withdrawal) (Shaw 1995). If there is

an opportunity to observe the patient in the

emergency department of the clinic or similar

setting 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. If this is not possible, then the

return of the patient to a setting in which

there is some supervision by family, significant others, or in a social detoxification program is desirable.

The decision as to whether to give the patient

a single medication dose prior to discharge

and perhaps provide one or two additional

medication doses to be administered in the

referral setting rests on adequacy of supervision, the probability of whether the patient

will drink while undergoing treatment, and

whether the patient can or will return for

assessments the following day. In some circumstances, no treatment may be safer than

treatment with medication. Mayo­Smith

(1997) has shown that benzodiazepines confer

protection against alcohol withdrawal seizures

and thus patients with previous seizures

should be treated early. The same applies to

delirium. Both of these topics will be explored

in greater detail in the next section.

Extremely heavy drinking in the weeks prior

to complete cessation also predicts more

severe withdrawal (Lejoyeux et al. 1998), but

confirming such a history often is difficult.

A less accepted and more controversial position on the indications for medication treatment for alcohol withdrawal springs from

studies that attempt to measure oxidative

stress, which is the formation of oxidative

free radicals (chemicals that damage proteins), and stress hormones during alcohol

withdrawal (Dupont et al. 2000; Tsai et al.

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1998). These studies have asserted that individuals who are undergoing mild withdrawal

without treatment still have the formation of

toxic oxidative products which have the hypothetical potential of producing neuronal damage and perhaps some cell death. Lending

support to this argument is the fact that alcohol withdrawal appears to be progressive in

that it worsens with each successive episode

(Malcolm et al. 2000) and that some patients

dependent on alcohol develop evidence of

dementia over time. On the other hand, age,

nutritional status, trauma, co­occurring conditions, and other unspecified events also

probably contribute to this process. 

The decision to treat a patient in alcohol

withdrawal or at potential risk for alcohol

withdrawal will in great part rest on the clinical judgment of the practitioner, relying on

the factors noted above in addition to the

issue of whether treatment may in fact actually do more harm than good. This topic is discussed below under the heading Limitations

of Benzodiazepines in Outpatient Treatment

(p. 60). For more information about medication­assisted treatment, see TIP 43,

Medication­Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs

(CSAT 2005d).

Benzodiazepine treatment of

alcohol withdrawal

Depending upon the clinical setting and the

patient circumstances, there are several acceptable regimens for treating alcohol withdrawal

that make use of benzodiazepines. These drugs

remain the medication class of choice for treating alcohol withdrawal. The early recognition

of alcohol withdrawal and prompt administration of a suitable benzodiazepine usually will

prevent the withdrawal reaction from proceeding to serious consequences. Patients suspected

of alcohol withdrawal should be seen promptly

by a primary care provider (physician, nurse

practitioner, physician assistant) who has experience in diagnosing and managing alcohol

withdrawal. Practitioners are reminded that

benzodiazepines have side effects and limitations. These limitations are far more prominent

when treating alcohol withdrawal in an outpatient setting.

Loading dose of a benzodiazepine 

Medical or nursing administration of a slowly

metabolized benzodiazepine, frequently intravenously, but sometimes orally, may be carried

out every 1 to 2 hours until significant clinical

improvement occurs (such as reducing the

CIWA­Ar score to 10 or less) or the patient

becomes sedated (Sellers and Naranjo 1985).

Patients at grave risk for the most severe complications of alcohol withdrawal or who are

already experiencing severe withdrawal should

be hospitalized and can be treated with this

regimen. 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.

Oversedation, ataxia (lack of muscular coordination), and confusion, particularly in elderly

patients, may occur with this protocol. The

treatment staff should closely monitor hemodynamic (blood pressure and pulse) and respiratory features. They should particularly be prepared to detect and rapidly treat apnea (no

breathing) with assisted ventilation. Having

experienced staff with adequate time to frequently monitor the patient and provide intravenous medication is necessary.

Symptom­triggered therapy 

Using the CIWA­Ar or similar alcohol withdrawal rating scales, medical personnel can be

trained to recognize signs and symptoms of

alcohol withdrawal, make a rating, and based

on that rating administer benzodiazepines to

their patients only when signs and symptoms

reach a particular threshold score. Studies

have demonstrated that appropriate training of

nurses in the application of the CIWA­Ar dramatically reduces the number of patients who

need to receive symptom­triggered medication

(Saitz et al. 1994; Wartenberg et al. 1990). This

regimen has been used successfully with short,

intermediate, and long half­life benzodiazepines.

58 Chapter 4
The training of staff in a standardized procedure of administering rating scales is important and periodic retraining to ensure continued reliability among raters is essential. A

typical routine of administration of symptomtriggered therapy is as follows: Administer

50mg of chlordiazepoxide (Librium) for

CIWA­Ar > 9 and reassess in 1 hour.

Continue administering 50mg chlordiazepoxide every hour until CIWA­Ar is < 10. Dosage

amount and frequency can be modified

depending on the individual clinical situation

as determined by the medical provider.

Patients with a history of withdrawal seizures

should receive scheduled doses of a long­acting benzodiazepine (e.g., diazepam [Valium],

20mg every 6 hours for 3 days) regardless of

CIWA­Ar score, and should receive additional doses if indicated by elevated CIWA­Ar

score. It must be noted here that symptomtriggered therapy is not recommended for

outpatient detoxification. Symptom­triggered

therapy requires monitoring and decisionmaking by a healthcare professional.

Gradual, tapering doses 

Before beginning any tapering regimen, the

patient must be fully stabilized; that is, all signs

and symptoms of withdrawal must be

improved. Without proper stabilization, no

tapering scheme will succeed. Once the patient

has been stabilized, oral benzodiazepines can

be administered on a predetermined dosing

schedule for several days and gradually

tapered over time. This is a commonly used

regimen.

Dosing protocols vary widely among treatment facilities based on the needs of the

patient population. One example is that

patients might receive 50mg of chlordiazepoxide or 10mg of diazepam every 6 hours during

the first day of treatment and 25mg of chlordiazepoxide or 5mg of diazepam every 6

hours on the second and third days. This

approach to dosing, that is, every 6 hours, is

not as accurate in tailoring medications to

counter symptoms; a more precise dosing regimen is titrating (adjusting dosage in light of

drug response) according to severity of symptoms. An alternative regimen might be the

administration of 1 to 2mg lorazepam two or

three times a day the first day, followed by

gradual reduction over the next 3 to 5 days.

The general approach to tapering is to establish an acute dose in the first 24 hours, then

to reduce it over the next three days: for

example, 400 chlordiazepoxide total on day 1,

then 300, 200, 100,

and off on day 5.

This has to be

extended if

lorazepam is used.

Doses of withdrawal Benzodiazepines

remain the

medication class

of choice for

treating alcohol

withdrawal.

medication are omitted if the patient is

sleeping soundly,

showing signs of

oversedation, or

exhibiting marked

ataxia. 

The use of gradual,

tapering doses is

appealing in settings

where trained nursing or medical

observations cannot

be made frequently;

however, this in

itself is a pitfall.

Under­ or overmedication with this regimen

can occur depending on benzodiazepine tolerance; the presence of chronic cigarette smoking, which induces benzodiazepine

metabolism; liver function; age; and the presence of co­occurring medical or psychiatric

conditions. The use of this regimen may be

problematic in the outpatient settings in

which it frequently is applied. Supplying the

patient with 4 to 5 days of a benzodiazepine

and facing the probability that the patient

may drink and take the benzodiazepine is a

hazard. It is important to enforce strict limitations on driving automobiles, climbing, or

operating hazardous machinery. 

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Single daily dosing protocol

Jauhar and Anderson (2000) compared single

daily dosing of diazepam to multiple daily dosing of chlordiazepoxide in inpatients being

treated for alcohol withdrawal. Patients in the

diazepam single daily dose group did as well as

the chlordiazepoxide multiple dosing group.

The authors suggest that this regimen might be

attractive in community or social detoxification

settings, particularly if patients could be monitored between administered doses. Further

study with a larger group of patients is needed.

The choice of the specific benzodiazepine for

any particular regimen depends on a number

of factors, but the most significant factor is that

the clinician administer one that she has the

most experience using. Despite 30 years of

research, no single benzodiazepine has emerged

as the number one drug of choice in treating

alcohol withdrawal. All benzodiazepines studied have worked better than placebo but have

been roughly equivalent with each other. Many

clinicians prefer long half­life benzodiazepines

such as chlordiazepoxide and diazepam, desiring less frequent daily dosing, relatively steady

serum levels, and the ability of these drugs to

self­taper based on their long half­lives.

Diazepam and chlordiazepoxide

Both diazepam and chlordiazepoxide have

excellent rapid oral absorption and are available for intravenous (IV) use. Intramuscular

use of these drugs is to be discouraged since

muscle absorption is erratic. One study suggests that if chlordiazepoxide (Librium) is

taken in overdose with alcohol, it is less likely

to be fatal than diazepam (Valium) (Serfaty

and Masterton 1993). Detractors of the use of

these two drugs point out that they have long

half­lives (although some clinicians see this as

an advantage because it prevents the emergence of withdrawal symptoms between doses),

have multiple active metabolites, and go

through many oxidative metabolic steps in the

liver. Older patients or patients with liver disease are likely to accumulate these medications

quickly without being able to metabolize them.

Possible consequences include oversedation or

ataxia, and on rare occasions, confusion may

ensue.

Lorazepam

Lorazepam (Ativan) has an intermediate halflife of about 8–15 hours, and although it usually is administered in multiple doses each day, it

can be given approximately twice per day.

Lorazepam, with its shorter half­life and lack

of storage in adipose (fatty) tissue, actually has

to be given more frequently than the long­acting preparations, not less. It is absorbed easily

orally, intramuscularly, and intravenously.

Older patients and patients with severe liver

disease tolerate it well and it is an effective

anticonvulsant in blocking a second alcohol

withdrawal seizure (D’Onofrio et al. 1999).

However, it has been suggested that seizures

may occur late in detoxification with short­acting benzodiazepines such as lorazepam and

oxazepam (Shaw 1995).

Oxazepam

Oxazepam (Serax) often is favored by internists

and hepatologists treating alcohol withdrawal

in patients with severe liver failure. It has a relatively short half­life of 6 to 8 hours. Its

metabolism is very simple and it has no

metabolites. The agent is relatively limited in

that its oral absorption is quite slow compared

to other benzodiazepines, it must be given

three to four times a day, and is only available

in the United States in an oral form.

Ultimately, the experience of the treating clinician, characteristics of the patient, and the setting in which he will be treated will determine

the choice of drug. Although all benzodiazepines are now generic in the United States,

costs vary and this too may be a factor in

choice.

Limitations of benzodiazepines in

outpatient treatment

Although benzodiazepines remain the mainstay

of treatment for alcohol withdrawal, they have

limitations that are particularly pronounced

when treating outpatients. Benzodiazepines’

potential interactions with alcohol can lead to

coma and respiratory suppression, motor inco60 Chapter 4
         

         

               

             

           

             

           

           

             

           

           

         

                 

           

       

         

         

   

           

               

         

                 

             

         

               

         

               

           

         

             

           

           

         

     

           

           

             

           

       

         

           

         

         

           

           

           

           

       

         

     

             

         

       

             

           

     

           

ordination (leading to falls and automobile

accidents), and abuse of the medications.

Abuse usually is in the context of the concurrent use of alcohol, opioids, or stimulants.

There are two other limitations of benzodiazepines that may be relevant in some clinical

settings for some patients. First, although benzodiazepines have been studied for more than

30 years and are effective for suppressing alcohol withdrawal symptoms at any one episode,

their ability to halt the progressive worsening

of each successive alcohol withdrawal reaction

is in question. There are now at least nine studies that have found that an ever­increasing

number of previous alcohol withdrawals

increases the severity of withdrawal, particularly seizures and delirium tremens, and

decreases responsiveness to benzodiazepines

(Ballenger and Post 1978; Booth and Blow

1993; Brown et al. 1988; Gross et al. 1972;

Lechtenberg and Worner 1990, 1992; Malcolm

et al. 2000; Shaw et al. 1998; Worner 1996). A

tenth study (Wojnar et al. 1999) found that

increasing severity of alcohol withdrawal symptoms was observed only in a minority (22 percent) of 418 repeatedly treated clients.

However, within this group of one in five individuals, seizures were three times more common than in the larger, nonprogressive group

and premature age of death was 7 years

younger than for the nonprogressive group. In

the majority of these studies, patients were

treated with benzodiazepines, although in a

few, phenobarbital was used.

A second, and at present more hypothetical,

concern about benzodiazepine use to treat outpatients in alcohol withdrawal is that they may

“prime” or reinstate alcohol use during their

administration. Two preclinical studies support

this premise (Deutsch and Walton 1977;

Hedlund and Wahlstrom 1998). A recent randomized, blinded, clinical trial comparing carbamazepine to lorazepam for the outpatient

treatment of alcohol withdrawal found that the

outpatients on lorazepam were three times as

likely to drink as those on carbamazepine. The

lorazepam group drank about twice as much

alcohol in the immediate post­detoxification

period than the carbamazepine group (Malcolm

et al. 2002).

For a list of potential contraindications to using

benzodiazepines to treat alcohol withdrawal in

certain patients, see Figure 4­3.

Other medications

Barbiturates

Barbiturates have been used for nearly a century for the treatment of alcohol withdrawal.

Most barbiturates, other than phenobarbital,

have fallen into disfavor because of severe

Figure 4­3

Potential Contraindications To Using Benzodiazepines To Treat 

Alcohol Withdrawal

•Previous allergic reaction

•Previous paradoxical disinhibition (e.g., violence, agitation, self­harm)

•Previous serious adverse outcomes that could have medico­legal consequences if they re­occur (e.g.,

fractured hip, status epilepticus [continuous seizures of several minutes])

•Severe alterations in mental status with low dose of benzodiazepines (e.g., confusion, delirium)

•An outpatient setting where benzodiazepine use with alcohol has occurred previously with extreme intoxication leading to injuries, coma, or apnea

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 61
lethal interactions

with alcohol, death Delirium and

seizures are the

two most

pathological

responses seen in

alcohol

withdrawal.

from overdose of the

agents alone, rapid

tolerance, and high

abuse potential.

Barbiturates are

highly addictive. In

clinical practice, the

medication is effective both for the

treatment of alcohol

withdrawal and

sedative­hypnotic

withdrawal although

few controlled trials

have been conducted with it (Wilbur

and Kulik 1981). Phenobarbital has a long

half­life and may rapidly accumulate.

Overdoses with phenobarbital also can be fatal.

Members of the consensus panel recommend its

use only in highly supervised settings.

Anticonvulsants

Anticonvulsants have been used in Europe for

a quarter of a century for the treatment of

alcohol withdrawal. Carbamazepine (Atretol,

Tegretol) has been shown in at least three trials

to be as effective as various benzodiazepines in

mild to moderate alcohol withdrawal (Malcolm

et al. 2001). Although less well studied, valproic acid also has been shown to be effective

(Reoux et al. 2001). Older, first­generation

anticonvulsants have limitations in that they

only have been studied in mild to moderate

withdrawal, can on rare occasions have serious

hepatic and bone marrow toxicities, interact

with several other classes of medication, and

are only available in oral forms. They are not,

however, controlled substances, are not

abused, and as previously noted, carbamazepine may have the propensity to reduce

some of the indices of drinking behavior immediately in the post­withdrawal treatment of outpatients. Newer drugs such as tiagabine, oxcarbazepine, and gabapentin do not appear to

have these liabilities, but sufficient studies have

not been done to confirm their effectiveness

and safety.

Other agents

Beta blockers and alpha adrenergic agonists

such as clonidine have been used in the treatment of alcohol withdrawal. They do not prevent seizures in delirium and have only modest

benefits for ameliorating symptoms of withdrawal. However, some patients will have

tachycardia (rapid heartbeat) and hypertension (high blood pressure) that will not be controlled by benzodiazepines, and beta blockers

and alpha adrenergic agonists can be of use in

these patients. Calcium channel antagonists will

also ameliorate some symptoms of alcohol withdrawal. As with beta blockers and clonidine,

calcium channel antagonists should be considered adjunctive therapy primarily to manage

extreme hypertension during withdrawal.

Antipsychotics

Antipsychotics have long been used to control

extreme agitation, hallucinations, delusions,

and delirium during alcohol withdrawal. Older,

low­potency drugs such as chlorpromazine generally are avoided since they can reduce the

seizure threshold. High­potency drugs such as

haloperidol (Haldol) also can reduce the

seizure threshold, but less commonly.

Haloperidol and related agents are available

for oral, intramuscular, and IV administration.

Clinicians should note that since antipsychotics

can lower the seizure threshold, their use during alcohol withdrawal should be undertaken

with great care and close supervision of the

patient is required.

Relapse prevention agents

Relapse prevention agents such as naltrexone

and acamprosate are under consideration as

additional therapies during late withdrawal

treatment, although they are not effective for

alcohol detoxification. Since one­third to onehalf of outpatients detoxifying with benzodiazepines will either drink or leave treatment

prematurely, naltrexone and acamprosate may

be valuable in assisting in reducing the probability of the individual drinking during late

detoxification. High­dose naltrexone therapy

has been associated with some liver toxicity,

but this has not been reported in individuals

taking therapeutic doses to enhance relapse

62 Chapter 4
     

               

           

         

           

       

               

           

         

             

             

             

       

         

               

             

       

     

     

             

           

             

             

           

         

         

             

         

       

           

           

       

             

         

           

                   

           

         

     

             

         

           

             

             

           

       

           

         

         

         

       

             

       

         

     

   

               

       

           

         

         

         

         

         

           

               

         

           

               

         

           

     

               

             

         

             

       

           

         

       

         

               

             

           

     

         

           

     

prevention. Acamprosate may produce diarrhea and this may be already present in some

individuals in alcohol withdrawal. Thus far no

well­controlled studies have been conducted to

provide guidelines as to when these medications

should be introduced during detoxification or

whether it would be better to wait until the

early phase of rehabilitation. For an extended

review, see Kranzler and Jaffe (2003).

Other medications

Abecarnil (Anton et al. 1997), and more recently baclofen (Addolorato et al. 2002), have both

shown promise in the treatment of alcohol withdrawal. However, insufficient information has

been accumulated on these drugs, and therefore they are not recommended for use in clinical patient settings. Their use in alcohol withdrawal should be considered experimental and

premature for the present.

Management of Delirium and

Seizures

Delirium and seizures are the two most pathologic responses seen in alcohol withdrawal. The

major goal of medical management is to avoid

seizures and a special state of delirium called

delirium tremens (DTs) with aggressive use of

the primary detoxification drug (e.g., higher

doses of a benzodiazepine). Prevention is

essential where DTs are concerned. DTs do not

develop suddenly but instead progress from

earlier withdrawal symptoms. Properly administered symptom­triggered medication

approaches will prevent DTs and limit overmedication that can occur when high­dose benzodiazepines are administered without regard

to clinical response. It can be challenging clinically to differentiate impending DTs versus

benzodiazepine toxicity on day 3 of detoxification. When in doubt, in most cases it is safer to

overmedicate than to undertreat and allow DTs

to develop. Flumazenil (Romazicon) can be

used to reverse benzodiazepine overdose.

Death and disability may result from DTs or

seizures without medical care. Several factors

are related to severity of alcohol withdrawal:

high amounts of alcohol being consumed in the

weeks prior to treatment, the severity of the

last withdrawal episodes, and the number of

previously treated or untreated withdrawal

episodes. Other factors such as increasing age;

the patient’s general health, including nutritional status; the presence of co­occurring medical, surgical, and psychiatric disorders; and

the use of medications (prescription, over­thecounter, or herbal) also can amplify severity of

withdrawal symptoms. Early proper medical

management of alcohol withdrawal reduces the

probability of these complications, assuming

early recognition.

For patients with a history of DTs or seizures,

early benzodiazepine treatment is indicated at

the first clinical contact setting (e.g., doctor’s

office, clinic, urgent care, emergency department). Patients with severe withdrawal symptoms, multiple past detoxifications (more than

three), and co­occurring unstable medical and

psychiatric conditions should be managed similarly.

Once an initial clinical screening and assessment have been made, and the diagnosis is reasonably certain, medication should be given.

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. Early thiamine

and multivitamin administration also should be

done at this time. Once full DTs have developed, they tend to run their course despite

medication management, and there is little evidence in the medical literature to suggest that

any medication treatment can immediately

abort DTs.

Patients presenting in severe DTs should have

emergency medical transport to a qualified

emergency department and generally will

require hospitalization. If the DTs are severe,

patients may need to be placed in an intensive

care unit (ICU), and in such settings continuous monitoring of cardiac rhythm, pulse, blood

pressure, oxygen saturation, temperature, and

respiration rates begins with the emergency

medical system and continues in the emergency

department and ICU.

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Early care will depend on medical and surgical

complications and may involve protocols from

advanced cardiac life support (ACLS) and/or

advanced trauma life support. Correction of

fluids and electrolytes (salts in the blood),

hyperthermia (high fever), and hypertension

are vital. Loading doses (rapid administration

of initial high doses) of IV diazepam or

lorazepam are recommended, as are IV thiamine (prior to IV glucose) and multiple vitamins. The physician should consider intramuscular or intravenous haloperidol (Haldol and

others) to treat agitation and hallucinations.

Nursing care is vital, with particular attention

to medication administration, patient comfort,

soft restraints, and frequent contact with orienting responses and clarification of environmental misperceptions.

Alcohol withdrawal seizures represent another

management challenge (Ahmed et al. 2000),

since no large­scale clinical studies have been

conducted to establish firmly best treatment

practices. The majority of alcohol withdrawal

seizures occur within the first 48 hours after

cessation or reduction of alcohol, with peak

incidence around 24 hours (Victor and Adams

1953). Most alcohol withdrawal seizures are

singular, but if more than one occurs they tend

to be within several hours of each other. While

alcohol withdrawal seizures can occur several

days out, a higher index of suspicion for other

causes is prudent. Someone experiencing an

alcohol withdrawal 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. The patient loses consciousness, and if seated usually slumps over,

but if standing will immediately fall to the floor.

The patient’s body is rigid, and breathing ceases. This part of the seizure is called the tonic

phase, which usually lasts for a few seconds

and rarely more than a minute.

The next part of the seizure (more dramatic

and generally remembered by witnesses) consists of jerking of head, neck, arms, and legs.

Breathing resumes during this clonic phase of

the seizure but may be irregular. During the

clonic phase, the lips, tongue, or inside of the

cheeks may be bitten. Involuntary urination or

a bowel movement may occur. Immediately

after the jerking ceases, the patient generally

has a period of what appears to be sleep with

more regular breathing. Vomiting may occur at

this time. The period of sleep may be a few seconds with awakening or a few minutes. Rarely,

the patient may appear not to waken at all and

have a second period of rigidity followed by

muscle jerking. This is known as status epilepticus. Upon awakening, the individual usually

is mildly confused as to what has happened and

may be disoriented as to where she or he is.

This period of post­seizure confusion generally

lasts only for a few minutes but may persist for

several hours in some patients. Headache,

sleepiness, nausea, and sore muscles may persist in some individuals for a few hours. See the

text box on the next page for what to do in the

event of a seizure.

Patients who start to retch or vomit should be

gently placed on their side so that the vomitus

(stomach contents vomited) may exit the mouth

and not be taken into the lungs. Vomitus taken

into the lungs is a severe medical condition

leading to immediate difficulty breathing and,

within hours, severe pneumonia.

Predicting who will have a seizure during alcohol withdrawal cannot be accomplished with

any great certainty. There are some factors

that clearly increase the risk of a seizure, but

even in individuals with all of these factors,

most patients will not have a seizure. Out of

100 people experiencing alcohol withdrawal

only two or three of them will have a seizure.

The best single predictor of a future alcohol

withdrawal seizure is a previous alcohol withdrawal seizure. Individuals who have had three

or more documented withdrawal episodes in

the past are much more likely to have a seizure

regardless of other factors including age, gender, or overall medical health. However, certain other factors may increase the risk of

seizures for all patients:

64 Chapter 4
             

           

   

       

         

     

           

           

         

             

             

           

         

     

         

         

           

         

                                   

                                     

         

                         

                                       

                                   

   

                                     

                             

           

                                 

                                 

       

                                   

                                     

                       

                               

                       

                         

                     

What To Do in the Event of a Seizure

•At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel.

•Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for

the clinic or hospital unit.

•While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt

to prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s head

and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen

by anyone.

•In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from

extreme head­banging by placing a soft object under the head and neck. Sometimes placing one’s hand or

shoe under the head is adequate.

•No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades).

Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially

swallowed and obstruct the airway.

•Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach

contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a

severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia.

•Even if the individual appears to become fully awake, alert, and oriented without any harm following a

seizure, it is strongly recommended that he be referred for medical evaluation.

•Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages

to reorient them as to what happened and where they are.

•Having drunk for more than two decades

•Having poor general medical health and poor

nutritional status

•Having had previous head injuries

•Having had disturbances of serum calcium,

sodium, potassium, or magnesium

Patients having a witnessed seizure can be

treated with IV diazepam or lorazepam and

ACLS protocol procedures. This reduces but

does not completely prevent the likelihood of a

second seizure (D’Onofrio et al. 1999). In the

rare patient with recurrent multiple seizures or

status epilepticus (continuous seizures of several minutes) an anesthesiology consultation may

be required for general anesthesia. Evaluation

of electrolyte disturbances, central nervous system (CNS) trauma, and consideration of sedative­hypnotic withdrawal should be reviewed.

Patients who have had a single witnessed or

suspected alcohol withdrawal seizure should

be immediately given a benzodiazepine,

preferably with IV administration. The study

by D’Onofrio and colleagues (1999) indicated

that a single dose of 1mg of IV lorazepam

reduced recurrent seizure risk, reduced rates

of return to emergency departments, and lowered hospitalization rates. Despite this

report, the consensus panel agrees that hospitalization for further detoxification treatment

is strongly advised to monitor and ameliorate

other withdrawal symptoms, reduce suffering,

and stabilize the patient for rehabilitation

treatment. 

The addition of anti­epileptic drugs (AEDs)

has not been established as effective (Chance

1991; Hillbom and Hjelm­Jager 1984; Rathlev

et al. 1994). This is primarily based on evaluations of phenytoin (Dilantin and others).

Newer AEDs have not been studied extensively for preventing alcohol withdrawal seizures.

The consensus panel suggests that AED therapy should be considered in alcohol withdrawal patients with multiple past seizures (of any

cause), a history of recent head injury, past

Physical Detoxification Services for Withdrawal From Specific Substances 65
     

         

         

       

         

             

             

           

             

         

           

           

         

       

         

               

           

       

           

         

             

         

       

           

         

     

       

       

       

           

     

       

           

           

       

         

         

         

             

           

         

           

       

           

           

           

   

               

             

       

             

         

   

         

             

           

         

           

         

           

         

         

       

         

           

                 

             

         

         

   

         

           

             

           

               

         

               

               

         

                 

meningitis, encephalitis, or family history of

seizures. Further evaluation of a first seizure

often warrants neurologic evaluation (computerized tomography and electroencephalogram), even if the seizure may be suspected to

have been due to alcohol withdrawal.

Patient Care and Comfort

Interpersonal support and hygienic care along

with adequate nutrition should be provided.

Staff assisting patients in detoxification should

provide whatever assistance is necessary to

help get patients cleaned up after entering the

facility and bathed thoroughly as soon as they

have been medically stabilized. Attention to the

treatment of scabies, body lice, and other skin

conditions should be given. Screening for

tuberculosis should be done. Dental and oral

care should be made available. The patient

should be screened for physical trauma,

including bruises and lacerations. Tetanus

immunization may be necessary. Patients with

an altered mental status or altered level of consciousness should be seen in emergency departments, evaluated, and possibly hospitalized.

Staff should continue to observe patients for

head injuries after admission because some

head injuries, such as subdural hematomas,

may not immediately be evident and cost considerations may preclude obtaining a brain

scan in some settings.

Other Immediate Concerns

Alcohol may interact with several classes of

medicine to produce serious CNS depression.

Some examples include benzodiazepines, barbiturates, meprobamate, and other sedative hypnotic groups. Metoclopramide and sedating

antipsychotic medicines such as phenothiazines

also can produce CNS suppression. A disulfiram­like (Antabuse) reaction characterized by

flushing, sweating, tachycardia, nausea, and

chest pain has been reported for metronidazole

and several antibiotics including, but not limited to, cefamandole, cefoperazone, and cefotetan. Acetaminophen in low doses may act

acutely with alcohol to produce hepatotoxicity

(liver damage). Clinicians also should determine whether the patient is using aspirin or

nonsteroidal anti­inflammatory medications

(for example, Motrin or Advil, both containing

ibuprofen) in conjunction with alcohol use.

Antidiabetic agents in concert with alcohol may

produce hypoglycemia (low blood sugar) and

lactic acidosis (blood that has become too

acidic). The therapeutic efficacy and margin of

safety for the use of anti­anxiety medications,

antidepressants, and antipsychotic medication

is thought by some to be lessened by alcohol

use, but this is based largely on anecdotal

information. Alcohol interacts with numerous

other classes of medications that lead to less

serious results. Some important examples are

sedatives, tranquilizers, antiseizure medications, and anticoagulants (blood thinners) such

as Coumadin. Patients who may be taking such

medications need to be carefully observed and

have their medications carefully monitored.

Opioids

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.

All opioids (e.g., heroin, morphine, hydromorphone, oxycodone, codeine, and methadone)

produce similar effects by interacting with

endogenous (produced by the body itself) opioid (:, *, and 6) receptors (that is, specific sites

on cells where these substances bind to the

cell). Opioid agonists stimulate these receptors

and opioid antagonists block them, preventing

their action.

Opioid Withdrawal Symptoms

All opioid agents produce similar withdrawal

signs and symptoms with some variance in

severity, time of onset, and duration of symptomatology, depending on the agent used, the

duration of use, the daily dose, and the interval

between doses. For instance, heroin withdrawal

typically begins 8 to 12 hours after the last

heroin dose and subsides within a period of 3

to 5 days. Methadone withdrawal typically

begins 36 to 48 hours after the last dose, peaks

66 Chapter 4
             

             

         

         

             

           

after about 3 days, and gradually subsides over

a period of 3 weeks or longer. Physiological,

genetic, and psychological factors can significantly affect intoxication and withdrawal severity. Figure 4­4 summarizes many of the common signs and symptoms of opioid intoxication

and withdrawal.

The clinician uses intoxication and withdrawal measures as guides to avoid under­ or overmedicating patients during medically supervised detoxification; the number and intensity

of signs determine the severity of opioid withdrawal. It is important to appreciate that

untreated opioid withdrawal gradually builds

in severity of signs and symptoms and then

diminishes in a self­limited manner. Repeated

assessments should be made during detoxification to determine whether symptoms are

improving or worsening. Repeated assessments also should address the effectiveness of

pharmacological interventions. Detoxification

strategies should aim to establish control over

the opioid withdrawal syndrome, after which

dose reductions can be made gradually. 

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 life­threatening. Rarely,

severe gastrointestinal symptoms produced by

opioid withdrawal, such as vomiting or diarrhea, can lead to dehydration or electrolyte

imbalance. Most individuals can be treated

with oral fluids, especially fluids containing

electrolytes, and some might require intravenous therapies. In addition, underlying

cardiac illness could be made worse in the

presence of the autonomic arousal (increased

blood pressure, increased pulse, sweating)

that is characteristic of opioid withdrawal.

Fever may be present during opioid withdrawal and typically will respond to detoxification. Other causes of fever should be evaluated, particularly with intravenous users,

Figure 4­4 

Signs and Symptoms of Opioid Intoxication and Withdrawal

Opioid Intoxication Opioid Withdrawal

Signs

Bradycardia (slow pulse)

Hypotension (low blood pressure)

Hypothermia (low body temperature)

Sedation

Meiosis (pinpoint pupils)

Hypokinesis (slowed movement)

Slurred speech

Head nodding

Symptoms

Euphoria

Analgesia (pain­killing effects)

Calmness

Signs

Tachycardia (fast pulse)

Hypertension (high blood pressure)

Hyperthermia (high body temperature)

Insomnia

Mydriasis (enlarged pupils)

Hyperreflexia (abnormally heightened reflexes)

Diaphoresis (sweating)

Piloerection (gooseflesh) 

Increased respiratory rate 

Lacrimation (tearing), yawning

Rhinorrhea (runny nose)

Muscle spasms

Symptoms

Abdominal cramps, nausea, vomiting, diarrhea

Bone and muscle pain

Anxiety

Source: Consensus Panelist Charles Dackis, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 67
because HIV infection, viral hepatiMethadone is the

most frequently

used agent

approved for

detoxification by

the FDA, and a	 

new medication,

buprenorphine,

has been

approved for use.	 

tis, abscesses,

infected injection

sites, and pneumonia occur commonly in this population and always

require medical

attention. Anxiety

disorders, especially those involving

panic anxiety, also

might show

increased intensity

during opioid withdrawal. Finally,

any condition

involving pain is

likely to worsen

during opioid withdrawal because of a

reduced pain

threshold and the

lack of analgesia

(pain relief) afforded by opioid use.

This phenomenon is particularly common
 

with dental pain and chronic back pain. 

Management of Withdrawal
 

Without Medications
 

It is not recommended that clinicians attempt

to manage significant opioid withdrawal symptoms (causing discomfort and lasting several

hours) without the effective detoxification

agents discussed below. Even mild levels of opioid use commonly produce uncomfortable levels of withdrawal symptomatology.

Management of this syndrome without medications can produce needless suffering in a population that tends to have limited tolerance for

physical pain.

Management of Withdrawal

With Medications

The management of opioid withdrawal with

medications is most commonly achieved

through the use of methadone (in addition to

adjunctive medications for nausea, vomiting,

diarrhea, and stomach cramps). Federal regulations restrict the use of methadone for opioid

withdrawal to specially licensed programs,

except in cases where the patient is hospitalized

for treatment of another acute medical condition. Methadone is the most frequently used

agent approved for detoxification by the Food

and Drug Administration (FDA), and a new

medication, buprenorphine (discussed below),

has been approved for use. Methadone can be

used for detoxification from heroin and all opioid agonists.

Another commonly used agent is clonidine

(Gold et al. 1984), an a­adrenergic agonist

that relieves most opioid withdrawal symptoms without producing opioid intoxication or

drug reward. However, since clonidine detoxification is less effective against many opioid

withdrawal symptoms, adjunctive medicines

often are necessary to treat insomnia, muscle

pain, bone pain, and headache. Adjunctive

agents should not be used in the place of an

adequate detoxification dosage. Additional

opioid agonists could be used theoretically for

detoxification but would have to be administered “off label,” because the FDA has

approved only methadone for this purpose.

Off­label use (prescribing an agent approved

for another condition) could be difficult to

justify, given the efficacy of methadone in

reversing opioid withdrawal. 

Detoxification is indicated for treatment­seeking persons who display signs and symptoms

sufficient to warrant treatment with medications and for whom maintenance is declined

or for some reason is not indicated or practical. In addition, individuals dependent on

opioids sometimes are hospitalized for other

health problems and may require hospitalbased detoxification even though they are not

68 Chapter 4
             

             

             

         

             

           

       

             

           

       

seeking substance abuse treatment. Such

patients also can be maintained on methadone

during the course of hospitalization for any

condition other than opioid addiction. The

hospital does not have to be a registered opioid treatment program, as long as the patient

was admitted for a detoxification treatment

for some substance other than opioids. On

the other hand, some persons may not have

used sufficient amounts of opioids to develop

withdrawal symptoms, and for others sufficient time may have elapsed since their last

dose to extinguish withdrawal and eliminate

the need for detoxification. 

Methadone 

This section discusses methadone as an agent

for detoxification. For detailed information

on methadone maintenance, readers are

referred to TIP 43 Medication­Assisted

Treatment for Opioid Addiction in Opioid

Treatment Programs (CSAT 2005d). While

methadone is one of the more common medications for opioid detoxification, its use is

highly regulated and it can only be prescribed

for withdrawal by a doctor at a Substance

Abuse and Mental Health Services

Administration (SAMHSA)­certified

methadone clinic or if the patient is being

hospitalized for another medical condition.

(Detoxification programs may become certified to prescribe methadone by undergoing

the process described in TIP 43.) Federal regulations allow for the use of methadone in

both a short­term detoxification treatment of

less than 30 days and a long­term treatment

of 30 to 180 days. The regulations also specify

that if a patient has failed two detoxification

attempts in a 12­month period he or she must

be evaluated for a different course of treatment (e.g., ongoing opioid substitution 

therapy).

Methadone is a long­acting agonist at the :­opioid receptor site that, in effect, displaces heroin (or other abused opioids) and restabilizes the

site, thereby reversing opioid withdrawal symptoms. If maintained for long enough, this stabilizing effect can even reverse the immunologic

and endocrinologic defects caused by long­term

heroin addiction. This is one of many important reasons to consider conversion to maintenance during most methadone detoxification

admissions.

Once the dose requirement for methadone has

been established, methadone can be given

once daily and generally tapered over 3 to 5

days in 5 to 10mg daily reductions. The initial

dose requirement is determined by estimating

the amount of opioid use and gauging the

patient’s response to administered

methadone. Clinicians should take care not to

underdose patients with methadone; adequate

dosage is vitally important. Patients sometimes exaggerate their daily consumption to

receive greater dosages of methadone. For

this reason, history is no substitute for a

physical examination that screens for signs of

opioid withdrawal. Treating clinicians should

not only be familiar with the intoxication and

withdrawal signs that are set forth in Figure

4­4 (p. 67), but also should be skilled in discerning these features of opioid withdrawal.

Avoidance of overmedicating is crucial during

methadone detoxification because excessive

doses of this agent can produce overdose,

whereas opioid withdrawal does not constitute

a medical danger in otherwise healthy adults.

For more information on methadone and

other medications used to treat opioid addiction, see TIP 43, Medication­Assisted

Treatment for Opioid Addiction in Opioid

Treatment Programs (CSAT 2005d).

Patients with significant opioid dependence

may require a starting dose of 30 to 40mg per

day; this dose range should be adequate for

even the most severe withdrawal. If the

degree of dependence is unclear, withdrawal

signs and symptoms can be reassessed 1 to 2

hours after giving a dose of 10mg of

methadone. The practice of giving a dose of

methadone and later assessing its effect (also

termed a challenge dose) is an important

intervention of detoxification. Sedation or

intoxication signs after a methadone challenge

dose indicate a lower starting dose. Similarly,

intoxication at any point of the detoxification

Physical Detoxification Services for Withdrawal From Specific Substances 69
       

             

               

             

           

             

         

         

           

             

         

       

             

           

             

     

             

       

   

             

     

     

         

           

           

             

           

           

           

         

signals the need to hold or more rapidly wean

(reduce to a zero dose) the methadone. Care

should be taken to avoid giving methadone to

newly admitted patients with signs of opioid

intoxication, since overdose could result.

Note that methadone stabilization is the treatment of choice for patients who are pregnant

and opioid dependent.

Clonidine (Catapres)

Clonidine was originally marketed and

approved for the treatment of high blood pressure but also has been used for opioid detoxification since 1978. While clonidine is not FDA

approved for treatment of opioid withdrawal, it

is widely used “off label” for this purpose

(Alling 1992) because the research literature

substantiates its effectiveness for this condition.

Advantages of clonidine over methadone in the

treatment of opioid withdrawal are as follows:

•Clonidine does not produce opioid intoxication and is not reinforcing.

•The FDA does not classify clonidine as having

abuse potential. Yet some abuse has been

reported. (See p. 107 under the section on

pregnant women and opioids.)

•Since clonidine does not interact with the

:­opioid receptor, detoxification occurs

without opioids.

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

One disadvantage to methadone detoxification

with naltrexone (an opioid antagonist), compared with clonidine, is that naltrexone, when

it is prescribed for abstinence, can precipitate

opioid withdrawal if given too soon after the

last methadone dose. This problem does not

exist with clonidine, making this agent particularly beneficial in a drug­free treatment program or a therapeutic community.

Nevertheless, patients addicted to opioids

generally prefer methadone over clonidine

detoxification. Although clonidine alleviates

some symptoms of opioid withdrawal, it usually is relatively ineffective for insomnia,

muscle aches, and drug craving. Completion

rates for opioid detoxification using clonidine

have been low (ranging from 20 to 40 percent); those patients who complete the procedure are more likely to be dependent on opioids other than heroin, have private health

insurance, and report lower levels of subjective withdrawal symptoms than those who do

not complete (Strobbe et al. 2003).

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 (under the

tongue) route of administration also may be

used. Clinicians should check the patient’s

blood pressure prior to clonidine administration and clonidine should be withheld if systolic blood pressure is lower than 90 or diastolic blood pressure is below 60. These

parameters can be relaxed to 80/50 in some

cases if the patient continues to complain of

withdrawal and is not experiencing symptoms

of orthostatic hypotension (a sudden drop in

blood pressure caused by standing).

Clonidine (0.1 to 0.2mg orally) can then be

given every 4 to 6 hours on an as­needed

basis. Clonidine detoxification is best conducted in an inpatient setting, as vital signs

and side effects can be monitored more closely in this environment. In cases of severe

withdrawal, a standing dose (given at regular

intervals rather than purely “as needed”) of

clonidine might be advantageous (Alling

1992). The daily clonidine requirement is

established by tabulating the total amount

administered in the first 24 hours, and dividing this into a three or four times per day

dosing schedule. Total clonidine should not

exceed 1.2mg the first 24 hours and 2.0mg

after that, with doses being held in accordance with parameters noted above. The

standing dose is then weaned over several

days. Clonidine must be tapered to avoid

rebound hypertensions. 

The clonidine transdermal (administered

through the skin) patch, FDA approved in

70 Chapter 4
1986 for the treatment of hypertension (high

blood pressure), also is used in opioid detoxification. However, the safety of the patch for

treatment of opioid withdrawal has not been

sufficiently studied in controlled clinical trials. The transdermal route of administration

has the disadvantage of continued clonidine

action even after the patch has been removed.

Blood pressure effects of clonidine can therefore be prolonged, leading to undesirable and

persistent reductions of blood pressure. For

this reason, it has been recommended that the

patch be used only if the patient’s blood pressure is monitored regularly (Alling 1992).

The clonidine patch is available in three 

sizes that deliver a total daily oral equivalent

clonidine dose of 0.2mg (3.5 cm2

), 0.4mg (7.0

cm2

), or 0.6mg (10.5 cm2). The patch supplies

clonidine for up to 7 days and one patch

application usually is sufficient. The convenience of one application allows the clinician

to avoid the disruption that multiple dosing

might have during rehabilitative programming. In particular, patients can focus on

rehabilitative treatment without being distracted by the need to ask repeatedly for oral

clonidine doses. Vital signs should be monitored at least four times daily to assess persistent signs and symptoms of withdrawal or

undesirable effects of clonidine on blood pressure. 

Buprenorphine

Buprenorphine, a partial a­opioid agonist that

is FDA approved in an injectable form

(Buprenex) for the treatment of pain, has

recently been approved as a detoxification

agent and for opioid maintenance treatment as

an alternative to methadone maintenance. A

number of clinical trials have reported it to be

effective for heroin detoxification (Becker et al.

2001; Bickel et al. 1988; Diamant et al. 1998),

and the medication should play an important

role in gradually removing patients from

methadone maintenance (Amass et al. 2004;

Banys et al. 1994; Johnson et al. 2000).

Buprenorphine is available in oral form as

Subutex, which contains only buprenorphine,

and is meant for patients who are starting

treatment for drug dependence. Another

form, Suboxone, contains buprenorphine and

naloxone and is intended for persons dependent on opioids who have already started and

are continuing medication therapy.

Buprenorphine has great affinity for the 

:­opioid receptor, in

spite of being only a

partial agonist, and

can displace other One advantage of

buprenorphine is

that it can be

dispensed at a

physician’s office,

unlike methadone,

which can be

dispensed only at

designated treatment centers.

opioids such as heroin. This feature gives

buprenorphine the

ability to precipitate

opioid withdrawal

when administered to

patients who have

recently used heroin

(Kosten and

McCance­Katz 1995). 

An advantage to

buprenorphine is its

safety. Because of

the partial agonist

action, buprenorphine has a “ceiling

effect” with regard to

overdose potential

(Walsh et al. 1994).

That is, unlike

methadone, which

produces increasing

respiratory suppression with increasing dose,

respiratory effects of buprenorphine tend to

level off due to its partial agonist action.

Another advantage of buprenorphine is that

it can be dispensed at a physician’s office,

unlike methadone, which can be dispensed

only at designated treatment centers. This

makes access to this medication for opioid

dependence much more convenient for both

patient and clinician. See TIP 40, Clinical

Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction (CSAT

2004a).

Physical Detoxification Services for Withdrawal From Specific Substances 71
Unlike methadone, buprenorphine may be

prescribed by physicians who are not connected with a certified opioid treatment program. However, there is a still a specific

training and certification process

physicians must

undergo in order to

prescribe the medication. Information

on the legal aspects

of prescribing

buprenorphine and

rules for carrying

out detoxification in

the physician’s

office can be found

at http://

www.buprenorphine.samhsa.gov/.

Information given

at the site includes

the following on the

Drug Addiction

Treatment Act

(DATA) of 2000:

“[DATA 2000]

expands the clinical

context of medicaInpatient

treatment can

provide additional

support, medical

supervision, and

rehabilitative	 

treatment that

serve as

disincentives to

relapse.	 

tion­assisted opioid addiction treatment by

allowing qualified physicians to dispense or

prescribe specifically approved Schedule III,

IV, and V narcotic medications for the treatment of opioid addiction in treatment settings

other than the traditional Opioid Treatment

Program (i.e., methadone clinic). In addition,

DATA 2000 reduces the regulatory burden on

physicians who choose to practice opioid addiction therapy by permitting qualified physicians

to apply for and receive waivers of the special

registration requirements defined in the

Controlled Substances Act” (SAMHSA 2002).

Terminating Methadone
 

Maintenance Treatment
 

Individuals seeking the discontinuation of

methadone maintenance require a much more

lengthy detoxification process than that

described above for heroin. The methadone

dose should be tapered gradually by 5 to

10mg/week until a daily dose of 30 to 40mg has

been attained. At that time, detoxification with

either clonidine or smaller doses of methadone

can be instituted. The use of clonidine has the

advantage of brevity as a complete clonidine

detoxification usually can be conducted within

2 to 3 weeks (Gold et al. 1984).

Once the daily dose requirement has been

established by using the principles outlined

above, the patient can be placed on a standing dose of clonidine. The dose required usually is in the range of 0.2mg, three to four

times daily, although titration (adjustment of

dosage in light of drug response) is necessary

based on the information gathered during the

clinical examination. Additional doses as

needed (sometimes abbreviated “PRN”) of

0.2mg clonidine also can be given and blood

pressure parameters must be followed prior

to the administration of standing and PRN

doses to avoid orthostatic hypotension. The

initial standing dose can be reduced to 0.1mg,

given three to four times daily, after one week

of detoxification, with PRN doses of 0.1mg

available. After a period of 1 week on this

reduced dosage, clonidine is given for an

additional week only if needed. Because clonidine does not reverse all opioid withdrawal

symptoms, especially insomnia, adjunctive

medications for symptom relief of insomnia,

nausea, diarrhea, etc. usually are required.

Clonidine detoxification is best conducted on

an inpatient basis to ensure appropriate vital

sign monitoring. Inpatient treatment also

reduces the impulse to relapse, especially if

the detoxification is difficult. 

Methadone detoxification can be continued

once a daily dose of 30 to 40mg is achieved, as

described above. The dose can be reduced to

20mg per day by a reduction of 5 to

10mg/week. Once the patient is on 20mg/day,

methadone can be reduced by 1 to 2mg daily,

depending on clinical measures of withdrawal. As with clonidine detoxification, the final

2 to 3 weeks of methadone detoxification is

associated with recidivism (relapsing).

72 Chapter 4
   

             

           

             

             

             

           

               

             

                 

               

             

               

         

         

           

             

               

     

   

           

             

         

       

           

             

             

         

           

               

       

           

               

     

     

           

           

       

     

       

           

     

               

           

           

         

             

           

Inpatient treatment, if available, can provide

additional support, medical supervision, and

rehabilitative treatment that serve as disincentives to relapse.

Rapid and Ultrarapid

Detoxification

Although there are few data showing that the

rapid or ultrarapid methods of opioid detoxification show a positive correlation with the likelihood of a patient’s being abstinent a few

months later, efforts persist to make the detoxification process shorter and easier. This stems

in part from the desire of the person addicted

to opioids for a rapid, painless procedure, and

in part from an attempt to coax more such persons into treatment (fewer than one in five people with substance use disorders in the United

States are in treatment at any time) (Office of

National Drug Control Policy 2002). Another

contributing factor is the American culture’s

search for rapidity in most endeavors. Finally,

the desire for rapid opioid detoxification is a

remnant of the belief system of a century ago,

when detoxification often was erroneously

equated with cure.

Rapid methods of detoxification have at their

core the use of narcotic antagonists; for example, naloxone, naltrexone, or nalmefene, to

precipitate narcotic withdrawal by displacing

exogenous opioids (those not produced by the

body itself) from the receptor sites. The ensuing severe symptoms then are managed by a

variety of medications and techniques. This

procedure was tried in the mid­1970s (Blachly

et al. 1975; Resnick et al. 1977), using naloxone

combined with benzodiazepines or propranolol

to ameliorate symptoms, but relief was insufficient for the technique to be considered useful.

With the discovery of clonidine as a nonopioid that could successfully treat much of the

withdrawal syndrome (Gold et al. 1978), the

method became more successful, but was still

problematic. Using combinations of clonidine,

naltrexone, benzodiazepines, and other

adjunct medications, the method was refined

and shortened during the 1980s (Charney et

al. 1982, 1986; Kleber et al. 1987; Riordan

and Kleber 1980; Vining et al. 1988) so that a

blocking dose of naltrexone—at least 25mg—

usually was used by the second or third day

of treatment. The rate­limiting factor of this

rapid clonidine­naltrexone method is its

capacity to adequately relieve the precipitated withdrawal symptoms in the conscious

patient. Golden and Sakhrani (2004) found

that 25 percent of the 20 patients they studied

who were undergoing rapid detoxification

using clonidine and naltrexone developed

delirium and had to discontinue the procedure after the first day, and another patient

dropped out before completion. 

The 1990s witnessed a variety of attempts to

overcome this barrier by using general anesthesia or heavy sedation. Although the ultrarapid procedure under anesthesia has

received wide publicity, controlled studies

that would make it possible to evaluate the

risk/benefit ratio are absent. The procedure

is still unproven and controversial. For a

brief review of studies done in this area, see

Stine and colleagues (2003).

Patient Care and Comfort

Opioid detoxification, when properly conducted, usually can be concluded without significant patient discomfort. Aside from the compassionate goal of preventing unnecessary suffering, appropriate opioid detoxification

strengthens the therapeutic alliance between

the patient and clinician and prevents patients

from leaving treatment prematurely.

Discomfort also can indicate that too low a dose

of the detoxification agent is being administered. Mere symptomatic treatment is not a

substitute for reversing opioid withdrawal

and care should be taken to avoid masking

symptoms that would better respond to

detoxification.

Nevertheless, patients receiving adequate

detoxification doses still may complain of

symptoms that can be treated with adjunctive

Physical Detoxification Services for Withdrawal From Specific Substances 73
   

   

     

         

           

       

             

               

       

       

           

       

         

       

         

             

medications. Insomnia can be treated with

diphenhydramine (Benadryl) 50 to 100mg,

trazodone (Desyrel) 75 to 200mg, or hydroxyzine (Vistaril) 25 to 50mg at bedtime.

Benzodiazepines should be avoided unless

required for concomitant alcohol or sedative

detoxification. Headache, muscle aches, and

bone pain can be managed with acetaminophen (e.g., Tylenol), aspirin, or ibuprofen

(e.g., Motrin) as needed. Abdominal cramps

are rare when the detoxification dose is sufficient but can be ameliorated with dicyclomine

(e.g., Bentyl) 10 to 20mg every 6 hours.

Mylanta or Maalox can be administered for

epigastric complaints and bismuth subcarbonate (e.g., Pepto­Bismol) 30 cc can be given

every 2 to 3 hours for diarrhea. Constipation,

a frequent complaint during methadone maintenance, usually can be managed with milk of

magnesia at 30 cc daily.

Opioid dependence, particularly intravenous

heroin dependence, is associated with a number of medical conditions. For this reason, a

complete physical examination, review of systems, and laboratory evaluation (when indicated) should be conducted. The patient

should be screened for tuberculosis as well as

for commonly encountered medical complications. These include HIV/AIDS, viral hepatitis (especially B and C), other sexually transmitted diseases, and opportunistic infections.

Injection sites should be examined for infection or abscess and patients should be

queried about night sweats, chills, nutritional

intake, diarrhea and gastrointestinal distress,

fever, and cough. History or evidence of trauma also should be elicited as part of a comprehensive assessment upon which a full

treatment plan will be based. In general,

patients should be ambulatory and able to

participate in rehabilitative activities during

detoxification. However, during the first 24

hours they may require bed rest or reduced

activity. 

Benzodiazepines 

and Other SedativeHypnotics

Intoxication and Withdrawal

Symptoms Associated With

Benzodiazepines and Other

Sedative­Hypnotics

Patients intoxicated with sedative­hypnotics

appear similar to individuals intoxicated with

alcohol. Slurred speech, ataxia, and poor physical coordination are prominent. If benzodiazepines are used alone, breath and blood alcohol levels should be zero. It should be remembered that benzodiazepines, when ingested

alone, intentionally, or accidentally in overdose, rarely lead to death by themselves.

Unfortunately, most individuals who ingest

benzodiazepines also may be using alcohol,

other sedative­hypnotics, or other drugs of

abuse, which in combination with benzodiazepines could be fatal if not managed appropriately.

Management of benzodiazepines and other

sedative­hypnotics in overdose is in part supported following principles of ACLS with particular attention to ventilation. Additionally,

removal of the benzodiazepine 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 at the benzodiazepine receptor. It can reverse the sedative and overdose effects of benzodiazepines

but not of alcohol or other sedative­hypnotics. The medication is administered via IV

by slow push (2 to 3 minutes) and dosage

varies, depending on whether one is treating

sedation reversal or overdose coma­reversal.

Flumazenil is only effective in benzodiazepine

overdose and is not an effective antidote

against other drugs. Clinicians should be

aware that in chronic benzodiazepine users

who are physically dependent, flumazenil

may induce seizures, high blood pressure,

74 Chapter 4
and delirium. So patients who are comatose

from benzodiazepines and are benzodiazepine

dependent may move quickly from coma to

acute benzodiazepine withdrawal symptoms

when flumazenil is administered.

Assessing the potential or actual severity of a

benzodiazepine and other sedative­hypnotic

abstinence syndrome is based primarily on

clinical information obtained from the patient,

significant others, and physical assessment.

Confirmation of length of benzodiazepine treatment with significant others, local pharmacies,

and treating physicians is useful. Specific name

of medication, dose, and duration of therapy

are vital. The presence or absence of alcohol

use is also important to know, as with the use of

other sedative­hypnotics, such as medications

for sleep. The existence of co­occurring psychiatric disorders such as panic disorder also are

important factors and should be investigated.

Cigarette smoking tends to induce the

metabolism of some benzodiazepines and this

can be a factor in scheduling a taper. Physical

assessment, with particular attention to mental

status, and neurologic exams are important.

Determination of vital signs also provides guidance. A urine drug screen may confirm the

presence of benzodiazepines but otherwise will

not be particularly helpful. Although sedativehypnotic withdrawal scales have been used in

research studies, they are not widely available

for clinical practice.

Medical complications of withdrawal from benzodiazepines include problems similar to those

seen in alcohol withdrawal. Seizures are particularly worrisome and may occur without being

preceded by other evidence of withdrawal. As

in alcohol withdrawal, seizures and delirium

represent the most extreme pathology seen.

Anecdotal reports appearing in the literature

also have described distortions in taste, smell,

and other perceptions. Since many individuals

who take benzodiazepines have underlying

anxiety disorders, it often is difficult during

periods of withdrawal to determine whether

symptomatology is related to withdrawal or the

emergence of panic attack symptoms. Elderly

patients who are being withdrawn from benzodiazepine are at risk for falls and myocardial

infarctions. Delirium without marked autonomic hyperactivity (no elevations of pulse,

blood pressure, or temperature) also may be

seen in the elderly. The management of benzodiazepine withdrawal is not recommended

without medical supervision. All benzodiazepines should be tapered rather than stopped

abruptly, regardless of dose or duration of

use—unless it is a

matter of use for only

a few days (Ashton

2002). Patients

intoxicated with

sedative­hypnotics

appear similar to

individuals

intoxicated with

alcohol. Slurred

speech, ataxia,

and poor physical

coordination are

prominent.

Management

of

Withdrawal

With

Medications

There are a limited

number of controlled

trials that can provide guidance regarding the management

of benzodiazepine

and other sedativehypnotic withdrawal.

For reviews, see

Rickels and colleagues (1999) and

Eickelberg and MayoSmith (1998). One

strategy that is appropriate is to begin with

a slow taper of the

benzodiazepine that the patient already is taking. This taper may be conducted over several

weeks or perhaps even months. This may be

effective in cases of long­acting benzodiazepines

but often is not effective in detoxification from

short half­life benzodiazepines. Sometimes

switching to another benzodiazepine in a

patient who has had serious loss of control and

abuse problems with his primary agent is therapeutic. Another strategy is to switch the

patient to another benzodiazepine with a long

half­life. Frequently chlorodiazepoxide and

Physical Detoxification Services for Withdrawal From Specific Substances 75
         

                

         

   

     

               

         

     

     

         

             

     

           

         

           

             

       

           

           

         

       

           

         

           

           

               

           

       

         

         

         

   

         

           

         

         

             

       

           

           

         

         

             

             

           

     

clonazepam are recommended. Figures 4­5 and

4­6 (p. 78) give the equivalent doses of these

medicines along with numerous other sedativehypnotics and benzodiazepines.

Another alternative is phenobarbital substitution. For patients who have used high doses of

benzodiazepines for an extended period of

time, hospitalization is always prudent.

Outpatient detoxification should be reserved

for patients whose doses of benzodiazepines

were mainly in therapeutic ranges, who do not

have polysubstance dependence, and who are

reliable and have reliable significant others to

aid in monitoring and supervising their

progress. In the outpatient setting, patients and

families need to be informed that even with

sound withdrawal treatment, seizures and

delirium are possible. The individual should be

instructed not to drive or operate dangerous

machinery during treatment and perhaps for

several weeks thereafter. Recurring assessment

will be necessary, particularly around times of

dosage reductions. Pregnant patients will need

to be detoxified slowly and in consultation with

an obstetrician.

A variety of cognitive and behavioral techniques have been proposed to assist in the presence of a medication taper. These techniques

alter negative cognitions regarding medication

cessation, provide patient education, and provide alternative cognitive and behavioral techniques for anxiety reduction and sleep

enhancement during detoxification (Spiegel

1999).

Anticonvulsants such as carbamazepine and

valproate, as well as sedating antidepressants

such as trazodone and imipramine, have been

advocated for use in withdrawal (Dickinson et

al. 2003). Rickels and colleagues (1999) assert

that these drugs have some beneficial effect in

the management of relatively low­dose benzodiazepine discontinuation in their ability to

reduce patients’ subjective complaints, but

that, in more severe withdrawal syndromes,

they do not decrease symptoms. Imipramine

can lower the seizure threshold and therefore

is not recommended. The use of anticonvulsants is probably best reserved as an adjunctive medicine to the long­acting benzodiazepine or phenobarbital. The use of buspirone for benzodiazepine detoxification is

ineffective and should not be considered. For

patients with major autonomic symptoms during withdrawal that cannot be controlled by

the primary treating agent, consideration of

the use of a low dose of clonidine or propranolol may be helpful. 

Preparing patients and starting detoxification

during a period of low external stressors, with

patient commitment to tapering, and a plan to

manage underlying anxiety disorders, also are

important in detoxification. A flexible detoxification schedule is advised. During periods

of increased withdrawal symptoms, dosage

should be stabilized or even increased for a

period of days. Frequent in­person or phone

contact with the patient is vital. Patients

being detoxified in the outpatient setting may

need to be seen several times per week, especially at times of dosage reductions.

Stimulants 

Cocaine and amphetamines (such as methamphetamine) are the most frequently abused central nervous system stimulants. These agents

are intensely rewarding and are self­administered by laboratory animals to the point of

death. Individuals dependent on stimulants

experience profound loss of control over stimulant intake, presumably in response to the

stimulation and disruption of endogenous (originating internally) reward centers (Dackis and

O’Brien 2001). They often use stimulants in a

binge pattern that is followed by periods of

withdrawal. It is not clear whether craving

occurs predominantly during stimulant with76 Chapter 4
Figure 4­5

Benzodiazepines and Their Phenobarbital Withdrawal Equivalents

Generic name Trade name Therapeutic dose

range (mg/day)

Dose equal to

30mg of phenobarbital for withdrawal (mg)**

Phenobarbital

conversion 

constant

Benzodiazepines

alprazolam Xanax 0.75–6 1 30

chlordiazepoxide Librium 15–100 25 1.2

clonazepam Klonopin 0.5–4 2 15

clorazepate Tranxene 15–60 7.5 4

diazepam Valium 4–40 10 3

estazolam ProSom 1–2 1 30

flumazenil Mazicon *** *** ***

flurazepam Dalmane 15–30* 15 2

halazepam Paxipam 60–160 40 0.75

lorazepam Ativan 1–16 2 15

midazolam Versed *** *** ***

oxazepam Serax 10–120 10 3

prazepam Centrax 20–60 10 3

quazepam Doral 15* 15 2

temazepam Restoril 15–30* 15 2

triazolam Halcyon 0.125–0.50* 0.25 120 

* Usual hypnotic dose.

** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal

equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high­dose

withdrawal signs and symptoms.

*** Not applicable.

Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.

Physical Detoxification Services for Withdrawal From Specific Substances 77
Figure 4­6

Other Sedative­Hypnotics and Their Phenobarbital 

Withdrawal Equivalents

Generic name Trade

name(s)

Common 

therapeutic

indication

Dose equal

to 30mg of

therapeutic

dose range

(mg/day)

Phenobarbital

for withdrawal (mg)**

Conversion 

constants

Barbiturates

amobarbital Amytal sedative 50–150 100 0.33

butabarbital Butisol sedative 45–120 100 0.33

butalbital Fiorinal,

Sedapap

sedative/

analgesic*

100–300 100 0.33

pentobarbital Nembutal hypnotic 50–100 100 0.33

secobarbital Seconal hypnotic 50–100 100 0.33

Others

buspirone Buspar sedative 15–60 *** ***

chloral hydrate Noctec,

Somnos

hypnotic 250–1,000 500 0.06

ethchlorvynol Placidyl hypnotic 500–1,000 500 0.06

glutethimide Doriden hypnotic 250–500 250 0.12

meprobamate Miltown,

Equanil,

Equagesic

sedative 1,200–1,600 1,200 0.025

methylprylon Noludar hypnotic 200–400 200 0.15

* Butalbital usually is available in combination with opioid or non­opioid analgesics.

** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal

equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high­dose

withdrawal signs and symptoms.

*** Not cross­tolerant with barbiturates.

Source: APA 1990; Wesson and Smith 1985.

78 Chapter 4
           

         

       

           

             

                 

         

         

       

           

         

           

           

     

           

     

           

       

         

         

         

               

         

       

             

           

           

             

         

           

   

         

       

         

         

         

         

     

             

         

     

       

               

         

           

                   

         

           

             

       

         

           

           

         

           

             

         

       

             

         

         

drawal or after these symptoms have largely

disappeared. While the processes that govern

addiction to cocaine and amphetamines are

believed to be similar, recent animal research

suggests that there are also subtle differences in

the ways in which these two types of drugs create sensitization (and perhaps addiction) in regular users (Li et al. 2005).

Stimulant Withdrawal

Symptoms

Stimulants are associated with withdrawal

symptoms that differ markedly from those seen

with opioid, alcohol, and sedative dependence

(see Figure 4­7). 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. Consequently, no

medications have been developed for this purpose. This situation is understandable because

stimulant withdrawal usually does not involve

medical danger or intense patient discomfort.

However, if stimulant withdrawal predicts poor

outcome, it may be a reasonable target for clinical interventions.

An often overlooked but potentially lethal

“medical danger” during stimulant withdrawal

is the risk of a profound dysphoria (depression, negative thoughts and feelings) that may

include suicidal ideas or attempts. This may

be, in part, a physiological response to cocaine

or amphetamine withdrawal and, in part, a

reaction to individuals’ acute realization of the

devastating psychosocial consequences after a

binge ends. While both cocaine and

amphetamine users may experience depression

during withdrawal, the period of depression

experienced by amphetamine users is more

prolonged and may be more intense.

Amphetamine users, in particular, should be

monitored closely during detoxification for

signs of suicidality and treated for depression if

appropriate.

Although the literature on cocaine withdrawal

is controversial, reasonable consensus supports

the constellation of symptoms depicted in

Figure 4­7 (Coffey et al. 2000; Cottler et al.

1993). These symptoms often disappear after

several days of stimulant abstinence but can

persist for 3 to 4 weeks (Coffey et al. 2000). In

addition, since individuals addicted to stimulants often fail to achieve abstinence, withdrawal symptoms can be a persistent component of

active addiction. In addition, individuals

addicted to stimulants may experience impairment in hedonic function (ability to experience

pleasure) that has been ascribed to stimulantinduced disruptions of endogenous reward centers (Dackis and O’Brien 2002). Research on

animals has found that exposure to high doses

of methamphetamine results in changes to both

the dopaminergic and serotonergic systems of

the brain (Nordahl et al. 2005) and dopamine

abnormalities among animals and humans who

had been ingesting cocaine (Schuckit 2000).

Figure 4­7

Stimulant Withdrawal Symptoms

•Depresion

•Hypersomnia (or insomnia)

•Fatigue

•Anxiety

•Irritability

•Poor concentration

•Psychomotor retardation

•Increased appetite

•Paranoia

•Drug craving

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 79
       

             

           

     

       

             

           

         

           

             

             

         

           

         

     

         

           

         

           

     

           

               

               

             

               

       

                 

               

               

         

             

         

           

           

         

         

         

         

         

       

           

                 

           

               

           

           

             

           

         

           

           

             

       

         

             

           

           

         

           

             

     

         

         

     

   

           

         

           

           

             

         

           

               

       

       

       

           

       

           

         

                 

           

           

         

Researchers have also observed abnormalities

in regions of the brain that govern attention

and memory in animals that were regularly

administered methamphetamine (Nordahl et al.

2005).

Although cocaine withdrawal has traditionally

been viewed as relatively mild (Satel et al.

1991; Weddington et al. 1990), evidence suggests that individuals dependent on cocaine

with severe stimulant withdrawal are more likely to have a poor clinical outcome (Kampman

et al. 2001a). The level of withdrawal symptoms, therefore, may be clinically significant

and should be monitored and recorded for

future treatment (Kampman et al. 2001b).

Kampman reported significantly higher

dropout rates in individuals dependent on

cocaine who scored high on the Cocaine

Selective Severity Assessment (CSSA), a reliable and valid structured interview designed to

capture cocaine withdrawal symptoms

(Kampman et al. 1998). Patients with high

scores on the CSSA were five times more likely

to leave treatment and four times more likely to

resume cocaine use than those with low scores

(Mulvaney et al. 1999). The CSSA is an easily

administered 18­item questionnaire. Each item

is a 7­point rating scale, so that a person can

score a number of points on any given question. Scores in excess of 22 indicate the presence of significant cocaine withdrawal. See

appendix C for more information on the CSSA.

Given the poor prognosis associated with

cocaine withdrawal, it is reasonable that more

clinical attention be directed toward this phenomenon.

Medical Complications of

Stimulant Withdrawal

As previously noted, stimulant withdrawal is

not usually associated with medical complications. However, patients with recent cocaine

use can experience persistent cardiac complications, including prolonged QTc interval and

vulnerability for arrhythmia and myocardial

infarction (Chakko and Myerburg 1995). QT is

an interval of time that can be measured on an

electrocardiogram (between the q wave and the

t wave), while QTc is the relative (or “corrected”) QT interval. Some conditions and many

drugs (LAAM, other opioids, and even antibiotics) can cause the interval to lengthen and

this can result in cardiac rhythm disturbances.

Anterior chest pain or cardiac symptoms

should therefore be fully evaluated in these

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

detoxification. Persistent headaches could represent a subdural, subarachnoid, or intracerebral bleed (bleeding in or around the brain)

and should be appropriately evaluated. It also

should be emphasized that people who abuse

stimulants usually become addicted to other

substances, such as alcohol, sedatives, or opioids, and therefore can experience any of the

complications ascribed to detoxification from

these substances. Covert (secretive) use of

other substances should be suspected and

assessed with urine toxicology.

Management of Withdrawal

Without Medications

The most effective means of treating stimulant

withdrawal involves establishing a period of

abstinence from these agents. Access to brief

hospitalization, a level of care previously available for those who abuse stimulants, has been

largely eliminated by managed care initiatives.

In its place, intensive outpatient treatment can

assist the patient to cease use long enough for

withdrawal symptoms to abate entirely.

Rehabilitative approaches to achieve stimulant

abstinence have been reviewed elsewhere

(Dackis and O’Brien 2001). The avoidance of

cue­induced craving is particularly important

in these individuals, especially in light of

research that shows limbic activation (activity

in a certain part of the brain) in response to

cue­induced craving (Childress et al. 1999). It

also is important that individuals dependent on

stimulants abstain from other addictive substances.

80 Chapter 4
Management of Withdrawal

With Medications

There are no medications with proven efficacy

to treat stimulant withdrawal. However,

researchers have investigated some medications

for cocaine detoxification. Amantadine may

help reduce cocaine use in patients with more

severe withdrawal symptoms (Kampman et al.

2000). Modafinil, an antinarcolepsy agent with

stimulant­like action, is currently under investigation by one research group as a cocaine

detoxification agent (Dackis and O’Brien

2002). One small study in Thailand found the

antidepressant mirtazapine (Remeron) was

effective at reducing a number of the symptoms

associated with amphetamine withdrawal

(Kongsakon et al. 2005). None of these medications, however, are approved for use in treating

stimulant withdrawal and further research is

needed. Gorelick and colleagues (2004) review

the full range of clinical literature on pharmacological intervention for cocaine addiction.

Patient Care and Comfort

Since stimulant withdrawal is not associated

with severe physical symptoms, adjunctive

medications are seldom required. These

patients often are sleep deprived and might be

unable to benefit from therapeutic activities

during the first 24 to 36 hours of abstinence.

They often are hungry and in need of large

meal portions initially as their food intake may

have been inadequate during active addiction.

Stimulant users also may be irritable and care

should be taken to avoid needless confrontation

during the initial withdrawal phase. Headaches

often are reported and can be treated symptomatically. Persistent headaches should be

evaluated, as cocaine can produce cerebrovascular disease. Similarly, chest pain of possible

cardiac origin should be evaluated medically

with electrocardiography, cardiac enzymes,

and appropriate medical attention. On occasion, patients undergoing withdrawal from

cocaine or amphetamines report insomnia and

may benefit from diphenhydramine (Benadryl)

50 to 100mg, trazodone (Desyrel) 75 to 200mg,

or hydroxyzine (Vistaril) 25 to 50mg at bedtime. Benzodiazepines should be avoided unless

required for concomitant alcohol or sedative

detoxification. As stimulant withdrawal symptoms wane, patients are best treated with an

active rehabilitative approach that combines

entry into substance abuse treatment with support, education, and changes in lifestyle.

Other Immediate Concerns

Central nervous system stimulants exert most

of their toxic effects through vasoconstriction

(constriction of the blood vessels).

Consequently, a number of medical conditions

can arise from

ischemia (lack of

proper blood supply) Intensive

outpatient

treatment can

assist the patient

to cease use long

enough for

withdrawal

symptoms to abate

entirely.

or infarction (death

of tissue as the result

of lack of blood supply) as a result of

stimulant use.

Myocardial (heart

muscle) infarction

and stroke are widely

recognized complications of stimulant use.

However, other problems such as spontaneous abortion, bowel

necrosis (tissue

death), and renal

(kidney) infarction

also have been

reported from

cocaine­induced vasoconstriction. Cardiac
 

arrhythmias also are common. Other medical
 

problems that are associated with stimulant
 

dependence include dental disease, neuropsychiatric abnormalities, and movement disturbances/disorders.
 

Antidepressants, such as selective serotonin
 

reuptake inhibitors, can be prescribed for the
 

depression that often accompanies methamphetamine or other amphetamine withdrawal.
 

Physical Detoxification Services for Withdrawal From Specific Substances 81
             

         

           

               

         

           

         

               

             

                   

           

             

               

           

         

       

         

           

           

   

                 

             

               

           

           

           

         

         

       

         

       

             

       

     

           

           

             

       

Inhalants/Solvents

Withdrawal Symptoms

Associated With

Inhalants/Solvents

The term “inhalants” is used to describe a

large and varied group of psychoactive substances that all share the common characteristic of being inhaled for their effects. They are

commonly found in household, industrial, and

medical products. These drugs are used primarily by adolescents, although some, especially the nitrates, are used by adults as well

(NIDA 2000). Figure 4­8 presents some of the

more commonly abused inhalants.

Dependence on inhalants and subsequent

withdrawal symptoms are both relatively

uncommon phenomena (Balster 2003). There

is no specific or characteristic withdrawal

syndrome that would include all drugs in the

inhalant class. Intoxication with the solvents,

aerosols, and gases often produces a syndrome most like that of alcohol intoxication

but lasting only 15 to 45 minutes (Miller and

Gold 1990). Rarely, symptoms similar to

sedative withdrawal have been described,

including “fine tremors, irritability, anxiety,

insomnia, tingling sensations, seizures and

muscle cramps” (Miller and Gold 1990, p.

87). Toluene withdrawal has been reported to

cause delirium tremens (Miller and Gold

1990). Longtime users also may exhibit weakness, weight loss, inattentive behavior, and

depression (NIDA 2005). It has been reported

that withdrawal symptoms can occur with as

little as 3 months of regular usage (Ron 1986).

When present, the withdrawal typically lasts

2 to 5 days (Evans and Raistrick 1987).

In addition to their short­term intoxicating

affects, nitrates are used to enhance sexual

pleasure by vasodilation (dilation of blood

vessels) that produces a rush and sensation of

warmth. There is no withdrawal syndrome

that has been associated with nitrate abuse.

There are no specific assessment instruments

available to measure inhalant withdrawal

symptoms. A patient who presents with a history of inhalant use and symptoms of sedative­like withdrawal should alert the clinician

to the possibility of inhalant withdrawal.

These patients require a complete history and

physical exam. Additionally, a blood alcohol

level and urine drug screen are helpful in the

cases of suspected polydrug abuse.

Medical Complications of

Withdrawal From

Inhalants/Solvents

There are a large number of medical complications associated with inhalant abuse and intoxication. Many of these complications are not the

result of withdrawal but may still be seen when

the patient presents to the clinician. Most

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

Additionally, damage to internal organs including the heart, lungs, kidneys, liver, pancreas,

and bone marrow has been reported.

Management of Withdrawal

Without Medications

It is crucial to provide the patient with an environment of safety that removes him from access

to inhalants. This can pose a challenge due to

the almost universal availability of these drugs

in society. Many of the medical consequences of

inhalant usage will remit once the patient

achieves abstinence (Balster 2003). The patient

should be monitored for withdrawal symptoms

and changes in mental status.

Most patients presenting for treatment of

inhalant dependence will be adolescents.

Ideally, they should be entered into an ageappropriate treatment program that meets

their medical and psychosocial needs.

Supportive care, including helping them to get

enough sleep and a well­balanced diet, usually

will be sufficient to get patients safely through

withdrawal (Frances and Miller 1998).

82 Chapter 4
   

         

         

               

         

         

             

       

             

         

               

     

     

   

   

           

     

         

             

     

         

   

     

Figure 4­8

Commonly Abused Inhalants/Solvents

Type Example Chemicals in Inhalant/Solvent

Adhesives Airplane glue Toluene, ethyl acetate

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

ketone, methyl butyl ketone

Special cements Trichloroethylene, tetrachloroethylene

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

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

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

Analgesic spray CFCs

Asthma spray CFCs

Fabric spray Butane, trichloroethane

PC cleaner Dimethyl ether, hydrofluorocarbons

Anesthetics Gaseous Nitrous oxide

Liquid Halothane, enflurane

Local Ethyl chloride

Cleaning agents Dry cleaning Tetrachloroethylene, trichloroethane

Spot remover Xylene, petroleum distillates, chlorohydrocarbons

Degreaser Tetrachloroethylene, trichloroethane, trichloroethylene

Management of Withdrawal

With Medications

Patients presenting with only inhalant withdrawal are unusual. Clinicians should promptly ascertain if the patient has been abusing any

other substances and proceed with appropriate

detoxification as clinically indicated. When a

patient presents with (1) a history of extensive

inhalant usage, (2) a sedative­like withdrawal

syndrome, and (3) no significant history or laboratory data that supports other substances,

then the clinician can assume that the patient is

in inhalant withdrawal.

As noted before, withdrawal from inhalants is

similar to withdrawal from sedative­hypnotics. No systematic detoxification protocol

has been established, although some clinicians

have found phenobarbital useful (CSAT

1995d). The usefulness of benzodiazepines is

unknown but would seem a reasonable alternative given our current understanding of

inhalant withdrawal (Brouette and Anton

2001). No other medications have been routinely used for inhalant withdrawal.

Patient Care and Comfort

For patients who have only been abusing

inhalants, treatment of insomnia during withdrawal is not usually necessary. Sedative substitution during the period of detoxification

may allow the patient to sleep. However, a

period of postdetoxification insomnia should

be expected and usually can be treated by the

Physical Detoxification Services for Withdrawal From Specific Substances 83
           

         

     

     

                 

Figure 4­8 (continued)

Commonly Abused Inhalants/Solvents

Solvents and gases Nail polish remover Acetone, ethyl acetate

Paint remover Toluene, methylene chloride, methanol acetone, ethyl

acetate

Paint thinner Petroleum distillates, esters, acetone

Correction fluid and thinner Trichloroethylene, trichloroethane

Fuel gas Butane, isopropane

Lighter Butane, isopropane

Fire extinguisher Bromochlorodifluoromethane

Food products Whipped cream Nitrous oxide

Whippets Nitrous oxide

“Room odorizers” Locker Room, Rush,

Poppers

Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal),

cyclohexyl

Source: Balster 2003.

recommendation of good sleep hygiene practices such as avoiding caffeine, daytime napping, and overstimulation in the evening. 

If the patient is able to refrain from inhalant

(and other substance) use and has no serious

psychiatric or medical consequences, then

outpatient treatment should be the first

option. Inpatient or residential treatment

should be used for those patients who cannot

achieve abstinence or have serious co­occurring medical or psychiatric disorders.

Hospitalized patients will need a thorough

history and physical exam. Therapy to

address denial, addiction, and pertinent psychosocial issues should be initiated as soon as

possible during the hospitalization.

Supportive care and abstinence will resolve

most medical problems associated with chronic inhalant usage (Balster 2003). 

Nicotine

In 2004, approximately 44.5 million adults

were cigarette smokers (23.4 percent were

men and 18.5 percent were women) (CDC

2005a). Nicotine addiction in the form of

cigarette smoking accounts for more deaths

each year than AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes,

and fires combined (U.S. Department of

Health and Human Services [U.S. HHS]

2000b). Between 1995 and 1999, there were

490,000 smoking­related premature deaths

annually, and smoking cost the country at

least $157 billion yearly in health­related economic losses. This amounts to approximately

$7.18 per pack of cigarettes (Fellows et al.

2002), a truly staggering figure. 

Smokers are at increased risk for several

medical problems, including myocardial

infarction, coronary artery disease, hypertension, stroke, peripheral vascular disease,

84 Chapter 4
     

chronic obstructive lung disease, chronic

bronchitis, and several types of cancer (lung,

stomach, head and neck, and bladder). Other

problems associated with nicotine addiction

include gastro­esophageal reflux disease and

gastric ulcerations, cataracts, and premature

wrinkling of the skin. There also appears to

be an antiestrogen effect (suppression of an

important hormone) that may lead to early

development of osteoporosis in women

(Okuyemi et al. 2000). 

In 1988, the U.S. Surgeon General’s Report

concluded that nicotine is the principal addictive agent in tobacco. Nicotine binds to nicotinic acetylcholine receptors in the brain and

has the direct ability to stimulate the release

of dopamine in the nucleus accumbens area.

The nucleus accumbens has long been considered the “reward center” in the brain. This

increase in dopamine is similar to what occurs

when patients use stimulants and is felt to be

an essential element in the reward process of

addiction (Glover and Glover 2001).

As many as 90 percent of patients entering

treatment for substance abuse are current

nicotine users (Perine and Schare 1999).

There has long been controversy in the field

of addiction medicine as to how best to handle

the problem of nicotine dependence in

patients seeking treatment for other types of

substance abuse. Traditionally, it has been

argued that patients would find that trying to

stop smoking while also contending with other

(more pressing) addiction problems would be

too difficult and distracting in early abstinence. However, others argue that nicotine

dependence is a lethal disease and that physicians have the responsibility to intervene in

this addiction with the same aggressiveness

they show toward other addictive substances.

This pro­intervention position has received

increasing attention from clinicians, inasmuch

as it is now understood that alcohol consumption is associated with increased nicotine

usage (Henningfield et al. 1984). Gulliver and

colleagues (1995) have demonstrated that the

urge to smoke is correlated with the urge to

drink, and others have shown that continued

nicotine dependence may be a relapse trigger

for resumption of drinking (Stuyt 1997). The

concern that smoking cessation may precipitate relapse to other substances of abuse has

not been supported in the literature (Hughes

1995).

Treatment programs that have attempted to

treat nicotine dependence in conjunction with

other drugs of addiction have met with limited success (Bobo and Davis 1993; Burling et

al. 1991; Hurt et al. 1994) and have generated increased interest in smoking cessation as

a part of a patient’s overall substance abuse

treatment (Sees and Clark 1993). One study

reported that forcing unmotivated patients

(or patients who did not consider smoking a

problem) to quit was countertherapeutic

(Trudeau et al. 1995). 

Moreover, it has traditionally been accepted

that nicotine detoxification concurrent with

detoxification from other substances makes

the undertaking more difficult. Several factors are involved including the following: (1)

patient ambivalence and/or lack of interest in

smoking cessation; (2) physician ambivalence

about the importance of smoking cessation

early in treatment; (3) staff’s use of nicotine;

(4) staff’s ambivalence about the importance

of nicotine cessation early in treatment; (5)

easy availability of cigarettes from peers,

family, visitors, staff, and at 12­Step meetings; (6) lack of sufficient training and expertise on the part of physicians and staff in

managing nicotine withdrawal; and (7) staff

resistance to patient smoking cessation

because withdrawal symptoms include irritability, anxiety, and depression, all of which

can make patients more difficult to manage.

Withdrawal Symptoms

Associated With Nicotine

The Diagnostic and Statistical Manual of

Mental Disorders, 4th edition, text revision

(DSM­IV­TR) (APA 2000) notes that typically,

a person in nicotine withdrawal will have four

Physical Detoxification Services for Withdrawal From Specific Substances 85
or more of the signs presented in Figure 4­9,

though some clinicians believe that three or

more is sufficient to make the diagnosis of

nicotine withdrawal. Furthermore, it should

be noted that symptoms vary in duration and

intensity, with decreased heart rate and lightheadedness resolving in 48 hours, while

increased appetite may remain present for

weeks to months (Glover and Glover 2001).

Smokers who have severe craving during

withdrawal are less likely to be successful in

their attempt at quitting (Hughes and

Hatsukami 1992). Depression during withdrawal also has been linked to relapse to

smoking (Covey et al. 1993).

Assessing Severity

Since 1978, the standard instrument used to

measure physical dependence on nicotine has

been the eight­item Fagerstrom Tolerance

Questionnaire (FTQ) (Fagerstrom 1978). A

later revision known as the Fagerstrom Test

for Nicotine Dependence (FTND) (see Figure

4­10) has been reduced to six questions

(Giovino et al. 1995; Heatherton et al. 1991).

Scores greater than seven are consistent with

nicotine dependence.

While both the FTQ and FTND are very useful for estimating a patient’s physical dependence on nicotine, there is still a need to

assess more accurately the degree to which

smoking behavior plays a role in maintaining

addiction. The Glover­Nilsson Smoking

Behavioral Questionnaire (GN­SBQ) is an 11­

question, self­administered test that evaluates

the impact of behaviors and rituals associated

with smoking (see Figure 4­11, p. 88). It was

designed to assist clinicians 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 that takes into

account both physical dependence and behavioral dependence (Glover et al. 2002).

Figure 4­9 

DSM­IV­TR on Nicotine Withdrawal

A. Daily use of nicotine for at least several weeks.

B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24

hours by 4 or more of the following signs:

1. Dysphoric or depressed mood

2. Insomnia

3. Irritability, frustration, or anger

4. Anxiety

5. Difficulty concentrating

6. Restlessness

7. Decreased heart rate

8. Increased appetite or weight gain

C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational,

or other important areas of functioning.

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

mental disorder.

Source: APA 2000, pp. 244–245. 

86 Chapter 4
   

         

       

     

     

               

         

           

     

         

         

                 

                 

                 

       

                  

            

             

                 

                       

     

   

   

         

   

   

Figure 4­10

Items and Scoring for the Fagerstrom Test for Nicotine Dependence

Questions Answers Points

1. How soon after you wake up do you smoke your Within 5 minutes 3

first cigarette? 6–30 minutes 2

31–60 minutes 1

After 60 minutes 0

2. Do you find it difficult to refrain from smoking in Yes 1

places where it is forbidden (e.g., in church, at the No 0

library, in the cinema, etc.)?

3. Which cigarette would you hate most to give up? The first thing in the morning 1

All others 0

4. How many cigarettes/day do you smoke? 10 or less 0

11–20 1

21–30 2

31 or more 3

5. Do you smoke more frequently during the first Yes 1

hours of waking than during the rest of the day? No 2

6. Do you smoke if you are so ill that you are in bed Yes 1

most of the day? No 0

Source: APA 1996.

To better understand a patient’s level of nicotine dependence, providers can assess biochemical markers including nicotine, cotinine, and carbon monoxide. Nicotine and its

metabolite cotinine can be measured in urine,

blood, or saliva. Cotinine continues to be present in bodily fluids for up to 7 days after cessation. Clinicians should use caution when

interpreting the meaning of nicotine and cotinine assays, as they are not specific to tobacco­derived nicotine and may indicate the

patient’s compliance with nicotine replacement therapy rather than smoking. 

Carbon monoxide is easily measured in

expired breath and can show whether the

patient has been smoking within a few hours

prior to the test. It can be used to monitor

smoking cessation for patients receiving nicotine replacement therapy and patients often

find it a helpful motivator in their attempt to

maintain abstinence (Benowitz 1983).

Medical Complications of

Withdrawal From Nicotine

There are no major medical complications precipitated by nicotine withdrawal itself.

However, patients frequently experience

uncomfortable withdrawal symptoms starting

within a few hours of cessation. In addition to

the symptoms previously noted, patients may

complain of increased coughing, a desire for

sweets, and difficulty concentrating (Hughes

and Hatsukami 1992). Clinicians should be

aware that withdrawal symptoms can masquerPhysical Detoxification Services for Withdrawal From Specific Substances 87
Figure 4­11

The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ)

Please indicate your choice by circling the number that best reflects your choice.

0 = Not at all; 1 = Somewhat; 2 = Moderately so; 3 = Very much so; 4 = Extremely so

How much do you value the following (Specific to Questions 1–2)?

1. My cigarette habit is very important to me. 0    1    2    3    4

2. I handle and manipulate my cigarette as part of the ritual of smoking. 0    1    2    3    4

Please indicate your choice by circling the number that best reflects your choice.

(Specific to Questions 3–11).

0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always

3. Do you place something in your mouth to distract you from smoking? 0    1    2    3    4

4. Do you reward yourself with a cigarette after accomplishing a task? 0    1    2    3    4

5. If you find yourself without cigarettes, will you have difficulties in concentrating

before attempting a task?

6. If you are not allowed to smoke in certain places, do you then play with your

cigarette pack or a cigarette?

7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa,

room, car, or drinking alcohol)?

8. Do you find yourself lighting up a cigarette routinely (without craving)?

9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick,

chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or

frustration, etc.?

10. Does part of your enjoyment of smoking come from the steps (ritual) you take

when lighting up?

11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe,

secure, or more confident if you are holding a cigarette?

TOTAL_______

Scoring for Behavioral Dependence

<12 Mild

12–22 Moderate

23–33 Strong

>33 Very Strong

0   1    2    3    4

0   1    2    3    4

0   1    2    3    4

0   1    2    3    4

0   1    2    3    4

0   1    2    3    4

0   1    2    3    4

Source: Glover et al. 2002

88 Chapter 4
         

           

         

         

         

               

           

           

         

           

             

             

         

             

               

       

   

ade as other psychiatric conditions, especially

anxiety and depression (see Figure 4­12).

Smoking cessation also may affect the

metabolism of other drugs primarily through

the Cytochrome P 450 (CYP450) system. This

system is one of many hepatic liver enzyme systems that is responsible for the metabolic

breakdown of various drugs into inactive compound products. Different drugs and compounds have varying affinities for the CYP450

system. The higher the affinity, the faster the

breakdown of the drug or compound in the

body. Some compounds can slow the

metabolism or breakdown of other drugs with a

lower affinity, leading to a buildup of that drug

or compound in the body.

During detoxification from nicotine, some

medications will have their metabolism

altered, including theophylline, caffeine,

tacrine, imipramine, haloperidol, pentazocine, propranolol, flecainide, and estradiol;

in general, these effects are short­lived and

seldom drastic. Nicotine also reduces beta

blockers’ ability to lower blood pressure and

heart rate and decreases the amount of sedation from benzodiazepines as well as decreases the amount of pain relief provided by

some opioids, most likely because of its stimulant effects (Zevin and Benowitz 1999). A

complete discussion of nicotine’s effects on

medications is beyond the scope of this TIP

and physicians are encouraged to consult the

Physicians’ Desk Reference (2004) or equivalent pharmaceutical guide. Figure 

4­13 (p. 90) shows the effects of abstinence

from smoking on blood levels of a number of

medications.

Management of Withdrawal

Without Medications

About one third of current smokers attempt

to quit smoking each year and more than 90

percent of these try to do so without any formal nicotine cessation treatment. Most smokers will make several attempts on their own to

quit and ultimately, only about 50 percent are

successful over a lifetime (U.S. HHS 2000b).

While some smokers are able to quit on their

own, others may require intervention in the

form of behavioral treatment and/or pharmacotherapy.

There are insufficient data available to determine who will benefit most from a particular

type of treatment. Some patients may prefer

to stop smoking without the use of medication. An elevated score on the GN­SBQ would

indicate a strong behavioral component to

smoking that might guide the clinician in recommending behavioral treatment as a primary intervention. Patients who also have elevated FTQ scores may benefit by a combination of behavioral and pharmaceutical intervention.

Figure 4­12

Some Examples of Nicotine Withdrawal Symptoms That Can Be

Confused With Other Psychiatric Conditions

Anxiety

Depression

Increased REM (rapid eye movement) sleep

Insomnia

Irritability

Restlessness

Weight gain

Source: APA 1996.

Physical Detoxification Services for Withdrawal From Specific Substances 89
   

Figure 4­13

Effects of Abstinence From Smoking on Blood Levels of 

Psychiatric Medications

Abstinence Increases Blood

Levels

Abstinence Does Not Increase

Blood Levels 

Effect of Abstinence on Blood

Levels Is Unclear

Clomipramine 

Clozapine

Desipramine

Desmethyldiazepam

Doxepin

Fluphenazine

Haloperidol

Imipramine

Oxazepam

Nortriptyline

Propranolol

Amitriptyline

Chlordiazepoxide

Ethanol

Lorazepam

Midazolam

Triazolam

Alprazolam

Chlorpromazine

Diazepam

Source: APA 1996.

The U.S. Public Health Service’s Treating

Tobacco Use and Dependence: Clinical

Practice Guideline is a comprehensive review

of the smoking cessation literature (Fiore et

al. 2000a). It discusses a range of nonpharmacological interventions for the management

of withdrawal from nicotine; these can be separated into two basic categories: self­help

interventions and behavioral interventions

(Anderson and Wetter 1997).

Self­help interventions

Many tobacco users prefer to attempt to quit

without any assistance from professionals. A

number of self­help products are available

that can assist them in their cessation

attempts. These include a wide array of pamphlets, manuals, video­ and audiotapes (e.g.,

from the American Lung Association and the

National Cancer Institute), 12­Step self­help

support groups, and telephone helplines. The

U.S. Public Health Service’s Guideline, which

analyzed all types of self­help interventions

together, found that the self­help approach to

cessation yielded results only slightly better

than no intervention at all. To date, self­help

interventions alone have not been very successful at helping people achieve abstinence

from tobacco. The Guideline suggests, however, that self­help can be a useful adjunct to

other forms of treatment (Fiore et al. 2000a). 

One type of self­help intervention that shows

some promise is the use of computer­generated personalized written feedback for patients.

The computer makes recommendations based

on an individual’s response to standardized

questions about her smoking (Etter and

Perneger 2001; Shiffman et al. 2000). 

Behavioral interventions

The U.S. Public Health Service study noted

that when physicians took as little as 3 minutes to advise their patients to stop smoking,

long­term quit rates were modestly improved

from 7.9 percent to 10.2 percent (Fiore et al.

2000a). Westmaas and colleagues note that

“simple, clear advice from a physician can be

considered an easy, cost­effective intervention

that not only moves smokers closer to the

decision to quit, but also may motivate some

smokers to make an actual attempt”

90 Chapter 4
   

           

               

         

             

         

           

         

           

             

(Westmaas et al. 2000, p. 58). The greater the

amount of time in face­to­face interventions,

the higher the success rate for patients, but

interventions as short as 3 minutes have been

found to be effective (Fiore et al. 2000a). A

counseling session of longer than 10 minutes

produced a cessation rate of 20.1 percent

compared to a rate of 10.9 percent for no

treatment. The guideline also indicated that if

cessation information is given by multiple

types of providers (e.g., physician, psychologist, dentist, nurse, and pharmacist) it can

have a dramatic effect on cessation rates,

increasing the rate to 23 percent compared to

10.8 percent for patients who had no

provider contact. 

A review of behavioral intervention studies

concluded that both supportive care by a

clinician and the ability of patients to develop

problemsolving and coping skills improved

success rates for smoking cessation (Anderson

and Wetter 1997). Other components such as

cigarette fading (gradually decreasing the

number of cigarettes smoked over a period of

time), establishing a quit date, enhanced environmental support, improved diet and

increased exercise, relaxation training, and

contingency contracting were not associated

with improved outcome. Aversive conditioning, such as rapid smoking techniques, is

effective but not routinely recommended

(Fiore et al. 2000a).

Management of Withdrawal

With Medications

A U.S. Public Health Service panel recommends that all primary care physicians provide a five­step intervention, known as the “5

A’s,” to all tobacco users. The panel recommends that all smokers who want to quit

should be offered active medication that has

been approved for assisting in smoking cessation unless there is a medical contraindication

(Fiore et al. 2000a). Figure 4­14 provides a

summary of the “5 A’s” for brief intervention.

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. Nicotine gum and nicotine

transdermal patch are now available over the

counter. After the acute withdrawal period,

patients are then weaned off the medication

until they become nicotine free. All NRTs are

Figure 4­14 

The “5 A’s” for Brief Intervention

Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong, and personalized manner urge every tobacco user to quit.

Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this

time?

Assist in quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. 

Arrange followup. Schedule followup contact, preferably within the first week after the quit date.

Source: Fiore et al. 2000a, p. 26.

Physical Detoxification Services for Withdrawal From Specific Substances 91
effective, with 1­year quit rates between 11 and

34 percent (Okuyemi et al. 2000).

There has been some concern about the

addictive potential of NRTs, and it has been

reported that 5 to 20 percent of patients using

nicotine polacrilex gum continue to use it for

more than 1 year (Hughes 1989). There was

also initial concern that the nicotine nasal

spray, with its rapid onset of action and high

plasma concentrations, might become a drug

of abuse. This has not been reported in the

literature, and it

could be speculated

that this is because

of the nasal spray’s

relatively uncomfortable side effects

that cause many

patients to dislike

the product (Schuh

et al. 1997). In general, withdrawal

symptoms from

NRTs are mild compared to those that

occur in smoking

cessation, and continued use of these

products may be the

result of patients’

fear of returning to

active smoking

(APA 1996). For

those patients who

continue to use

NRTs, providers

should balance the patient’s continued dependence on nicotine with the considerable

health benefit of decreasing active tobacco

usage. It is clear that constituents of tobacco

other than nicotine are responsible for causing cancer. No ill effects have been attributed

to long­term use of nicotine replacement therapy (Benowitz and Gourlay 1997).

Patients should be

encouraged to use

combined NRT

treatments if they

are unable to quit	 

using a single type

of first line

pharmacotherapy.

Bupropion SR

Bupropion SR (Sustained Release) was initially

manufactured under the name Wellbutrin as a

treatment for major depressive disorder. In

1997, the FDA approved bupropion SR for

smoking cessation, and it has been marketed

under the name Zyban. Bupropion is a novel

antidepressant that is involved primarily with

dopamine but also affects adrenergic mechanisms in the central nervous system. Its exact

mechanism 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 in order to get the drug to therapeutic

levels. This is an ideal time for the patient to

focus on making behavioral changes and enlisting social support to augment his quit attempt.

Bupropion SR has proven useful in smoking

cessation with a 12­month abstinence rate of

35.5 percent compared to a placebo at 15.6

percent and the nicotine patch at 16.4 percent

(Westmaas et al. 2000). The most commonly

reported side effects include dry mouth and

insomnia. Bupropion SR should not be used in

patients with a history of seizures, heavy alcohol use, head trauma, or with anorexia or

bulimia.

Other nonnicotine 

pharmacotherapy

Covey and colleagues examined nonnicotine

pharmaceutical products that have been evaluated in controlled trials of smoking cessation

(Covey et al. 2000). These drugs include the

following:

•The alpha­2 agonist antihypertensive,

clonidine

•The tricyclic antidepressant, nortriptyline

•The monoamine oxidase inhibitor (MAOI)

antidepressant, moclobemide

•The serotonin 5­HT1A agonist anxiolytic,

buspirone

92 Chapter 4
     

     

           

           

   

             

             

         

           

               

           

             

       

           

           

           

                 

             

           

       

           

           

           

           

             

       

         

         

               

                 

             

             

               

           

               

         

•The antihypertensive CNS nicotinic receptor

blocker, mecamylamine

•Oral dextrose tablets

Although none of these agents has been

approved by the FDA for smoking cessation,

clonidine, nortriptyline, and moclobemide have

all been found to be effective treatments (Covey

et al. 2000). Clonidine may be a helpful

adjunct to nicotine replacement during acute

nicotine withdrawal. Doses of 0.05mg to 0.1mg

three times a day can be tried as tolerated

(sedation and low blood pressure are concerns), and the medication needs to be tapered

when discontinued to avoid rebound hypertension.

The Public Health Service’s Treating

Tobacco Use and Dependence: Clinical

Practice Guideline (Fiore et al. 2000a) has

classified nortriptyline and clonidine as second­line treatments. Clonidine is an antihypertensive and may be appropriate for

patients addicted to certain types of drugs but

not appropriate for others. The antidepressant selective serotonin reuptake inhibitor

(SSRI) fluoxetine has been tested in a number

of multisite trials (Cook et al. 2004; Hitsman

et al. 1999; Niaura et al. 2002) and found to

have a small benefit at best, although for

patients who experience mild depressive

states it may be a worthwhile adjunctive

treatment. The usefulness of other SSRIs for

smoking cessation is unknown, but studies

have generally been unfavorable. More information on smoking cessation for people with

co­occurring substance use and other mental

disorders can be found in appendix D of TIP

42, Substance Abuse Treatment for Persons

With Co­Occurring Disorders (CSAT 2005c).

Combination drug therapy

Combining NRT products

NRT products typically provide less than half

the nicotine plasma levels that cigarette users

achieve through smoking (Benowitz et al. 1997;

Dale et al. 1995; Gupta et al. 1995; Lawson et

al. 1998). To attempt to increase nicotine levels, several clinical trials have evaluated the

effectiveness of combining available products.

The simultaneous use of nicotine gum and the

nicotine patch has been evaluated in several

studies. Short­term gains in cessation were seen

with the combination compared to either medication alone, but no long­term benefits in abstinence were demonstrated (Anderson and

Wetter 1997). Blondal and colleagues (1999)

compared the combination of nicotine nasal

spray and the nicotine patch to the patch alone

and found that at 3 months 37 percent of the

patients were smoke free (compared to 25 percent for the patch alone). An open­label study

of the combined use of nicotine inhaler and the

nicotine patch found a 12­week cessation rate

of 30 percent and good tolerability for the combination (Westman et al. 2000).

So­called “combination NRT” involves combining different types of nicotine replacement

products, such as the patch and gum, on the

premise that doing so will boost nicotine

blood levels. Further rationale for this practice is that a “passive” nicotine delivery system (i.e., patch) produces relatively steady

levels of nicotine in the body that prevent the

user from going below a threshold minimum

while “active” NRTs (i.e., gum, inhaler,

spray, sublingual tablet, etc.) permit the user

to respond to situational cravings with ad libitum dosing on an acute basis. Several clinical

trials have evaluated the effectiveness of combining available NRT products (for a review

see Silagy et al. 2000). After reviewing available data, the Guideline panel (Fiore et al.

2000a) felt that there was moderately strong

evidence to conclude that “Combining the

nicotine patch with a self­administered form

of nicotine replacement therapy (either the

nicotine gum or nicotine nasal spray) is more

efficacious than a single form of nicotine

replacement, and patients should be encouraged to use such combined treatments if they

are unable to quit using a single type of firstline pharmacotherapy” (Fiore et al. 2000a, p.

77).

Physical Detoxification Services for Withdrawal From Specific Substances 93
             

         

             

           

               

         

             

   

           

       

             

           

           

             

           

       

             

               

                   

             

           

           

       

     

           

           

         

               

               

         

           

           

             

           

   

NRT using high­dose nicotine

patch therapy

The highest dose of nicotine available by patch

is 22mg. Several studies have evaluated

whether higher doses of nicotine (up to 44mg)

improve abstinence rates. The effect of this

strategy has been small and the routine use of

higher dose patches is not recommended

(Hughes et al. 1999; Killen et al. 1999).

Combining nicotine patch

and bupropion SR

In a double­blind, placebo­controlled study,

the combination of bupropion SR and the nicotine transdermal patch showed higher abstinence rates at 12 months (35.5 percent) compared to bupropion SR alone (30.3 percent),

nicotine patch alone (16.4 percent), or placebo

patch and pill group (15.6 percent) (Jorenby et

al. 1999). This combination was well tolerated.

Clinicians who use this combination should

first start the patient on bupropion SR 150mg

for 3 days and then increase the dosage to

150mg twice daily for 1 to 2 weeks prior to the

day of smoking cessation. On the “quit day,”

nicotine patch therapy should be initiated and

the combination treatment continued for 3 to 6

months (Okuyemi et al. 2000).

Patient Care and Comfort

Most smokers attempt cessation on an outpatient basis and without any assistance from

professionals. However, if a patient decides

that she or he wants help with smoking cessation, it is important for the clinician to present

a supportive and nonjudgmental attitude and

develop a therapeutic alliance with the patient.

It must be emphasized that nicotine dependence is a chronic relapsing disorder and that

patients often make several attempts at quitting

before succeeding.

Most smokers who want treatment will seek

help from their primary care physician. The

physician has the responsibility of providing

pharmaceutical treatment, education about

common problems associated with cessation,

and emotional support to patients attempting

to quit. Discussing nicotine withdrawal symptoms can often help allay patient concerns. 

Fear of weight gain is a barrier for many who

want to quit smoking (French et al. 1995).

This is an especially important issue for

women and may deter their attempts to stop

smoking (Gritz et al. 1989). Though the

health gains of stopping smoking clearly outweigh the health risks of weight gain, this

argument does little to assuage patients’

fears. Dieting during smoking cessation is not

recommended in general and has been shown

to increase the likelihood of smoking relapse

(Hall et al. 1992). Physicians should, however, recommend both exercise and proper

nutrition for patients attempting to stop

smoking. Patients should be informed that

alcohol use also is considered a risk factor for

relapse to smoking by most clinicians

(Shiffman 1982), and patients who can

abstain from drinking during the withdrawal

period should do so. 

Patients generally will find a smoke­free environment helpful during quit attempts. If the

patient lives in a household where others

smoke, household members and friends can

help by not smoking in front of the patient

and limiting the number of smoking cues in

their residence.

Patients with more severe nicotine dependence may benefit from enrollment in a specialized smoking cessation program. They

might also benefit from more intensive medical management using several drugs (NRT +

anticraving), medication for longer periods of

time, closer followup, and longer enrollment

in treatment. There are a number of cessation

programs available from organizations such

as the American Lung Association

(http://www.lungusa.org) and the American

Cancer Society (http://www.cancer.org). Some

community and local organizations also sponsor smoking cessation programs. For the most

severely dependent smokers, there are a limited number of residential facilities that treat

nicotine dependence on an inpatient basis

(Hurt et al. 1992). Providers of detoxification

94 Chapter 4
services should be familiar with the programs

available in their communities in order to

make referrals.

Marijuana and Other

Drugs Containing THC

Marijuana and hashish are the two substances containing THC (delta­9­tetrahydrocannabinol) commonly used today. The field

of addiction medicine has given considerable

attention to the question of whether there is a

specific withdrawal syndrome associated with

cessation from prolonged THC use. In the

past, many have stated that there is no acute

abstinence syndrome that develops in people

who abruptly discontinue THC (CSAT

1995d). More recently this has been called

into question and most experts now believe

that a THC­specific withdrawal syndrome

does occur in some patients who are heavy

users (Budney et al. 2001), though cannabis

withdrawal is not yet included in the APA’s

Diagnostic and Statistical Manual of Mental

Disorders.

The THC abstinence syndrome usually starts

within 24 hours of cessation. The amount of

THC that one needs to ingest in order to

experience withdrawal is unknown. It can be

assumed, however, that heavier consumption

is more likely to be associated with withdrawal symptoms. The most frequently seen symptoms of THC withdrawal are anxiety, restlessness and irritability, sleep disturbance, and

change in appetite (usually anorexia). Other

symptoms of withdrawal are less frequently

seen and appear to include tremor, diaphoresis (sweating), tachycardia (elevated heart

rate), and GI disturbances, including nausea,

vomiting, and diarrhea. Cognitive difficulties

including depression also have been reported

and may persist but usually improve with

time. There are no medical complications of

withdrawal from THC, and medication is generally not required to manage withdrawal. 

Clinicians may see a variety of the symptoms

mentioned above, but these generally require

no immediate medication during the detoxification period and usually are self­limiting.

However, the clinician should be aware of the

potential for more persistent problems.

Screening the patient for suicidal ideation or

other mental health

problems is warranted. Some reviews Most experts now

believe that a

THC­specific withdrawal syndrome

does occur in some

patients who are

heavy users,

though cannabis

withdrawal is not

yet included in the

APA’s Diagnostic

and Statistical

Manual of 

Mental Disorders.
 

have advocated the

use of buspirone as

an alternative to

benzodiazepines for

the management of

persistent generalized anxiety (Gatch

and Lal 1998). Other

common problems

encountered during

withdrawal can be

managed with nonaddictive, supportive

medications. For

patients with more

persistent difficulty

sleeping, clinical

experience suggests

that Trazodone may

be useful. Trazodone

can lead to low blood

pressure upon standing, dizziness, and

may increase falls,

particularly in individuals over age 60.
 

Benzodiazepines and
 

other addictive medications should be
 

avoided.
 

The patient should be encouraged to maintain
 

abstinence from THC as well as other addictive substances. Some patients will require a
 

substance­free, supportive environment to
 

achieve and maintain abstinence. Clinicians
 

should educate all patients about the effects
 

of withdrawal, validate their complaints, and
 

reassure them that their symptoms will likely
 

improve with time. Symptomatic relief may be
 

provided in order to increase the patient’s
 

comfort.
 

Physical Detoxification Services for Withdrawal From Specific Substances 95
There are no clinical assessment instruments

available that measure THC withdrawal.

Both animal and human studies indicate that

a withdrawal syndrome starts within 24 hours

of cessation and may last for up to a week. 

Anabolic Steroids

Anabolic steroids, as differentiated from corticosteroids and female gonadotropic hormones, are androgens (male hormones) and

subject to abuse as a means of increasing

muscle mass. These

agents also can proInterventions

directed toward

cessation should

involve patient

education regarding

the dangers and

medical complications of anabolic

steroids, their

behavioral effects,

and a thorough

evaluation of the

patient’s rationale

for misuse.	 

duce aggressive,

manic­like behavior

that may include

delusions (Lukas

1998). Males

involved in professional sports,

weight lifting, body

building, or other

pursuits that value

muscular mass are

more likely to use

these substances

than are women,

although use in

women has been

reported.

Adolescents use

anabolic steroids to

improve their

appearance and

may have increased

access to these compounds (Yesalis et

al. 1993). The large

numbers of anabolic steroid preparations that have

medical and veterinary uses are primarily obtained illegally through diversion.

High doses of anabolic steroids can be medically dangerous but side effects, usually

involving endocrine, liver, central nervous

system, and cardiac function, tend to be

reversible upon cessation of anabolic steroid

use. However, neither cessation nor disclosure of anabolic steroid use can be assumed

when treating these individuals. 

Withdrawal Symptoms

Associated With Steroids

Anabolic steroids can be associated with withdrawal symptoms emerging after their abrupt

discontinuation. Withdrawal symptoms

include (in descending order of prevalence)

craving for more steroids, fatigue, depression, restlessness, anorexia (loss of appetite),

insomnia, reduced libido (sex drive),

headaches, and nausea (Lukas 1998). It is not

known how commonly this syndrome occurs,

but steroid withdrawal appears more likely in

heavy users. The clinician’s index of suspicion should be raised when evaluating individuals who are predisposed to steroid misuse

and who exhibit these symptoms. Also indicative of possible steroid abuse are certain

physiological signs of androgen exposure,

including hair loss, acne, dysuria (difficult or

painful urination), small testicles, edema of

the extremities, and rapid weight gain.

Females can develop decreased breast size,

acne, virilism (clitoral enlargement, excessive

and abnormal bodily hair growth, male pattern baldness) and amenorrhea (suppression

of menstruation). Males who abuse steroids

have been reported to possess a distorted

body image and may inaccurately view themselves as small and weak (Pope et al. 1993).

Medical Complications of

Steroid Withdrawal

Due to anabolic steroids’ long duration of

action, side effects that might emerge cannot

be quickly reversed by the discontinuation of

these substances. Therefore, related side

effects might require medical management

beyond the simple recommendation that

steroids immediately be discontinued.

Persistent side effects include urinary tract

infections, bladder irritability, skin blistering

(at the injection site), erythema (abnormal

skin redness) when given as a skin patch, and

96 Chapter 4
   

       

         

             

           

           

         

           

           

     

           

         

         

             

           

         

       

priapism (prolonged erections lasting hours).

The latter condition involves a painful penile

erection and constitutes an emergency that

requires specialized medical attention. Edema

(swelling) of the hands or feet, commonly seen

with anabolic steroids, can be treated with

diuretics (medications that increase urine

flow). Elevated liver function tests and jaundice usually resolve with cessation of anabolic

steroid administration, although hepatic carcinoma (cancer of the liver) has been reported. Other side effects such as headache, nausea, vomiting, acne, insomnia, and lethargy

are time­limited and resolve after steroid cessation. Behavioral disturbances, such as psychosis or severe aggressiveness, should be

treated symptomatically with appropriate

psychopharmacological interventions. In

extreme cases of psychotic or manic presentations, emergency psychiatric hospitalization

might be necessary to address dangerousness

to self or others. 

Management of Steroid

Withdrawal

There is no recommended detoxification protocol for anabolic steroids. The key medical

goal is that of persuading the patient to cease

steroid misuse. This intervention should be

followed by evaluating and treating any side

effects (discussed above) that might be present. Interventions directed toward cessation

should involve patient education regarding

the dangers and medical complications of

anabolic steroids, their behavioral effects,

and a thorough evaluation of the patient’s

rationale for misuse. A family meeting often is

helpful if agreed upon by the patient.

Unfortunately, education alone often is insufficient. Patients with distorted body images

might be especially difficult to dissuade from

steroid misuse, and referral to psychotherapy

by a qualified clinician trained in the treatment of body image disorder should be considered. Similarly, patients who derive significant muscle gain from anabolic steroids might

be resistant to cessation and may conceal continued steroid use. 

Patient Care and Comfort

Patient comfort during steroid withdrawal can

be achieved by addressing side effects, if present, that are discussed above. Counseling also

is a useful intervention and specialized psychiatric interventions may be necessary. If the

individual also is using other substances of

abuse, referral to drug or alcohol rehabilitative

treatment should be made.

Club Drugs

Club drugs represent diverse classes of drugs

that include sedative­hypnotic type agents as

well as stimulant/hallucinogens. Club drugs are

illicit drugs used in the setting of nightclubs,

dance clubs, parties, and “raves.” Raves are

overnight dance parties, usually with several

hundred people in attendance.

Abuse of these drugs by adolescents and

young adults has risen greatly in recent years.

All healthcare professionals need familiarity

with their short­ and long­term effects.

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 problems. With

some of these compounds, there appears to be

the potential for neurotoxicity (destructive

effects on the nervous system) and persistent

psychiatric and neurologic syndromes. At the

present time, much of the available information regarding club drugs comes from surveys

and anecdotal case reports. Human laboratory studies and rigorously controlled clinical

trials are not common. 

One difficulty in assessing the effects of intoxication, overdose, withdrawal, and long­term

health consequences of club drugs is that in

general, there are no baseline evaluations of

individuals before they used club drugs. Also,

these individuals abuse more than one substance. Some of these patients may have had

moderate to severe psychopathology (including psychosis) prior to their introduction to

club drugs. In the past, some club drugs were

Physical Detoxification Services for Withdrawal From Specific Substances 97
referred to as “designer drugs” because of

their production in a laboratory rather than

being processed from plant products.

Hallucinogens

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

have some adrenergic effects as well.

Hallucinogens also are referred to as

psychedelics and psychomimetics. The more

traditional hallucinogens such as lysergic acid

diethylamide (LSD) are considered primarily

serotonergic­acting agents. Some of the other

compounds include phenylethylamines which

have hallucinogenic properties but act like

amphetamines as well. These drugs include

mescaline and MDMA (3,4­methylenedioxy­Nmethylamphetamine). Other drugs include

MDA (3,4­methylenedioxyamphetamine) and

DOM (dimethyloxymethylamphetamine). (See

section on ecstasy below.) Other hallucinogens

are acetylcholine antagonists. These include

belladonna, drugs such as benzotrophine

used to treat parkinsonian symptoms, and

many common over­the­counter antihistamines. 

Hallucinogen intoxication often begins with

autonomic effects, sometimes nausea and

vomiting, and mild increases of heart rate,

body temperature, and slight elevations of

systolic blood pressure. Dizziness and dilated

pupils may occur. The prominent effects during intoxication are sensory distortions with

illusions and hallucinations. Visual distortions are more common than auditory or tactile ones. So­called “bad trips” may involve

anxiety including panic attacks, paranoid

reactions, anger, violence, and impulsivity.

Either due to delusions or misperceptions,

individuals may feel they can fly or have special powers, and thus injure themselves in

falls or other accidents. Suicide attempts also

can occur during “bad trips” and possible

suicidal ideation should be carefully evaluated, even though it may be quite transient. 

Withdrawal syndromes have not been reported with hallucinogens; however, considerable

attention has been paid to residual effects

such as delayed perceptual illusions with anxiety, “flashbacks,” residual psychotic symptoms, and long­term cognitive impairment.

Controversies around these issues are not

important in the clinical setting. The important thing is to determine whether residual

symptoms are present and provide an appropriate environment and appropriate care for

the individual who has them. Generally, staff

of emergency rooms, clinics that treat people

who abuse substances, and social detoxification centers have individuals who are very

familiar with “talking down” individuals with

bad hallucinogenic trips. 

Acute intoxication and bad trips usually can

be managed with placement of the individual

in a quiet, nonstimulating environment with

immediate and direct supervision so that the

patient does not cause harm to herself or to

others. Occasionally, a low dose of a short­ or

intermediate­acting benzodiazepine may be

useful to control anxiety and promote sedation. Individuals with chronic depressive­like

reactions may require antidepressant therapy. Individuals with residual psychotic symptoms are likely to require antipsychotic medications. On rare occasions, the use of a low

dose, high­potency antipsychotic medication

may be required orally or parenterally (any

method other than the digestive tract, e.g.,

intravenously, subcutaneously, or intramuscularly). Assessment of residual psychiatric

and cognitive symptoms should be made prior

to treatment referral.

Gamma­hydroxybutyrate

(GHB)

GHB use has increasingly been reported in

night clubs and at raves by adolescents and

young adult populations. GHB is a compound

that is produced in the central nervous system, and it acts as an inhibiting neurotransmitter similar to GABA (Shannon and Quang

2000). In pharmacologic (medication­propor98 Chapter 4
tioned) doses, GHB serves as a sedative­hypnotic medication. GHB intoxication may look

like alcohol or sedative­hypnotic intoxication.

Although GHB is illegal, psychotropic compounds similar to GHB such as gammahydroxy lactone (GBL) and 1,4­butanediol

(1,4­BD) are widely available chemical compounds and may be obtained through catalogs

and the Internet. These compounds produce

effects similar to those of GHB. At the present, overdose syndromes are more likely to

be seen than withdrawal syndromes.

Overdose syndromes may require airway and

respiratory management. GHB has been studied in Europe (Addolorato et al. 1999a) in a

randomized, single­blind study comparing it

to diazepam as a treatment for alcohol withdrawal. GHB was as effective as diazepam in

suppressing alcohol withdrawal symptoms

and was said to be quicker in reducing anxiety and agitation with less sedation than

diazepam. Because of its history of abuse in

the United States, it is unlikely to be viewed

as a therapeutic agent any time in the near

future.

Miotto and Roth (2001) describe a GHB withdrawal syndrome, noting that it shares features of both alcohol and benzodiazepine

withdrawal. They have found this syndrome

most pronounced in patients who have taken

GHB around­the­clock, at 2­ to 4­hour intervals. The GHB withdrawal syndrome has the

prolonged duration of symptoms found in

benzodiazepine withdrawal and features

delirium tremens that appear early (often

within an hour) with peak manifestations

occurring within 24 hours; the delirium may

last up to 14 days. Confusion, psychosis, and

delirium are the most prominent features of

GHB withdrawal, and the autonomic effects

(i.e., tremor, diaphoresis [sweating], hypertension, and temperature changes) are less

severe than found in alcohol withdrawal.

They note that brief periods of significant

tachycardia (rapid heart rate) begin early in

GHB withdrawal. Garvey and Fitzmaurice

(2004) also report seizure activity in a case of

GHB withdrawal in a male who had been

using the substance regularly over a 2­year
 

period, and Rosenberg and colleagues (2003)
 

note that in severe cases GHB withdrawal
 

may be life­threatening. 

Milder cases of GHB withdrawal syndrome
 

may be managed with benzodiazepines such
 

as lorazepam and supportive care. However,
 

in more severe cases high doses of intravenous benzodiazepines (e.g.,
 

lorazepam) or barbi­ Withdrawal
 

syndromes have not
 

been reported with
 

hallucinogens;
 

however, considerable attention has
 

been paid to
 

residual effects such
 

as delayed
 

perceptual illusions
 

with anxiety,
 

“flashbacks,”
 

residual psychotic
 

symptoms, and
 

long­term cognitive

impairment.

turates (e.g., phenobarbital, pentobarbital) may be
 

required (Miotto

and Roth 2001;
 

Rosenberg et al.

2003). Patients
 

experiencing GHB

withdrawal are likely to have a high tolerance for the sedative effects of benzodiazepines and
 

require large and

frequent doses to
 

manage the withdrawal (Miotto and
 

Roth 2001); in cases

where high doses of
 

lorazepam prove

ineffective, pentobarbital may be

effective (Sivilotti et
 

al. 2001). Clonidine

may be used to treat
 

episodes of tachycardia (rapid heart
 

rate) (Miotto and

Roth 2001).

Ecstasy

MDMA (3, 4­methylenedioxy­methamphetamine) commonly known as ecstasy, was

synthesized around the turn of the century and

patented by Merck Pharmaceuticals in 1914

(Christophersen 2000; Parrot et al. 2000).

These drugs are phenel­ethylene stimulants

Physical Detoxification Services for Withdrawal From Specific Substances 99
           

           

             

             

           

             

       

     

   

         

             

     

             

             

         

           

           

         

           

               

         

with various substitution groups off the benzene ring that give the medications hallucinogenic properties. There are a number of related compounds that are designated by their initials (MDMA, MDA, MDEA, DOM, 2­CB, and

DOT). Clinicians are likely to have to manage

the complications of intoxication and overdose

but not withdrawal.

Patients using MDMA or related compounds

frequently are hyperactive and hyperverbal,

reporting heightened tactile and visual sensations. They frequently will use camphor on

the skin in facial masks, gloves, and other

clothing to heighten their tactile sensations.

Sometimes light sticks are used to heighten

visual experiences at raves. Hyperthermia,

dehydration, water intoxication with low sodium, rhabdomyolysis (severe muscular injury

and breakdown of muscle fibers), renal failure, cardiac arrhythmia, and coma have been

reported. 

MDMA has been proven to be toxic to serotonergic neurons in several animal studies.

Heavy ecstasy users can have paranoid thinking, psychotic symptoms, obsessional thinking, and anxiety (Parrott et al. 2000).

Impaired cognitive performance in heavy

ecstasy users also has been identified

(Gouzoulis­Mayfrank et al. 2000). Ecstasy

users performed more poorly than control

groups in complex attention, memory, and

learning tasks. The duration or permanence

of such effects has not yet been well studied. 

Ketamine and PCP

(Phencyclidine)

Ketamine and PCP (phencyclidine) were both

developed in the 1950s as anesthetic agents for

humans. Phencyclidine was briefly marketed

for human anesthetic use but taken off the

market because of an unusual high incidence of

psychotic symptoms. PCP remains in legitimate

use for veterinarian anesthesia for large animals as does ketamine for small animals.

Although both drugs were originally developed

for intravenous use, they are now manufactured illicitly as oral drugs of abuse. PCP frequently is sold as LSD.

Some studies have found that ketamine and

PCP act specifically at the MDMA/glutamate

receptor as noncompetitive MDMA receptor

antagonists. Research in animals indicates

that both drugs are reinforcing, in that animals will press a bar to obtain doses of either

drug. Furthermore, in these same animal

models, abstinence syndromes have been

observed. Withdrawal symptoms in humans

have included depression, drug craving,

increased appetite, and hypersomnolence

(excessive sleep). 

In the clinical setting, syndromes of acute

intoxication with hallucinations, delusions,

agitation, and violence are the most pressing

problems. A human laboratory study (Lahti

et al. 2001) conducted a comparison of

ketamine and placebo in normal volunteers

never exposed to ketamine and to people with

schizophrenia with a previous history of

ketamine use. In both groups, ketamine produced a dose­related, but brief, increase in

psychotic symptoms. The magnitude of

ketamine­induced positive psychotic symptoms was similar for both groups, although

the schizophrenia group had higher baseline

scores. 

Although originally MDMA receptor antagonists were felt to have neuroprotective effects

(preventing damage to brain cells) and have

been explored as post­stroke medications,

there is some evidence now that ketamine and

PCP may in fact have some neurotoxic

effects. Studies (e.g., Curran and Monaghan

2001) have found greater memory impairment

among chronic ketamine users than infrequent ketamine users. Acute human laboratory studies by this group indicate persistent

memory impairment with ketamine exposure.

This same study did not find persistent psychotic features beyond acute use. 

In the clinical setting, ketamine and PCP use

require management for the agitation and

psychotic features produced during acute use.

Occasionally, patients will have such large

100 Chapter 4
overdoses, intentionally or accidentally, that

they will require airway management and

ventilatory support for some hours. The

behavioral management of the agitation and

violence that may be seen is best managed in

a controlled environment with limited stimuli

and very close supervision. Occasionally, oral

or parenteral uses of sedating medications

such as benzodiazepines will be required. In

extreme cases, restraints may be required for

protection of the patient and staff. 

Following acute management, assessment of

persistent mood and cognitive effects must be

made prior to any treatment attempts. The

persistence of psychotic symptoms may represent an underlying psychiatric disorder that

may require medication treatment. There are

no studies to guide the treatment of ketamine

or PCP detoxification. The need to manage

withdrawal symptoms from these drugs is

unlikely, but if it should arise, benzodiazepines should be administered.

Other

Rohypnol is a benzodiazepine that is sold

under trade names in Europe and Mexico as a

sedative­hypnotic. Rohypnol is occasionally

used as a club drug and at dance clubs. In the

last decade it began to be smuggled into the

United States and was commonly used among

homeless youth involved in the sex industry.

Rohypnol has a reputation as a “date rape”

drug because it can produce powerful amnestic

and hypnotic effects, as well as coma. For further details on benzodiazepines, see the benzodiazepine section regarding intoxication and

potential withdrawal reactions.

Management of

Polydrug Abuse: An

Integrated Approach

One of the most significant changes in detoxification services in recent years has been the

increase in the number of patients requiring

detoxification from more than one substance.

In an evaluation of admissions to publicly

funded detoxification programs in

Massachusetts between 1984 and 1996,

McCarty and colleagues (2000) found a steady

increase in the number of patients using both

alcohol and other substances in the month

prior to admission. In 1988, 26 percent of

admissions reported using two or more substances in the previous month; by 1996 that

number had nearly

doubled to 50 percent (McCarty et al.

2000). There is no One of the most

significant changes

in detoxification

services in recent

years has been the

increase in the

number of

patients requiring

detoxification

from more than

one substance.

reason to believe that

this trend has not

appeared elsewhere

in this country. As

Miller and colleagues

(1990a) note, “For

the contemporary

drug addict, multiple

drug use and addiction that includes

alcohol is the rule”

(p. 597).

In the Massachusetts

evaluation, which

did not include marijuana or nonopioid

prescription medication use, the most

commonly seen combination of substances was alcohol

and cocaine. Thirty

percent of patients

admitted for detoxification in 1996 reported using this combination; 12 percent used alcohol, cocaine, and

heroin together; 10 percent combined alcohol

and cocaine; and 7 percent combined heroin

and cocaine (McCarty et al. 2000). Other

studies, evaluating patient populations at

inpatient treatment centers, found that

between 70 and 90 percent of patients who

reported cocaine abuse also abused alcohol.

Rates of alcohol dependence among

methadone patients and patients dependent

on heroin were between 50 and 75 percent,

Physical Detoxification Services for Withdrawal From Specific Substances 101
           

             

           

           

           

           

             

           

         

           

       

           

       

         

                                 

                           

                                   

                                   

                                     

                                   

                                         

                                       

                               

                                       

                                     

                               

         

An Example of Potential Problems: 

Detoxification for Polydrug Abuse

Mr. L is a 43­year­old male with a 25­year heroin dependence. He is well known to the detoxification center,

having been through the program there (which consisted primarily of support and hydration) on many

occasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time he

arrived, his course usually was about the same: 2 or 3 days of serious stomach cramps, nausea, and diarrhea, then a few days of feeling poorly, and then a return to the community. This time, however, was different. He looked “sicker” than usual. Mr. L usually was a compliant patient; now he was hostile and belligerent. He seemed to be talking to himself and did not seem as alert as he should have been. The staff asked

him several times if he had used anything else and each time he denied it. His drug of choice was always

heroin—he drank alcohol once in a while, and occasionally smoked marijuana when he could not get anything else. On the third day of detoxification, Mr. L seemed acutely more ill. On his way to the bathroom he

was observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand mal

seizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates,

opioids, and trace amounts of benzodiazepines

and 80 to 90 percent who were being treated

for cannabis abuse also reported alcohol

abuse (Miller et al. 1990a). 

Clinicians need to be constantly aware that a

patient may be abusing multiple substances.

Even if a patient admits the abuse of one substance he may not admit to using others.

Patients may not see that other substances

are a problem, they may be worried about the

legal consequences of use, or they sometimes

may not even be aware of what substances

they have been using. For these reasons, clinicians should not rely on patients’ self­reports

to determine which substances are being

used. Interviews with family, friends, or others who know the patient may be helpful, but

these also are insufficient. The consensus

panel strongly recommends that all patients

receive an immediate urine drug screening

upon admission to a detoxification program to

determine the types of substances being

abused. It is not necessarily true that the person is drug free simply because a drug is not

detected on a drug screen. It is possible that

the toxicology is not able to detect the class or

type of drug. Staff should be aware of what

the program/detoxification center/hospital

tests for, what is not tested for, what cannot

be tested for or found, and the limitations of

“dip” tests.

Prioritizing Substances of

Abuse

While substances of abuse may have complex

interactions, it is not always possible to determine how those interactions will affect withdrawal. Therefore, it is generally best practice

to prioritize the substances an individual has

been dependent on and treat them sequentially

according to the severity of the withdrawal produced by the substance. The substances with

the most serious withdrawal syndromes, those

where the withdrawal syndrome can be fatal,

are alcohol and the sedative­hypnotics. When

detoxifying a patient who has been dependent

upon multiple substances, the sedative­hypnotics must be addressed first.

Oral methadone, LAAM, or buprenorphine

should be used to stabilize withdrawal from

opioids while tapering the dose of the sedative­hypnotic or anxiolytic (anti­anxiety medication) by 10 percent each day. After the

patient has been tapered off of the sedativehypnotic or anxiolytic, withdrawal from the

substitute opioid can begin (Wilkins et al.

1998). Some patients can successfully be

detoxified from both sedative­hypnotics and

opioids simultaneously, but this requires a

great deal of medical and nursing attention.

Most patients will benefit from opioid mainte102 Chapter 4
             

       

           

               

         

       

             

           

           

       

           

           

           

           

           

           

         

         

           

           

   

         

     

             

         

     

             

           

       

   

             

           

           

           

           

         

     

             

           

           

                 

         

         

             

     

           

                 

               

         

     

               

               

               

               

                 

             

               

         

             

                 

       

               

             

           

             

             

     

     

     

             

         

           

             

       

     

           

         

         

         

         

         

             

             

     

         

           

         

nance for an extended period of time following the completion of sedative withdrawal.

If the patient has been abusing multiple sedative­hypnotic substances or a sedative­hypnotic

and alcohol, withdrawal should be handled in

the same way as withdrawal from one such substance. The patient should be administered a

regularly decreasing dosage of sedative­hypnotic, usually a benzodiazepine that the clinician is

comfortable with and accustomed to using. The

dosage should be decreased according to the

patient’s physiologic response. Providers also

may administer an anticonvulsant such as carbamazepine (Tegretol XR), even in the absence

of epilepsy or withdrawal seizures, to help

ensure patient safety (Wilkins et al. 1998).

Phenobarbital also may be used for detoxifying

patients who have been abusing both alcohol

and benzodiazepines. When the dose of alcohol

and sedative­hypnotics that a patient is taking

is not known, tolerance testing as previously

described can be helpful in determining the

dose of phenobarbital.

When treating patients detoxifying from substances other than sedative­hypnotics, management of opioid detoxification should be the next

priority. Generally, other substances of abuse,

including stimulants, marijuana, hallucinogenics (LSD and similar drugs), and inhalants, will

not require specific treatment in patients who

are being detoxified from sedative­hypnotics

and/or opioids.

Patients may abuse a wide range of substances

in various combinations, and the clinician must

be vigilant in assessing and treating withdrawal

from multiple substances. The case study above

illustrates some of the serious problems the

clinician faces in evaluating and treating

patients withdrawing from multiple substances.

In the private sector, where money for toxicological screening is readily available, the first

question many would ask concerning the case

of Mr. L. is, “Why wasn’t the drug screen done

sooner?” However, those working in public

facilities will recognize that such screenings

often are unavailable or available only after an

extended turnaround time. Toxicological

screening, even a hand­held screening, can be

an expensive item for what often is a very limited budget. Besides, in this case, the patient was

believed to be a known quantity—someone who

only used heroin.

This scenario is not uncommon. It is likely that

the patient himself was unaware of what was in

his body. One of the more frightening facts concerning the purchase of illicit drugs is the lack

of knowledge of what is in them. To make buyers believe that they are buying a higher­quality product than they are, drugs often are cut

with adulterants (inferior ingredients) that can

produce effects similar to the drug they think

they are buying. In this case, Mr. L may have

been buying barbiturates and benzodiazepines

in his heroin for some time without knowing it,

a fact that could have had deadly consequences. Both are sedating and could have

given him some of the comfortable sedation and

euphoria he was seeking from his drug of

choice. Unfortunately, however, where opioid

withdrawal is not life­threatening, withdrawal

from barbiturates can be. Furthermore, he

could have gotten PCP in the marijuana he

occasionally used, again without knowing it.

Alternative

Approaches 

Alternative methods that have been studied scientifically do not claim to be stand­alone withdrawal methods, nor stand­alone treatment

modalities. Alternative approaches are

designed to be used in a comprehensive, integrated substance abuse treatment system that

promotes health and well­being, provides palliative symptom relief, and improves treatment

retention. Therefore, because isolation of any

of these approaches as an independent variable

in rigorous controlled studies is difficult, if not

impossible, there are no conclusive data on the

effectiveness of alternative methods

(Trachtenberg 2000).

Auricular (ear) acupuncture has been used

throughout the world, beginning in Hong Kong,

as an adjunctive treatment during opioid

Physical Detoxification Services for Withdrawal From Specific Substances 103
               

       

           

             

       

           

           

             

         

           

     

       

       

     

     

       

             

                 

           

         

       

             

             

       

detoxification for about 30 years. Its use in the

United States originated in California

(Seymour and Smith 1987) and New York

(Mitchell 1995) but has not been subjected to

rigorous controlled research. One report

(Washburn et al. 1993) noted that patients

dependent on heroin with mild habits appeared

to benefit more than those with severe withdrawal symptoms, which acupuncture did not

alleviate. The 1997 National Institute of Health

Consensus Statement on acupuncture stated

that acupuncture treatment for addiction could

be part of a comprehensive management program. The National Acupuncture

Detoxification Association has developed

acupuncture protocols involving ear acupuncture in group settings that originated at Lincoln

Hospital in the Bronx and are used by over 400

drug treatment programs and 40 percent of

drug courts. SAMHSA’s National Survey of

Substance Abuse Treatment Services (NSSATS)

found that 5.4 percent of the 13,720 facilities

polled in 2001 offered acupuncture as a service

(Office of Applied Studies 2002b).

Acupuncture is one of the more widely used

alternative therapies within the context of

addictions treatment. It has been used as an

adjunct to conventional treatment because it

seems to reduce the craving for a variety of

substances of abuse and appears to contribute to improved treatment retention rates.

In particular, acupuncture has been viewed

as an effective adjunct to treatment for alcohol and cocaine disorders, and it also has

played an important role in opioid treatment

(i.e., methadone maintenance). It is used as

an adjunct during maintenance, such as when

tapering methadone doses. The ritualistic

aspect of the practice of acupuncture as part

of a comprehensive treatment program provides a stable, comfortable, and consistent

environment in which the client can actively

participate. As a result, acupuncture

enhances the client’s sense of engagement in

the treatment process. This may, in part,

account for reported improvements in treatment retention (Boucher et al. 2003). A 1999

CSAT­funded study showed that patients

choosing outpatient programs with acupuncture were less likely to relapse in the 6

months following discharge than were patients

who had chosen residential programs

(Shwartz et al. 1999).

Ear acupuncture detoxification, which was

originally developed as an alternative treatment for opioid agonist pharmacotherapy, is

now augmenting pharmacotherapy treatment

for patients with coexisting cocaine problems

(Avants et al. 2000). The advocates of

acupuncture have joined with the advocates

of opioid agonist pharmacotherapy to create a

holistic synthesis. Each has contributed to the

success of the other, both clinically and in

public perception.

Care must be taken to ensure sterile acupuncture needles in the heroin­dependent population, given the high incidence of HIV infection, viral hepatitis, and other infections.

Acupuncture is not recommended as a standalone treatment for opioid withdrawal. 

Other alternative management approaches

that are not supported by controlled studies

include neuroelectric therapy (the administration of electric current through the skin)

and herbal therapy. In fact, the former has

been shown to be no better than placebo in a

controlled study (Gariti et al. 1992). The use

of herbs for healing purposes dates back to

the dawn of civilization, while the use of

herbs in the treatment of substance abuse has

been documented since 1981 in methadone

programs, free clinics, therapeutic communities, outpatient programs, and hospitals

(Nebelkopf 1981). Herbal remedies are used

in substance abuse detoxification and treatment in a number of cultures around the

world. However, in no scientific studies have

herbs been isolated as a discrete variable to

test their efficacy. Much research is currently

being conducted on the effectiveness of herbal

medicine on a wide variety of physical 

conditions.

104 Chapter 4
Considerations for

Specific Populations 

All individuals undergoing detoxification are

especially vulnerable. Patients who experience

negative attitudes from staff may experience

further loss of self­esteem, may leave detoxification prematurely, or may experience other

psychologically damaging feelings. Negative

experiences can undermine the recovery process. It is important to recognize that individuals do not fit into just one population category.

A person will be a member of several populations (e.g., a Latina woman who is pregnant,

bisexual, and has psychiatric diagnoses of posttraumatic stress disorder and major depression) and may benefit from a number of the

considerations discussed below. It also should

be noted that the information in the specific

populations sections should not be used to categorize individuals or leave the reader with the

impression that the information below will fit

all individuals who are members of a group.

Pregnant Women

While in detoxification, pregnant women

should receive comprehensive medical care,

especially since this may be the first time they

have sought any type of care or treatment.

Ideally, programs detoxifying pregnant women

from alcohol and illicit drugs should include

the following services:

•Detoxification on demand

•Woman­centered medical services

•Transportation services to and from detoxification (as well as to substance abuse treatment afterward)

•Childcare services

•Counseling and case management services

•Access to drug­free, safe, affordable housing

•Help with legal, nutritional, and other social

service needs

While it is recognized that provision of all of

these services is an ideal to be striven for, at a

minimum detoxification programs must have

strong linkages to agencies that provide the

above­mentioned services and should set up

systems to ensure that pregnant women can

access the additional services they need.

Pregnant women who present for detoxification

will benefit from a comprehensive medical

examination that includes a careful obstetrical

component. Since it is estimated that approximately 44 to 70 percent of women who abuse

substances have a history of physical, emotional, and sexual Pregnant women

who present for

detoxification will

benefit from a

comprehensive

medical examination that includes

a careful

obstetrical

component.

abuse (Moylan et al.

2001; Stevens et al.

1997), care should be

given to the comfort

of the patients during

the examination. One

of the major internal

barriers that prevents

pregnant women from

seeking treatment is

the shame and stigma

attached to substance

use, especially during

pregnancy. Any negative experience

encountered during

detoxification can

lead these women to

leave treatment and

not return.

Detoxification during

pregnancy poses a

special risk in that

care should be taken

to ensure the health and safety of both the

mother and fetus. From a clinical standpoint,

before giving any medications to pregnant

women it is of vital importance that they

understand the risks and benefits of taking

these medications and sign informed consent

forms verifying that they have received and

understand the information provided to them.

Since pregnant women often present to treatment in mid­ to late­second trimester and polydrug use is the norm rather than the exception

(Jones et al. 1999), it is important first to

Physical Detoxification Services for Withdrawal From Specific Substances 105
screen these women for dependence on the two

classes of substances that can produce a lifethreatening withdrawal: alcohol and sedativehypnotics. Pregnant women should be made

aware of all wraparound services that will

assist them in dealing with newborn issues,

including food, shelter, medical clinics for inoculations, as well as programs that will help with

developmental or physical issues that the

neonate (newborn baby) may experience as a

result of substance

exposure.

A National

Institutes of

Health consensus

panel	 

recommended

methadone

maintenance as

the standard of

care for pregnant

women with	 

opioid

dependence.

Alcohol

When pregnant

women are detoxified from alcohol,

benzodiazepine

tapers appear to be

the current practice

of choice. The current state of knowledge suggests that

benzodiazepine

therapy in general

does not have as

much of a teratogenic (producing a

deformed baby) risk

as do other anticonvulsants as long as

they are given over

a short time period.

It appears that

short­acting benzodiazepines, like the

ones described to

treat alcohol withdrawal above, can

be used in low doses for acute uses such as

detoxification, even in the first trimester

(Robert et al. 2001). Long­acting benzodiazepines should be avoided—their use during

the third trimester or near delivery can result

in a withdrawal syndrome in the baby (Garbis

and McElhatton 2001). 

Although no teratogenic effects have been

observed, little is known about the effects of

naltrexone, naloxone, or nalmefene administration during pregnancy. Although propranolol (Inderal), labetalol (Trandate), and

metoprolol (Lopressor) are the beta blockers

of choice for treating hypertension (high

blood pressure) during pregnancy

(McElhatton 2001), the impact of using them

for alcohol detoxification during pregnancy is

unclear. The use of SSRIs, a class of antidepressant medication, is safer for the mother

and fetus than are tricyclic antidepressants

(Garbis and McElhatton 2001). Fluoxetine

(Prozac) is the most studied SSRI in pregnancy and no increased incidence in malformations was noted, nor were there neurodevelopmental effects observed in preschool­age

children (Garbis and McElhatton 2001).

However, possible neonatal withdrawal signs

have been observed. Given that the greatest

amount of data are available for fluoxetine,

this is the recommended SSRI for use during

pregnancy (Garbis and McElhatton 2001). 

The use of anticonvulsants, such as valproic

acid, is associated with several disfiguring

malformations. If this type of medication

must be used during pregnancy, the woman

must be told that there is substantial risk of

malformations (Robert et al. 2001).

Barbiturate use during pregnancy has been

studied to some extent, and phenobarbital is

used therapeutically during pregnancy, but

the risk of any anticonvulsive medication

should be discussed with the patient (Robert

et al. 2001). There also are reports of a withdrawal syndrome in the neonate following

prenatal exposure to phenobarbital (Kuhnz et

al. 1988).

Opioids

While it is not recommended that pregnant

women who are maintained on methadone

undergo detoxification, if these women

require detoxification, the safest time to

detoxify them is during the second trimester.

For further information, consult the forthcoming TIP Substance Abuse Treatment:

Addressing the Specific Needs of Women

(SAMHSA in development e) and TIP 43

106	 Chapter 4
Medication­Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs

(CSAT 2005d). In contrast, it is possible to

detoxify women dependent on heroin who are

abusing illicit opioids by using a methadone

taper. 

Before starting a detoxification, women

should weigh the risks and benefits of detoxification, since many women eventually

relapse to drug use and thus place themselves

and their fetuses at risk for adverse consequences (Jones et al. 2001b). During pregnancy, the protein binding of many drugs, including methadone and diazepam (a benzodiazepine), is decreased (e.g., Adams and

Wacher 1968; Dean et al. 1980; Ganrot 1972)

with the greatest decrease noted during the

third trimester (Perucca and Crema 1982).

This decreased binding may be due to the

decreased levels of albumin reported during

pregnancy (Yoshikawa et al. 1984). From a

clinical standpoint, it may be that pregnant

women could be at risk for developing greater

toxicity and side effects, yet at the same time

an increase in metabolism of the drug may

result (such as found with methadone). This

may result in reduced therapeutic effect from

the drug, since many women require an

increase in their dose of methadone during

the last trimester (Pond et al. 1985). 

Other medications used to treat the withdrawal signs and symptoms include clonidine.

Clonidine is used as a second­line drug to

treat hypertension (high blood pressure) during pregnancy and appears to lack teratogenic

effects (McElhatton 2001). It has reportedly

been abused by pregnant women. Some pregnant women take clonidine with their

methadone because it is hard to detect in

urine and it increases the high they get from

methadone. However, little is known about its

effects on the baby following therapeutic

doses given in a detoxification context or

doses taken in higher than therapeutic

amounts (Anderson et al. 1997a).

Buprenorphine has been examined in pregnancy and appears to lack teratogenic effects

but may be associated with a withdrawal syndrome in the neonate (Jones and Johnson

2001). 

A National Institutes of Health consensus

panel recommended methadone maintenance

as the standard of care for pregnant women

with opioid dependence. Methadone currently

is the only medication recommended for medication­assisted treatment for pregnant

women. Clinical trials are being conducted to

determine the efficacy and safety of

buprenorphine with pregnant women but it

has not yet been approved for use with this

population. Two early studies on treatment of

pregnant women with opioid dependence with

buprenorphine showed promising results

(Fischer et al. 2000; Johnson et al. 2001).

Comer and Annitto (2004) conclude, from

their review of the research literature, that

buprenorphine should be used more aggressively to detoxify pregnant women who want

to be opioid­free at delivery.

Because of the potential for premature labor

and delivery and risks of morbidity and mortality to the fetus related to withdrawal from

opioids, it is recommended that a pregnant

woman who is dependent on opioids be maintained during pregnancy (Kaltenbach et al.

1998). Other reasons to stabilize a pregnant

woman on methadone rather than attempt

withdrawal are the risks of relapse, consequences associated with HIV and use of multiple needles, and the potential lack of prenatal

care.

The Federal government mandates that prenatal care be available for pregnant women

on methadone. It is the responsibility of treatment providers to arrange this care. More

than ever, there is need for collaboration

involving obstetric, pediatric, and substance

abuse treatment caregivers. Comprehensive

care for the pregnant woman who is opioid

dependent must include a combination of

methadone maintenance, prenatal care, and

substance abuse treatment. 

Physical Detoxification Services for Withdrawal From Specific Substances 107
         

               

           

         

             

           

             

               

       

         

       

     

         

       

           

         

Pregnant women should be maintained on an

adequate (i.e., therapeutic) methadone dose.

An effective dose prevents the onset of withdrawal for 24 hours, reduces or eliminates

drug craving, and blocks the euphoric effects

of other narcotics. An effective dose usually is

in the range of 50–150mg (Drozdick et al.

2002). Dosage must be individually determined, and some pregnant women may be

able to be successfully maintained on less

than 50mg while others may require much

higher doses than 150mg. The dose often

needs to be increased as a woman progresses

through gestation, due to increases in blood

volume and metabolic changes specific to

pregnancy (Drozdick et al. 2002; Finnegan

and Wapner 1988).

Generally, dosing of methadone is for a 24­

hour period. However, because of metabolic

changes during pregnancy it might not be possible to adequately manage a pregnant woman

during a 24­hour period on a single dose.

Split dosing, particularly during the third

trimester of pregnancy, may stabilize the

woman’s blood methadone levels and effectively treat withdrawal symptoms and craving. 

Breastfeeding is not contraindicated for

women who are on methadone. Very little

methadone comes through breast milk; the

American Academy of Pediatrics (AAP)

Committee on Drugs lists methadone as a

“maternal medication usually compatible with

breastfeeding” (AAP 2001, pp. 780–781). 

Benzodiazepines

The principles of detoxification from benzodiazepines are the same for pregnant and nonpregnant patients. It is important to taper the

dose of benzodiazepine slowly in order not to

induce fetal withdrawal or other adverse consequences in the fetus or mother.

Detoxification is most likely safest during the

second trimester in order to avoid spontaneous abortion or premature labor. For more

information, see the forthcoming TIP

Substance Abuse Treatment: Addressing the

Specific Needs of Women (SAMHSA in development e). There is a documented withdrawal

syndrome in neonates who have been prenatally exposed to benzodiazepines (Sutton and

Hinderliter 1990), and this syndrome may be

delayed in onset more than that associated

with other drugs. 

Stimulants

The principles of detoxification from stimulants

such as cocaine are the same for pregnant and

nonpregnant women. Since there is no current

pharmacotherapy to use in tapering individuals

from stimulant use, the use of any medications

to treat medical complications that might arise

from the withdrawal should only be done after

discussion with the patient of the risks and benefits of each medication.

Solvents

The principles of detoxification from solvents

are the same for pregnant and nonpregnant

women. It should be noted that based on a

review of case reports, there is a complex

array of characteristics that appear to be similar to fetal alcohol effects. Fetal Alcohol

Syndrome (FAS) is characterized by growth

deficiency (born small for gestational age;

failure to grow at a normal rate), particular

facial features (e.g., eyes are too close together, ears are set low on the head), and CNS

dysfunctions (mental retardation, microencephaly [small brain size]) and brain malformations (Costa et al. 2002). Thus fetal development in pregnant women who have a history of solvent abuse should be evaluated and

carefully monitored (Jones and Balster 1998). 

Nicotine

There is extensive documentation that smoking

during pregnancy causes numerous adverse

fetal consequences (see Schaefer 2001).

Cigarette smoking during pregnancy is the

largest modifiable risk for pregnancy­related

morbidity and mortality in the United States

(Dempsey and Benowitz 2001). While women

108 Chapter 4
are undergoing detoxification, they should be

offered education about the risk of cigarette

smoking during pregnancy and, ideally, prevented from smoking. This is especially important since cigarette smoking is strongly associated with decreased birth weight, which is a predictor of developmental problems in newborns

(Ernst et al. 2002). If women are unable to stop

smoking using behavioral interventions, nicotine replacement products may be used; however, the woman should fully understand the

possible risks and benefits of these pharmacotherapies (Jones and Johnson 2001).

It also is important to point out to patients

that there are data to suggest that women may

derive less benefit from NRT than do men

and that they may derive greater benefit from

some non­NRT medications (e.g., bupropion),

thus producing quit rates in women comparable with those in men (Perkins 2001).

However, the data regarding the use of

bupropion during pregnancy are limited. 

Examinations of the acute effects of NRT in

pregnant women reveal that nicotine has minimal impact on the maternal and fetal cardiovascular systems. NRT may well be viewed as

the lesser of two evils, inasmuch as smoking

cigarettes delivers, in addition to nicotine,

thousands of chemicals. Among these are

many that also are viewed as developmental

toxins (e.g., carbon monoxide and lead). It is

doubtful that the reproductive toxicity of

cigarette smoking is primarily related to nicotine. Thus, if NRT is to be used during pregnancy, the dose of nicotine in NRT should be

similar to the dose of nicotine that the pregnant woman received from her ad lib (whenever desired) smoking. Although intermittentuse formulations of NRT (e.g., chewing gum)

have been recommended over continuous­use

formulations (e.g., transdermal patch) due to

reductions in the total dose of nicotine delivered to the fetus (Dempsey and Benowitz

2001), it is unknown what the impact of intermittent acute doses followed by withdrawal of

nicotine has on the fetus.

Marijuana, anabolic steroids,

and club drugs

The principles of detoxification from these

drugs is the same for pregnant and nonpregnant women. The use of anabolic steroids during pregnancy is rare; however, these can be

catastrophic to a pregnancy, and if use is

found, a detailed ultrasound examination is

recommended to determine the morphological

(physical or structural) development of the

fetus (Scialli 2001).

Although the class of

club drugs is relatively new there have

been a few reports

(McElhatton et al.

1999) suggesting that

there is an increased

risk of congenital

malformation in

neonates prenatally

exposed to ecstasy.

Other club drugs

such as flunitrazepam (Rohypnol)

may have effects similar to those of some
 

benzodiazepines;

however, this is speculative. For comprehensive information
 

on the treatment of

this specific population, see the forthcoming TIP

Substance Abuse
 

While women are

undergoing

detoxification,

they should be

offered education

about the risk of

cigarette smoking

during pregnancy
 

and, ideally,
 

prevented from
 

smoking.

Treatment:
 

Addressing the Specific Needs of Women
 

(SAMHSA in development e).
 

Older Adults

It has been recommended that, when treating

older adults, there should be a policy of using

age­specific group treatment that is both supportive and nonconfrontational (Royer et al.

2000; West and Graham 1999). Older adults

may be dealing with depression, loneliness,

Physical Detoxification Services for Withdrawal From Specific Substances 109
        and loss of career or a loved one. Thus, as a

standard policy, older adults should be

screened for depression and grief or lossrelated issues. Similar to the situation with

other specific populations, the detoxification

setting should ideally have in place a policy

that mandates, at a minimum, well­established linkage with general medical services

and specialized services for the aging, because

of their increased vulnerability to physical

ailments. Establishing policies that create an

environment that is positive and does not tolerate “ageism”—a general tendency to react

negatively toward elderly adults—is important for the optimal treatment of older individuals. 

Alcohol and other drug­related disorders in

elderly individuals often are more severe than

those of younger individuals and they are at

increased risk for co­occurring medical disorders. It is the medical complications rather

than age itself for which detoxification in a

medical setting is needed. The elderly may

have slower metabolism of medications making dosage adjustments necessary in some

cases. The elderly also may be at greater risk

for drug interactions, since they may be

receiving medications to treat other problems.

A complete and careful assessment with ongoing monitoring should be done to examine the

existence of diseases such as, but not limited

to, heart disease, respiratory disease, diabetes, and dementia. Potential for falls also

should be evaluated in the context of prescribed medications. The previously presented protocols for detoxification from alcohol,

opioids, benzodiazepines, stimulants, solvents, nicotine, marijuana, anabolic steroids,

and club drugs (anabolic steroids and club

drug abuse are rare in this population)

appear to be applicable to the elderly population as long as sensitivity to the withdrawal

medication is considered. TIP 26, Substance

Abuse Among Older Adults (CSAT 1998f),

provides comprehensive information on the

treatment of this population.

People With Disabilities or CoOccurring Conditions

In any patient population, the clinician

should expect to encounter persons with disabilities including co­occurring medical or

mental disorders. These patients often will

require special assistance to overcome both

physical and psychological barriers in undergoing detoxification and treatment, including

their own psychological barriers that must be

overcome, as well as those attitudinal and

communication barriers that often prevent

complete and clear understanding between

patient and clinician or clinician and institution. Effective communication is essential for

effective services. Accommodations must take

into consideration the expressed preference of

the individual with a disability. Substance

abuse treatment programs need to be in compliance with two Federal laws regarding this

matter: the 1992 Amendments to the

Rehabilitation Act of 1973 and the Americans

with Disabilities Act [ADA] of 1990.

According to the ADA, programs must

remove or compensate for physical or architectural barriers to existing facilities when

accommodation is readily achievable, meaning “easily accomplishable and able to be carried out without much difficulty or expense”

(P.L. 101­336 § 301). Providers should examine their programs and modify them to eliminate four fundamental groups of barriers to

treatment for people with disabilities and/or

co­occurring disorders: (1) attitudinal barriers; (2) discriminatory policies, practices, and

procedures; (3) communications barriers; and

(4) architectural barriers. Federal, State, and

other sources of assistance might be available

to fund ADA­related improvements. See TIP

29, Substance Use Disorder Treatment for

People With Physical and Cognitive

Disabilities (CSAT 1998g) for further information. 

The following passage clarifies terms and

addresses the basic issues presented by

patients with disabilities and/or co­occurring

disorders. Diseases, disorders, and injuries,

110 Chapter 4
whether congenital or acquired, can have

diverse effects on organs and body systems.

Conditions (and diseases) such as multiple

sclerosis, traumatic brain injury, spinal cord

injury, diabetes, and cerebral palsy can lead

to impairments, such as impaired cognitive

ability, paralysis, blindness, or muscular dysfunction. These impairments in turn cause

disabilities, which limit an individual’s ability

to function in various areas of life, such as

learning, reading, and mobility. While diseases, impairments, and disabilities are distinct categories, they often are used interchangeably. These essential terms are defined

in Figure 4 ­15.

The field of disability services has developed

its own terminology to discuss physical, sensory, and cognitive disabilities (see definitions

below), and many treatment providers of people with substance use disorders will not be

familiar with these terms as the profession

defines them. WHO has devised a method for

the classification of impairments and disabilities (WHO 1980). This complex system has

been simplified here into four main categories:

1.	 Physical impairments are caused by congenital or acquired diseases and disorders

or by injury or trauma. For example,

spinal cord injury is a disorder that can

cause paralysis, an impairment.

2.	 Sensory impairments include blindness

and deafness, which may be caused by

congenital disorders, diseases such as

encephalopathy or meningitis, or trauma

to the sensory organs or the brain.

3.	 Cognitive impairments are disruptions of

thinking skills, such as inattention, memory problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability

to follow a set of steps in order to accomplish a task), misperception of time, and

perseveration (constant repetition of

meaningless or inappropriate words or

phrases).

Figure 4­15

Some Definitions Regarding Disabilities

Disease: An interruption, cessation, or disorder of body functions, systems, or organs.

Impairment: Any loss or abnormality of psychological, physiological, or anatomical structure or functions.

Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in

the manner or within the range considered normal for a human being. A disability is always perceived

in the context of certain societal expectations, and it is only within that context that the disadvantages

resulting from a disability can be properly evaluated.

Functional capacities: The degree of ability possessed by an individual to meet or perform the behaviors, tasks, and roles expected in a social environment.

Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain

social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation),

physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deafness), or affective (e.g., depression) in origin and nature. They represent substandard performance on

the part of the individual in meeting life activities and reflect the interaction between the person and the

environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure

4­16, p112.)

Sources:  Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.

Physical Detoxification Services for Withdrawal From Specific Substances 111
Figure 4­16

Impairment and Disability Chart

Impairment Category Common Disabilities

Physical Spina bifida

Spinal cord injury

Amputation

Diabetes

Chronic fatigue syndrome

Carpal tunnel

Arthritis

Sensory Blindness

Hearing impairment

Deafness

Deaf­blindness 

Visual impairment

Cognitive  Learning disabilities

Traumatic brain injury

Mental retardation 

Attention deficit disorder 

Affective  Depression

Bipolar disorder

Schizophrenia

Eating disorder

Anxiety disorder

Posttraumatic stress disorder

Source: CSAT 1998e.

4.	 Affective impairments are disruptions in

the way emotions are processed and

expressed. For the purposes of this discussion, affective impairments are considered

to include problems caused by both affective and mood disorders, such as major

depression and mania. These impairments

include the symptoms of mental disorders,

such as disorganized speech and behavior,

markedly depressed mood, and anhedonia

(joylessness).

One of the most important practices that

should be in place as a standard in any detoxification setting is routine screening for disabilities and co­occurring medical and/or psychiatric conditions. The failure to recognize

these problems in patients can result in poor

outcomes (Cook et al. 1992). Additionally,

intoxicated individuals with co­occurring

depressive disorders are at high risk for suicide attempts. Of course, an individual

patient may present with two or more disabilities and/or co­occurring disorders. Clinicians

treating people with co­occurring substance

use and mental disorders should consult TIP

42, Substance Abuse Treatment for Persons

With Co­Occurring Disorders (CSAT 2005b).

112	 Chapter 4
       

         

     

           

               

       

         

             

         

           

All programs should make a good faith effort

to provide equal access in as comprehensive a

manner as possible for all patients. Individual

unique needs should be taken into account

when providing services. For example,

patients with physical, sensory, or cognitive

disabilities may need help with self­care (e.g.,

eating, grooming), moving (e.g., using stairs,

walking), communication (e.g., reading,

speaking), learning, social skills, and executive functions (e.g., planning and organization, decisionmaking). Unresponsiveness to

instructions, lack of participation in discussions and activities, forgetfulness, or confusion by an individual with cognitive disabilities should not be viewed as a lack of motivation, resistance, or denial. Programs may

need to develop the expertise or engage an

expert on cognitive disabilities to determine

the limitations resulting from the substance

abuse and those resulting from the disability.

Both require patience in the response.

Information presented to the person with a

cognitive disability should include different

and complementary media; for example, visual and tactile materials can reinforce the

usual verbal interaction.

Programs also may need to alter their policies

regarding the use of drugs prescribed for pain

control, since most medications of this class

are drugs with a high abuse potential. A number of patients with substance use disorders

also live with chronic pain. Living in a drugfree state may not be desirable if it is associated with unrelieved pain, which can be quite

disabling. The clinician should explore with

patients what pain management options have

been tried in the past, and which management

medications are being used currently.

Patients should be encouraged to discuss

their feelings about pain and how it affects

their daily life, and especially to what extent

it curtails or prevents their participation in

the activities of daily living. 

There are a number of alternative treatments

for chronic pain. Acupuncture is already in

use in some treatment programs for detoxification to help relieve symptoms of withdrawal. Physical therapy and exercise, chiropractic care, biofeedback, hypnotism, and therapeutic heat or cold are some other approaches to caring for persons with physical problems. Most of these alternative treatments

have limited or no research support of their

efficacy; yet some clinicians believe they

work. Thus, consultation with experts on

their use is necessary before starting a person

with chronic pain on these remedies. 

An alternative model supports the idea that

patients should be treated simultaneously in

substance abuse treatment, mental/physical

health, and detoxification settings, yet treatments may occur in separate facilities and be

conducted by separate staff. The consequent

task for all is to be supportive and knowledgeable about each other’s interventions.

The severity of the addiction and

medical/psychiatric problems at the time of

detoxification entry should determine which

acute services the patient receives first.

Naturally, a person’s medical and psychiatric

disabilities must be accounted for in the

preparation of any treatment plan. In some

cases, substance abuse treatment cannot

begin until issues relating to medical and psychiatric disabilities are settled. 

There are a number of resources for clinicians to employ, including experts in the field

of disability services. Figure 4­17 (p. 114) discusses ways of locating expert help for treating patients with disabilities and/or co­occurring disorders.

Finally, integrated treatment combines substance abuse treatment, treatment for cooccurring disorders, and detoxification services

into one program. For more complete information on the treatment of many of these disorders, see chapter 5.

African Americans

For African Americans, entrance into detoxification has been associated with enrolling in further treatment, reductions in HIV/AIDS risk

behaviors, and linkages with social and healthPhysical Detoxification Services for Withdrawal From Specific Substances 113
           

             

           

         

             

             

       

         

         

       

     

             

             

Figure 4­17

Locating Expert Assistance

“Experts” in disability services can be located in several ways, depending upon the nature of the patient’s

disability and the local resources available. Patients who understand their disability may in fact be the best

“experts” on their condition and specific needs; however, it is not uncommon that persons requiring treatment for substance use disorders will not understand basic aspects of their situation or condition. In such

cases, immediate family members or close friends may be important sources of information and guidance.

The treatment team also should consider contacting other sources:

•A disability­specific service organization (e.g., United Cerebral Palsy, organizations for the blind or deaf

such as the National Association of the Deaf and American Deafness and Rehabilitation Association, the

Association for Retarded Citizens)

•Social workers

•Case managers

•Rehabilitation specialists

•Psychologists

•Nurses or physicians associated with a social service agency providing disability services for the individual

patient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard of

hearing, the Department of Veterans Affairs’ physical rehabilitation unit, community case management

services)

•Other organizations recognized by the disability community (e.g., Centers for Independent Living, governors’ committees for persons with disabilities, Paralyzed Veterans of America, local or State consumer

coalitions for persons with disabilities)

Source: CSAT 1998e.

care services (Lundgren et al. 1999). African

Americans are at greater risk than other populations for the co­occurrence of diabetes and

hypertension (high blood pressure) that can

predispose them to a risk of stroke. This

should be taken into account when placing and

monitoring them on withdrawal medications.

In treating African­American patients, treatment efficacy and therapist efficacy may be

associated with the therapist’s understanding

of how race plays a role in recovery

(Luborsky et al. 1988; Pena et al. 2000). In

addition, when working with counselors from

other cultures, African Americans may display mistrust and a reluctance to show any

weakness. To overcome this mistrust and to

build rapport, especially when the clinician is

discussing the detoxification process, it is particularly important for the clinician to keep in

mind the standard of respecting the client as

an equal partner in treatment. For further

information on this subject (as well as information on working with members of other

cultural/ethnic groups), see the forthcoming

TIP Improving Cultural Competence in

Substance Abuse Treatment (SAMHSA in

development a). 

The previously discussed protocols for detoxification from all substance of abuse appear

adequate for the detoxification of African

Americans. However, there are a few further

aspects to consider:

•If treating African Americans with beta

blockers, propranolol is less effective in

treating African Americans than Caucasians

(Pi and Gray 1999).

•African Americans are more likely (15 to 25

percent) to have less of the enzyme activity

114 Chapter 4
           

             

             

       

       

             

             

         

               

           

           

       

             

           

         

           

           

         

         

       

         

       

         

           

             

       

           

             

           

       

     

         

           

   

   

           

       

         

             

               

           

             

             

     

             

         

                 

       

       

           

           

           

         

         

             

   

           

             

                 

             

           

             

             

       

         

needed to eliminate diazepam than others, so

it may have a longer half­life in African

Americans than it does in other ethnic groups

(Pi and Gray 1999).

•Since co­occurring disorders such as depression frequently are seen in people with substance use disorders, it is important to know

that African Americans may require lower

doses and may be at greater risk of developing toxic side effects when prescribed antidepressants, since they are likely to metabolize

tricyclic antidepressants and SSRIs less efficiently than Caucasians (Pi and Gray 1999).

•Although the clearance of nicotine is similar

for African Americans and Caucasians, the

clearance of cotinine, a metabolite of nicotine, is slower in African Americans, which

may cause different smoking patterns than

found in Caucasians (Ahijevych 1998).

Asians and Pacific Islanders

This group is the most diverse in nations of

origin and has widely differing languages,

beliefs, practices, dress, and values. Often

the only common thread among these people

is their geographic origin (Chang 2000).

Although this group appears to have lower

rates of alcohol and illicit drug use, these

problems should not be overlooked; members

of this group may not seek treatment until the

problems are quite severe. Successful treatment involves the family and important values include balance, harmony, wisdom, and

modesty. Thus, it may be important to talk to

the family about the process of detoxification

and dispel their fears and concerns as well as

the patient’s. 

Asians and Pacific Islanders tend to be concerned about the clinician’s credibility and

trustworthiness. Generally speaking, maleness, mature age, the projection of self­confidence, possession of sound cultural competence skills, good educational background,

and level of experience are of importance. In

addition, a concrete logical approach to the

problem at hand is valued (Brems 1998). The

previously discussed protocols for detoxification from all substances of abuse appear adequate for the detoxification of Asians and

Pacific Islanders. During the detoxification

process, there are a number of issues to consider:

•If possible and appropriate, incorporate traditional healing methods (e.g., meditation

and religious exercises). These can help

reduce stress and anxiety and promote recovery (Chang 2000). While there is a large

immigrant population among many AsianAmerican groups, it is erroneous to assume

that all are foreign born. Variation in practice of traditional healing methods is considerable and consistent with generational differences. When considering detoxification,

recognize the importance of bicultural practices, values, and beliefs that might influence

responsiveness to treatment.

•When discussing detoxification medications,

discuss with patients their feelings about taking “Western” medications for detoxification.

In some Southeast Asian cultures, Western

medications are believed to be too strong for

the Asian person. It is important to assess a

person’s feelings about these since the patient

may not wish to disagree with the clinician

yet may be noncompliant in taking the medications. Compliance with detoxification medication may be better achieved if doses are

reduced or regimens shortened, yet this

should only be attempted if it is in the best

interest of the patient.

•Racial differences in alcohol sensitivity

among Asians and Caucasians have long been

recognized, with more than 80 percent of

some Asians compared to 10 percent of

Caucasians being sensitive to alcohol (i.e.,

having a flushing reaction) (Wolff 1972,

1973). This is the result of genetic differences

in alcohol metabolizing enzymes.

Approximately 50 percent of Asians lack the

enzyme ALDH2, found in the liver, that helps

the body get rid of alcohol (Hsu et al. 1985;

Yoshida et al. 1985). One reason for lower

drinking rates among Asians may be the

flushing reaction in the face and body following alcohol ingestion and an increase in skin

temperature. Other uncomfortable signs and

symptoms associated with the negative reacPhysical Detoxification Services for Withdrawal From Specific Substances 115
           

         

       

    tion to alcohol ingestion can include nausea,

dizziness, headache, fast heartbeat, and anxiety (Caetano et al. 1998).

•Five studies have shown that the metabolism

of codeine is slower in Chinese people than

in Caucasians. Chinese patients seem to

require lower doses of codeine, since the

slower metabolism leads to a higher concentration of codeine in the blood (Smith and

Lin 1996). 

•If treated with beta blockers, Asians require

much lower doses than Caucasians, since

they are very sensitive to this medication’s

blood pressure and heart rate effects (Pi

and Gray 1999). 

•Asians as a group have a higher number of

individuals than other ethnic groups who

are poor metabolizers of diazepam. This

may result in the need for lower doses,

since they report greater sedative effects

with a typical dose (Lesser et al. 1997). It

also may be that a lower body fat, which is

typical of Asian­American individuals, can

lead to differences in the pharmacokinetics

of lipophilic drugs (Lesser et al. 1997). 

•In treatment for co­occurring depression

and a substance use disorder, Asians

appear to metabolize clomipramine more

slowly than Caucasians (Pi and Gray 1999).

In contrast, Asians may metabolize

phenelzine faster, resulting in the need for a

higher dose relative to that which would be

appropriate for Caucasians (Pi and Gray

1999). 

•Chinese Americans tend to metabolize nicotine 35 percent more slowly than

Hispanics/Latinos and Caucasians. Thus,

they may need to smoke less frequently and

take in less nicotine to achieve the same

nicotine levels as do Hispanics/Latinos and

Caucasians. This may have implications for

the dosing of NRTs (Benowitz et al. 2002). 

•Smoking rates among male Asian

Americans, especially immigrant males, are

exceedingly high and masked by the lower

rates among Asian­American females.

American Indians

There are currently more than 500 federally

recognized American­Indian tribes, and there

is among them great variability in appearance, dress, values, religious beliefs, practices, and traditions. More than 200 different

languages are spoken by American­Indian

tribes. Alcohol use varies widely among tribes

(Mancall 1995). Of all ethnic and racial

groups, American Indians have the greatest

rates of alcohol and illicit drug use (Office of

Applied Studies 2002a).

An early study of treatment utilization by

American Indians found that there was a significant association between involvement in

society and treatment outcomes. Those

involved in either the traditional Indian society or both the traditional Indian society and

Caucasian society had more than a 70 percent

success rate, whereas those involved in neither society had a 23 percent success rate

(Ferguson 1976). At a 10­year followup, those

who had reported greater Indian culture affiliation and more severe liver dysfunction at

baseline had better alcohol treatment outcomes (Westermeyer and Neider 1984). 

When engaging an American Indian in the

process of detoxification, moving through the

process too quickly or abruptly can be perceived as showing a lack of caring and is considered contrary to trust building (Brems

1998). The pace of conversation is important;

a slower pace is more agreeable than a rapid

conversation. Moreover, a confrontational

approach also is not advised with this population (Abbott 1998). American Indians may

want a close and involved relationship with

their therapists and often want the clinician

to be a friend or relative (Brems 1998). The

trust often is built by idle small talk to a level

of shared understanding. Use of fables and

illustrative stories to express ideas can be

extremely helpful. According to the forthcoming TIP Improving Cultural Competence in

Substance Abuse Treatment (SAMHSA in

development a), avoidance of eye contact also

is traditional. The Talking Circle is a native

116 Chapter 4
tradition that can be helpful in the treatment

process (Canino et al. 1987; Coyhis 2000).

The previously discussed protocols for detoxification from all substances of abuse appear

adequate for the detoxification of American

Indians. The following are some issues to consider during detoxification.

•Fetal Alcohol Syndrome is 33 times higher in

this population than the national average

(SAMHSA in development a). This may be

important for pregnant women coming to

detoxification and also may be important if

the adult has FAS.

•Indian women who drink have a six­fold

increase in cirrhosis of the liver relative to

Caucasian women (Heath 1989).

•Although some American Indians have

reported a flushing response to alcohol, it

appears that the flushing reaction in

American Indians is milder and less adverse

than that experienced by Asians (Gill et al.

1999).

•If Alcoholics Anonymous or other 12­Step

programs are to be introduced, framing the

steps in terms of a circle rather than a ladder

may be better received, since the circle is

important concept in Indian culture

(SAMHSA in development a).

•If possible and appropriate, other traditional

methods that can help recovery are sweat

lodges, vision quests, smudging ceremonies,

sacred dances, and four circles (Abbott

1998).

•Overall, detoxification for this population is

the same as for other populations, but

American Indians are likely to seek treatment

later and have more medical complications

and poorer nutrition (Abbott 1998).

Hispanics/Latinos

Hispanics/Latinos are now the largest ethnic

minority group in America. Assessment of the

patient’s level of acculturation can be helpful

in understanding substance abuse patterns.

Language is one of the most difficult barriers

to treatment entry and success for

Hispanics/Latinos. However, simply knowing

Spanish or Portuguese does not guarantee

cultural sensitivity or competence. For

instance, it is important that the treatment

staff understand the role of the family. The

functional family can be extended and should

take into account people who have day­to­da

contact with and a role in the family

(Markarian and Franklin 1998).

Hispanics/Latinos are likely to view drug

dependency as moral failing or personal

weakness. Traditional healing such as folk

y

remedies and folk

healers may provide

benefit. The previously discussed protocols for detoxification from alcohol,

opioids, benzodiazepines, stimulants,

solvents, nicotine,

marijuana, anabolic

steroids, and club

drugs appear adequate for the detoxification of

Hispanics/Latinos.

Gays and

Lesbians

Approximately 5 to

33 percent of all lesbian and gay individuals are estimated to

have a substance

abuse problem

(Cochran and Mays

2000; Hughes and

Wilsnack 1997). A

Hispanics/Latinos

are now the

largest ethnic

minority group in

America.

Assessment of the

patient’s level of

acculturation can

be helpful in

understanding

substance abuse

patterns.

contributing factor may be the stress and

anxiety associated with the social stigma

attached to homosexuality. Further, alcohol

and drugs may serve as an escape and ease

social interactions at social settings such as

bars. More information on this subject will be

available in the forthcoming TIP Improving

Cultural Competence in Substance Abuse

Treatment (SAMHSA in development a). The

previously discussed protocols for detoxificaPhysical Detoxification Services for Withdrawal From Specific Substances 117
         

             

         

           

         

           

       

           

       

           

           

             

           

             

           

   

             

           

             

           

           

               

             

   

tion appear adequate for gay and lesbian

patients. Since numerous misconceptions and

stereotypes exist concerning gay and lesbian

individuals, it is important for the clinician to

assess his beliefs and take care not to impose

them on the patient. 

There are a number of principles of care for

treating gay and lesbian individuals, which

are outlined in A Provider’s Introduction to

Substance Abuse Treatment for Lesbian,

Gay, Bisexual, and Transgender Individuals

(CSAT 2001). These principles include: (1)

counselors’ being able to monitor their own

feelings about working with this population of

patients in order to provide professional, ethical, and competent care; (2) helping patients

heal from the negative experiences of homophobia and heterosexism; (3) helping patients

understand their reactions to discrimination

and prejudice; and (4) helping patients accept

personal power over their own lives by helping them improve their self­images and build

support networks. 

Adolescents

The previously discussed protocols for detoxification from all substances of abuse appear adequate for the detoxification of adolescents;

however, there are several additional aspects to

consider:

•Physical dependence generally is not as

severe, and response to detoxification is more

rapid than in adults.

•Retention is a major problem in adolescent

treatment (Thurman et al. 1995).

•Peer relationships play a large role in treatment. Among adolescents who do not use

drugs, few of their friends reported use. In

one study, among those who reported specific

drug use, over 90 percent of their friends

reported using the same drug (Dinges and

Oetting 1993).

•It is estimated that 75 percent of those

reporting steroid use are high school students, and most of them are male. Detoxification from steroids does not typically require

specific pharmacological intervention unless

there is liver toxicity or suicidal intent

(Giannini et al. 1991). The use of club drugs

is higher in this population than in others.

TIP 31, Screening and Assessing Adolescents

for Substance Use Disorders (CSAT 1999d),

and TIP 32, Treatment of Adolescents With

Substance Use Disorders (CSAT 1999f), provide comprehensive information on the treatment of adolescents.

Incarcerated/Detained Persons

Substance use disorders are common among

inmate populations. At the time of arrest and

detention, it has been estimated that 70 to 80

percent of all inmates in local jails and State

and Federal prisons had regular drug use or

had committed a drug offense, and 34 to 52

percent of these inmates were intoxicated at

the time of their arresting offense (Federal

Bureau of Prisons 2000; Mumola 1999).

Although women comprise a small proportion

of the incarcerated population (12.3 percent

in jails and 7.4 percent in State and Federal

prisons) than men (Harrison et al. 2004),

females have a greater prevalence of illicit

drug use (i.e., 40 percent compared to 32 percent were under the influence of drugs at the

time the crime was committed) than do males

(Greenfeld and Snell 1999). 

Persons who are incarcerated or detained in

holding cells or other locked areas should be

screened for physical dependence on alcohol,

opioids, and benzodiazepines and provided

with needed detoxification and treatment.

Screening should occur over time, since the

onset and intensity of withdrawal is dependent on the type of drug taken, when the person last took the drug, and how long the drug

lasts in the person’s body. The duration of

detention will affect what detoxification services can be provided, and many facilities will

not be able to provide detoxification or continuing care services. There are some special

considerations for the detoxification of this

population:

•Abrupt withdrawal from alcohol can be lifethreatening. 

118 Chapter 4
•Abrupt withdrawal from opioids or benzodiazepines is not life­threatening but can

cause severe withdrawal signs and symptoms and great distress. 

•It should be determined whether dependence on either opioids or benzodiazepines

is the result of illicit use and not the result

of taking medications that have been prescribed to treat pain or anxiety disorders. 

•If medically supervised withdrawal is indicated, the substitution of a long­acting drug

from the same class of substances the

patient is using (e.g., giving methadone to

treat heroin dependence) and the gradual

tapering of that substance (no faster than

10 to 20 percent per day) should be conducted under closely monitored settings. 

•There are cases when individuals maintained on opioid agonist medications are

detained or incarcerated. If the incarceration is 30 days or less, the individual should

be maintained on her usual dosage. If the

incarceration is longer, the individual may

be appropriate for gradual dose tapering. 

•Persons who transition from a state of opioid dependence to a drug­ or medicationfree state are at greater risk of overdose

upon relapse to opioid use.

•Many correctional facilities have restrictions on the use of methadone or LAAM and

special provisions for maintaining or tapering the individual may need to be made. 

•If medications are provided to medically

detoxify inmates, the Federal Bureau of

Prisons’ Clinical Practice Guidelines for

Detoxification of Chemically Dependent

Inmates (2000) suggest retaining strict control over access to these medications to prevent diversion or misuse (e.g., eating clonidine patches to obtain a state of euphoria). 

TIP 44, Substance Abuse Treatment for

Adults in the Criminal Justice System (CSAT

2005b), and TIP 30, Continuity of Offender

Treatment for Substance Use Disorders From

Institution to Community (CSAT 1998b), provide more detailed information about the

treatment of this population. TIP 21,

Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in

the Justice System (CSAT 1995b), also provides information about incarcerated youth.

Physical Detoxification Services for Withdrawal From Specific Substances 119
   

   

   

   

In This
 Chapter...
 

General Principles
 

of Care for
 

Patients With CoOccurring Medical
 

Conditions
 

Treatment of
 

Co­Occurring
 

Psychiatric
 

Conditions
 

Standard of Care
 

for Co­Occurring
 

Psychiatric
 

Conditions
 

5 Co­Occurring Medical
 

and Psychiatric

Conditions 

Patients undergoing detoxification frequently present with medical

and psychological conditions that can greatly affect their overall wellbeing and the process of detoxification. These may simply be preexisting medical conditions not related to substance use or the direct

outcome of the substance abuse. In either case, the detoxification process can negatively affect the co­occurring disorder or vice versa.

Furthermore, people who abuse substances often present with medical

conditions in advanced stages or in a medical crisis. Co­occurring

mental disorders also are likely to be exacerbated by substance abuse.

For more on treating patients with co­occurring psychiatric disorders,

the reader should refer to TIP 42, Substance Abuse Treatment for

Persons With Co­Occurring Disorders (Center for Substance Abuse

Treatment [CSAT] 2005c).

This chapter is intended primarily for medical personnel treating

patients in detoxification settings, though nonmedical staff may find it

informative as well. This chapter is not meant to take the place of

authoritative sources from internal medicine. Rather, it presents a

cursory overview of special conditions, modifications in protocols, and

the use of detoxification medications in patients with co­occurring

conditions or disorders. Overall treatment of specific conditions is not

addressed unless modification of such treatment is needed. 

121
   

   

   

   

General Principles of

Care for Patients With

Co­Occurring Medical

Conditions

Patients who use substances can present with

any of the conditions or combinations of conditions that can be found in the general population. In most cases, the management of the

medical condition in the patient with a substance use disorder diagnosis does not differ

from that of any other patient. However, the

medication used for detoxification and the

actual detoxification protocol may need to be

modified to minimize potentially harmful

effects relevant to the co­occurring condition.

Detoxification staff providing support should

be familiar with the signs and symptoms of

common co­occurring medical disorders.

Likewise, personnel at medical facilities (i.e.,

emergency rooms, physicians’ offices) should

be aware of the signs of withdrawal and how

it affects the treatment of the presenting medical conditions. 

The setting in which detoxification is carried

out should be appropriate for the medical

conditions present and should be adequate to

provide the degree of monitoring needed to

ensure safety (e.g., oximetry [a measurement

of the amount of oxygen present in the

blood], greater frequency of taking vital

signs, etc.). Acute, life­threatening conditions

need to be addressed concurrently with the

withdrawal process and intensive care unit

monitoring may be indicated. 

Clinicians should keep in mind that consultation with specialists in infectious diseases,

cardiology, pulmonary medicine, hematology,

neurology, and surgery may be warranted.

Whenever possible, consent should be sought

to involve the patient’s primary healthcare

provider in the coordination of care.

Attending medical staff should be aware that

co­occurring medical conditions present an

opportunity to engage patients. By focusing

on the adverse effects of the substance abuse

on the overall health of patients, staff members are in a position to help patients see the

importance of engaging in treatment for their

substance use disorders. Patients should have

appointments for followup care made prior to

detoxification discharge for all chronic medical conditions, conditions needing further

evaluation, and substance abuse treatment.

This section highlights the conditions most

frequently seen in individuals who abuse substances, though it is not inclusive. Disorders

of the following systems will be covered: gastrointestinal (including the gastrointestinal

[GI] tract, liver, and pancreas), cardiovascular system, hematologic (blood) abnormalities, pulmonary (lung) diseases, diseases of

the central and peripheral nervous system,

infectious diseases, and special miscellaneous

disorders. Where special considerations are

needed for a patient presenting with a given

disorder in a detoxification setting they are

listed following the heading “Special

Considerations.”

Gastrointestinal Disorders

Frequently, the use of substances can present

a range of gastrointestinal problems. Cocaine

use, for example, can result in various gastrointestinal complications, including gastric

ulcerations, retroperitoneal fibrosis, visceral

infarction, intestinal ischemia, and gastrointestinal tract perforations (Linder et al.

2000). Gastrointestinal disorders may affect

many different organs and organ systems

(e.g., liver, pancreas), making diagnosis difficult. Since symptoms can be vague and

patients are not always able to articulate the

specific problem, diagnosis can be difficult.

For a simple rule of thumb, urgent attention

is needed if the patient is diagnosed with any

of the following:

•Appendicitis

•Abdominal aortic aneurysm

•Perforated peptic ulcer

•Boerhaave’s Syndrome (spontaneous

esophageal rupture)

•Obstructed or strangulated bowel

122 Chapter 5
•Ischemic bowel disease (a condition that

results from inadequate blood supply to the

intestines)

•Abcess of the pancreas or liver

•Ruptured spleen or other trauma to the

abdominal area

Other possible diagnoses of abdominal pain

include:

•Hepatitis

•Peptic ulcer (nonperforating)

•Peritonitis

•Acute pancreatitis

•Pelvic inflammatory disease

•Endometriosis

•Nephrolithiasis (kidney stones)

•Inflammatory bowel disease

•Ovarian cysts

Clinicians should also be aware of some deceptive causes of abdominal pain:

•Myocardial infarction

•Pulmonary emboli

•Herpes zoster (shingles)

•Acute pylonephritis (kidney infection)

Specific co­occurring gastrointestinal disorders

requiring special attention in patients undergoing detoxification are discussed below.

Reflux esophagitis

Reflux esophagitis can be a result of alcohol’s

effect on the lower esophageal sphincter (i.e.,

relaxation) and a decrease in peristalsis of the

distal esophagus, allowing gastric contents to

come into contact with the lower esophagus.

Typical symptoms include burning in the epigastric or retrosternal area (commonly called

“heartburn” or “indigestion”). Esophageal

bleeding can result from reflux esophagitis and

esophageal varices (resulting from portal

hypertension).

Special considerations

Several drugs used in typical protocols, such as

beta blockers and calcium channel blockers,

may decrease lower esophageal sphincter pressure and aggravate reflux (Dell’Italia 1994).

Mallory–Weiss Syndrome

Mallory–Weiss Syndrome is caused by torn

mucosa of the esophagus at the gastroesophageal junction due to protracted or violent vomiting. Mallory–Weiss Syndrome is the

etiology of 5 to 15 percent of all upper GI

bleeds (Schuylze­Delrieu and Summers 1994).

Boerhaave’s

syndrome

Boerhaave’s syndrome is manifested

by rupture of the

esophagus. Patients

presenting with this

condition complain of

acute epigastric pain

(83 percent of

patients), vomiting

(79 percent), and

shortness of breath

(39 percent) as the

predominant, nonspecific symptoms. This

lack of specificity can

delay making the correct diagnosis (Brauer

et al. 1997).

Tachycardia,

cyanosis, and subcutaneous emphysema

also can be seen. If

this condition is left
 

Co­occurring

medical conditions

present an

opportunity to

engage patients in

treatment for

their substance

use disorders.

untreated, the prognosis is severe.
 

Gastritis

Gastritis is described as the disruption of the

gastric mucus lining that allows gastric acid to

contact the mucosa with resultant inflammation

and possible bleeding. The patient presents

with nausea, vomiting, and abdominal pain

(Ivey 1981). Alcohol increases gastric acid

secretion and reduces the mucosal cell barrier,

Co­Occurring Medical and Psychiatric Conditions  123
allowing back­diffusion of the gastric acid into

the mucosa. This frequently causes an occurrence of erosive gastritis in the individual with

an alcohol use disorder (Fenster 1982).

Special considerations

Aspirin and nonsteroidal medications should be

avoided in the withdrawal protocols.

Pancreatitis

Pancreatitis can be

caused by many factors, although studies suggest that alcohol may be a factor

in anywhere from 5

to 90 percent of all

cases (Apte et al.

1997), with some

experts suggesting

about 60 percent of

all cases result from

excessive alcohol

consumption

(Yakshe 2004). The

acute condition presents with abdominal pain, which is

described as sharp,

burning, and constant and is located

in the epigastric

area of the

Detoxification	 

staff providing

support should be

familiar with the

signs and

symptoms of common co­occurring

medical conditions.

abdomen with radiation to the back.

Presenting symptoms and signs can include

abdominal tenderness, decreased bowel

sounds, low­grade fever, tachycardia, nausea,

and vomiting. Pancreatitis can proceed to a

chronic condition where pancreatic calcification, diabetes mellitus, malabsorption, and

chronic abdominal pain occur.

Special considerations

There may be a need to forbid oral intake of

food and medications, necessitating a change

of route of administration of both food and

medications to intravenous forms. In alcohol

withdrawal protocols, Ativan might be considered as an appropriate agent, as it can be

administered intravenously or intramuscularly. Opioids may have to be used to control

pain.

Liver disorders

Liver disease can range from fairly benign

fatty liver, which presents usually as an

asymptomatic enlargement of the liver associated with mild elevation of the serum liver

enzymes, to a broad spectrum of viral infections and the toxic consequences of alcohol

and other drug use. The end point of liver

disease is liver necrosis or failure. Midway in

the progression of liver disease is acute alcoholic hepatitis. The presentation is one of

liver tenderness, jaundice, fever, ascites, and

an enlarged liver. The patient is quite sick

and frequently has nausea and vomiting.

Special considerations

Alcoholic hepatitis usually needs acute medical treatment to prevent electrolyte imbalance

and dehydration. Protocols may have to be

adapted if the patient cannot take oral

agents.

Portal hypertension

Portal hypertension is a frequent consequence of liver disease. If elevation of the

portal pressure goes untreated, esophageal

varices develop and hemorrhage can ensue.

Treatment of acute hemorrhage includes

endoscopic sclerotherapy or ligation. Initial

therapy should include prompt and adequate

intravascular volume replacement, correction

of severe anemia and coagulopathies, and

adequate airway management.

Special considerations

Propranolol or isosorbide therapy is effective

in the prophylaxis of variceal bleeding

(Trevillyan and Carroll 1997), though beta

blockers can interfere with measuring the

true heart rate that determines the content of

many detoxification protocols. If bleeding is

124	 Chapter 5
present, changeover to intravenous medication protocols is recommended, as the patient

will not be able to take oral medications.

Cirrhosis

Cirrhosis, or the formation of fibrous tissue

in the liver, leads to a state of increased resistance in the hepatic venous circulation. The

inability of blood to flow freely gives rise to

portal hypertension with ensuing esophageal

varices, splenomegaly, ascites, dilatation of

superficial veins, peripheral edema, and hemorrhoids.

Liver necrosis can be seen in patients who use

inhalants, particularly chronic use of benzene

and carbon tetrachloride. African Americans

and Hispanics/Latinos have higher mortality

rates from cirrhosis of the liver resulting from

alcohol abuse than do Caucasians and Asians

and Pacific Islanders (Sutocky et al. 1993).

Liver function test abnormality and jaundice

can occur in individuals who use anabolic

steroids, but this usually resolves on cessation

of the drugs. Studies in the elderly show that

1­year mortality was 50 percent among

patients over age 60 with cirrhosis, versus 7

percent for those under age 60 (Potter and

James 1987). Great care needs to be used

when giving diuretics to elderly patients with

cirrhosis, since their total body water may

already be decreased, making them more susceptible to fluid and electrolyte depletion

(Scott 1989).

Alcohol­related hepatic injury is seen in a

higher proportion of women due to a possible

potentiation (strengthening) of this effect by

estrogen (Brady and Randall 1999). 

Special considerations

For the treatment of alcohol withdrawal,

lorazepam (Ativan) is well tolerated in

patients with severe liver disease (D’Onofrio

et al. 1999) as is oxazepam (Serax), with its

short half­life of 6 to 8 hours and simple

metabolism with no metabolites. 

Cardiovascular Disorders

The presentation of chest pain or discomfort

remains one of the most difficult differential

diagnoses to sort through, as disorders of several systems can cause this single complaint.

Inability to correctly diagnose this symptom

can be brought about by the patient’s inability to be interviewed and give succinct symptoms (the intoxicated or severely withdrawing

patient), a sociocultural or educational level

that does not allow for the verbal nuances

necessary to making a diagnosis, or fabrication of symptoms by a patient seeking to

obtain pain medications or other drugs. 

A normal resting electrocardiogram does not

rule out the presence of organic heart disease

and the presence of nonspecific changes does

not necessarily mean that heart disease is present. Final diagnoses can range from reflux to

myocardial infarction brought about by

underlying ischemic heart disease or the use

of cocaine. Frequently, lung diseases can have

as their presenting symptom chest discomfort.

The consensus panel believes that this condition should never be overlooked or minimized

and it is imperative that an especially prompt

diagnosis be made and treatment be undertaken to ensure patient safety.

Underlying cardiac illness could be worsened

by the presence of autonomic arousal (elevated blood pressure, increased pulse and sweating) as seen in alcohol, sedative, and opioid

withdrawal. Thus prompt attention to these

findings and aggressive withdrawal treatment

is indicated. Special considerations for the

treatment of specific cardiac conditions are

outlined below.

Hypertension

Hypertension frequently is seen in the detoxification patient. Evaluation should include a

complete history to determine if the elevated

blood pressure predated the present withdrawal status. Consideration should be given

to include serum electrolytes, urinalysis,

BUN/creatinine, and an EKG in the detoxifiCo­Occurring Medical and Psychiatric Conditions  125
cation unit’s initial workup. More elaborate

workup can be carried out after completion

of detoxification.

Propranolol (Inderal), labetalol (Trandate)

and metoprolol (Lopressor) are the beta

blockers of choice for treating hypertension

during pregnancy (McElhatton 2001), however, the impact of using them for alcohol

detoxification during pregnancy is unclear. If

treating African Americans with beta blockers, clinicians should be aware that propranolol is less effective in this population than it

is in Caucasians (Pi and Gray 1999). Asians

require much lower doses of beta blockers

than Caucasians, inasmuch as they tend to be

very sensitive to the blood pressure and heart

rate effects (Pi and Gray 1999).

Special considerations

The presence of a hypertensive history and

poorly controlled blood pressures may have

an effect on the proper evaluation of withdrawal as the examiner would have difficulty

determining whether the elevated blood pressure was due to withdrawal or to the underlying hypertensive history. Thus modifications

of the usual parameters and scheduling of

detoxification medications should be considered. In any event, severe elevation of blood

pressure should be treated concurrently with,

at minimum, salt restriction and rest. If the

blood pressure is still elevated in several days

despite a reduction in other withdrawal

parameters and symptoms, then medication is

warranted.

Beta blockers and clonidine have been used

in the treatment of alcohol withdrawal and

clonidine also has been used in opioid protocols. These medications can help control

blood pressure and also work well in the protocol. Calcium channel antagonists have also

been used to ameliorate some of the symptoms

of alcohol withdrawal and can be used concurrently for blood pressure control.

Ischemic heart disease

Ischemic heart disease presents as chest pain

or pressure, palpitations, dizziness, and/or

shortness of breath and requires immediate

attention, which will dictate what setting is

appropriate for the detoxification.

Cocaine use is associated with various cardiovascular complications including angina pectoris, myocardial infarction, and sudden

death. It is estimated that over half of the

64,000 patients evaluated annually for

cocaine­associated chest pain will be admitted

to hospitals for evaluation of myocardial

ischemia. Only about 6 percent of patients

will demonstrate biochemical evidence of

myocardial infarction (Hoffman and

Hollander 1997). The typical patient with

cocaine­related myocardial infarction is a

male in his mid­30s with a history of chronic

tobacco and repetitive cocaine use (Hollander

1995). This effect of cocaine appears to be

increased because the drug causes an increase

in myocardial oxygen demand and thus a

decrease in oxygen supply. These two factors,

which are caused by vasospasm and vasoconstriction of the coronary arteries, may lead to

cardiovascular disorders.

Patients with recent cocaine use can experience persistent cardiac complications such as

prolonged QT interval and vulnerability for

arrhythmia and myocardial infarction

(Chakko and Myerburg 1995). (QT is the Q to

T interval measured on EKGs. If the interval

is prolonged, it can lead to cardiac rhythm

disturbances.) Amphetamines are rarely

reported as the cause of myocardial infarction, though a case report shows that a

patient subsequently experienced a non–Qwave anterior wall infarction associated with

amphetamine use (Waksman et al. 2001).

Cocaine use and HIV infection have been

associated with an increased incidence of cardiac dysfunction, but concomitant exposure

may cause a synergistic effect (Soodini and

Morgan 2001).

126 Chapter 5
Special considerations

Beta­adrenergic blocking agents may exacerbate cocaine­induced coronary arterial vasoconstriction and thereby increase the myocardial ischemia. Nitroglycerin and verapamil

reverse cocaine­induced hypertension and

coronary arterial vasoconstriction and are

the medications of choice in the patient who

uses cocaine and presents with chest pain

(Pitts et al. 1999). Cocaine may cause platelet

activation leading to acute coronary events—

thus more aggressive antiplatelet therapy may

be indicated (Callahan et al. 2001).

Cardiomyopathy

Cardiomyopathy is caused by degenerative

changes of the cardiac muscle with enlargement of the heart (cardiomegaly) and left ventricular failure. Alcoholic cardiomyopathy

presents with a similar picture as cardiac failure from other etiologies, with shortness of

breath on exertion, shortness of breath when

the patient is lying flat, and edema of the

lower extremities. 

Besides alcohol as the etiology, a dilated cardiomyopathy can be seen with use of the

inhalant trichlorethylene. Cardiomyopathy in

the elderly patient with an already underlying

ischemic or atherosclerotic heart disease can

be quite debilitating. Women have shown

alcohol metabolism different from that of men

and distinct pathophysiologic mechanisms,

which frequently lead to a higher sensitivity

to alcohol­induced heart damage. The prevalence of cardiomyopathy in women is equal to

that in men, despite cases in which women

have consumed far less ethanol (FernandezSola and Nicolas­Arfelis 2002).

Special considerations

Alcoholic cardiomyopathy may respond poorly to digitalis with increased likelihood of digitalis toxicity (Zakhari 1991).

Arrhythmias

Arrhythmias (irregular heartbeats) can be

seen in the presence of ischemia and cardiomyopathy. Two specific cases of arrhythmogenic disorders are “holiday heart,” where

the patient who has ingested alcohol presents

with supraventricular arrhythmia

(Greenspon and Schaal 1983), and the individual who uses cocaine with the stimulant

leading to significant atrial and ventricular

arrhythmias. Consumption of anabolic

steroids also has

been associated with

hypertension, Cocaine use is

associated with

various

cardiovascular

complications

including angina

pectoris,

myocardial

infarction, and

sudden death.
 

ischemic heart disease, cardiomyopathy, and arrhythmia

(Sullivan et al.

1999). 

Special considerations 

Treatment of arrhythmia in the person who

abuses substances is

similar to that for the

patient who does not

abuse substances,

though the setting of

detoxification may

have to be altered to

allow for cardiac
 

monitoring (telemetry).

Hematologic

Disorders

Hematologic (blood) disorders can be seen due

to several factors, such as a direct toxic effect

of the drug on the bone marrow, as seen in

alcohol and benzene use, or as a result of malabsorption of essential nutrients (B12, folate),

or as a general poor state of nutrition.

Co­Occurring Medical and Psychiatric Conditions  127
Anemia

Anemia can be seen due to folate deficiency,

iron deficiency, B12 deficiency, acute blood

loss, or more frequently as a combination of

factors. Folate deficiency can cause a megaloblastic anemia, which is diagnosed by

macroovalocytes and hypersegmented neutrophils seen on a peripheral blood smear.

Iron deficiency anemia results from blood loss

and thus subsequent iron loss. This can be

seen in low­level

gastrointestinal

bleeding, after

childbirth, and as a

result of menstrual

Traumatic brain	 

injury (TBI)	 

should always be

considered in

patients with

neurological

impairment.	 

blood loss. The presentation of anemia

usually is nondescript with generalized fatigue and

weakness. With

severe anemia,

shortness of breath

on exertion and an

elevated heart rate

can be seen.

Specific to the

megaloblastic anemias (B12 and

folate deficiency)

one can see neurologic complications

such as peripheral

neuropathy.

White blood cell disorders

White blood cell disorders can occur due to

malnutrition and liver disease. Lymphopenia

may be present in the patient with HIV disease.

Platelet disorders

Platelet disorders frequently are attributable

to the direct effect on the bone marrow by the

substance being abused or, as seen in alcoholrelated thrombocytopenia, are due to bone

marrow suppression. Splenomegaly caused by

portal hypertension also can cause a low

platelet count (thrombocytopenia), which is

due to enlargement of the spleen and abnormally high platelet storage. Thrombocytopenia also can be seen in cases of vitamin B12

and folate deficiency.

The African­American patient with sickle cell

disease or trait can be severely affected (inasmuch as the patient already has an impaired

oxygen delivery system) if other harm threatens the bone marrow.

Special considerations

Elevated heart rates can hinder the use of the

heart rate as a parameter in various detoxification protocols.

Pulmonary Disorders (Other

Than Infectious)

Pulmonary disorders are common in people

who abuse substances, in part because of the

high rate of nicotine use in this population

(Graham et al. 2003).

Aspiration pneumonia

Alcohol or other drug ingestion may reduce a

patient’s gag reflex, leading to the blockage of

the airways. Aspiration pneumonia occurs

when oro­pharyngeal secretions and/or gastric

contents enter into the lower airways. This serious condition may require prolonged hospitalization.

Asthma

Asthma, a chronic condition characterized by

exacerbations of bronchial spasm manifested

by wheezing, should be differentiated from

bronchospasm, which is related to inhaled

drugs and usually is self­limited. Treatment is

similar to that provided to patients who do

not use substances, with the addition of cessation of the substance use. 

The patient with underlying chronic asthma

can be severely compromised if the use of a

smokeable drug causes exacerbation of an

already impaired system.

128	 Chapter 5
         

             

         

           

Special considerations

Asthma medications can cause a significant

increase in heart rate, which can affect the

evaluation of withdrawal protocols that use

heart rate as one of the parameters.

Chronic Obstructive

Pulmonary Disease

Chronic obstructive pulmonary disease

(COPD) (emphysema, chronic bronchitis) frequently is due to cigarette use and the resulting alterations of the pulmonary immune system, inflammation, and destruction of lung

parenchyma. Presentation includes shortness

of breath on exertion, a cough producing

mucous, and wheezing.

African Americans who smoke cigarettes take

in more nicotine, and therefore more tobacco

smoke toxins per cigarette, than Caucasians

(Perez­Stable et al. 1998).

Daily marijuana smoking has been shown to

have adverse effects on lung function including a productive cough, wheezing, and excessive sputum production. However, the habitual marijuana­only smoker, in the absence of

alpha­1­antitrypsin deficiency, would have to

smoke four to five marijuana cigarettes per

day for a span of at least 30 years to develop

overt manifestations of COPD (Van Hoozen

and Cross 1997).

Special considerations 

During nicotine withdrawal and cessation

treatment, different levels of nicotine absorption, as seen in some groups, will affect dosing

for nicotine replacement therapies (PerezStable et al. 1998). The patient with COPD,

especially if elderly, would be sensitive to the

sedating effects of many of the detoxification

protocol medications, especially the benzodiazepines, which may have to be reduced in

dosage to avoid respiratory depression and

worsening hypoxemia and hypercarbia

(decrease in oxygen and increase in carbon

dioxide). For smokers, always consider the

use of the nicotine replacement agents, particularly in hospitalized patients. Evaluation for

infections and the use of oxygen, steroids,

and inhalers is dictated by the clinical picture. During detoxification, if nicotine use is

not allowed, there can be significant effects

on drug levels (see chapter 4).

Neurologic System

The neurologic system of patients with substance use disorders is affected directly in the

toxic effects on cell membranes, effects on

neurotransmitters, associated metabolic

changes from other underlying disorders, and

changes in blood flow. Researchers have

found that the majority of those with an alcohol use disorder (75 percent) have some

degree of cognitive impairment (Goldstein

1987). Specific disorders found in patients

with substance use disorders can affect the

central nervous system and the peripheral

system. For example, a broad array of neuropathologic changes are seen in the brains of

people who use heroin. The main findings are

due to infections as a result of endocarditis or

HIV infection. Other complications include

hypoxic­ischemic changes with cerebral

edema, ischemic neuronal damage thought to

be due to heroin­induced respiratory depression, stroke due to thromboembolism, vasculitis, septic emboli, and hypotension.

Myelopathy occurs as a result of possible isolated vascular accident in the spinal cord,

and a distinct condition, leukoencephalopathy, has been described after the inhalation of

pre­heated heroin (Buttner et al. 2000).

As a final note, traumatic brain injury (TBI)

should always be considered in patients presenting with neurological impairment. People

who abuse substances are at high risk of falls,

motor vehicle accidents, gang violence,

domestic violence, etc., which may result in

head injury (Graham et al. 2003).

Unrecognized TBI can affect the treatment

outcome. 

Co­Occurring Medical and Psychiatric Conditions  129
     

     

       

             

         

       

       

           

           

             

       

           

       

Wernicke­Korsakoff’s

Syndrome

Wernicke­Korsakoff’s Syndrome is composed

of Wernicke’s encephalopathy and

Korsakoff’s psychosis. Wernicke’s

encephalopathy is an acute neurological disorder with a triad of

•Oculomotor dysfunction (bilateral abducens

nerve palsy—eye muscle paralysis)

•Ataxia (loss of muscle coordination)

•Confusion

Weakness and nystagmus are also seen in this

syndrome on examination of the eyes.

Wernicke’s encephalopathy is clearly related to

thiamine deficiency.

Korsakoff’s psychosis is a chronic neurological condition resulting from thiamine deficiency that includes retrograde and antegrade

amnesia (profound deficit in new learning and

remote memory) with confabulation (patients

make up stories to cover memory gaps).

Special considerations 

Thiamine initially is given parenterally and

then oral administration is the treatment of

choice. Always give thiamine prior to glucose

administration.

Alcohol and sedative 

withdrawal seizures

Alcohol and sedative withdrawal seizures represent a significant medical challenge (Ahmed

et al. 2000), since no large clinical studies

have been conducted to firmly establish the

best treatment practices. Up to 90 percent of

alcohol withdrawal seizures occur in the first

48 hours and usually are single and nonfocal.

Repeated episodes of drinking and withdrawal are thought to predispose people to

seizures due to a kindling phenomenon (Post

et al. 1987). Patients with a history of withdrawal seizures are at greatest risk and

should receive prophylactic doses of a longacting benzodiazepine (e.g., chlordiazepoxide

50mg every 6 hours for 24 hours) when detoxifying from alcohol.

Individuals with an alcohol use disorder show

an increase in seizures due to withdrawal,

metabolic insults such as hypoglycemia or

electrolyte imbalance, or head trauma. In one

study, researchers found that of 195 cases of

seizures in those with an alcohol use disorder,

59 percent were due to alcohol withdrawal, 20

percent to head trauma, and 5 percent to vascular disorders (Earnest et al. 1988).

Special considerations

Evaluation of a first seizure should include a

neurological evaluation and evaluation for

head trauma. Metabolic etiologies, such as low

magnesium levels, should be considered.

Mayo­Smith (1997) has shown that benzodiazepines confer protection against alcohol

withdrawal seizures and thus patients with

previous seizures should be treated early with

this class of medications. The consensus panel

suggests that anti­epileptic drug therapy

should be considered in alcohol withdrawal

patients with multiple past seizures (of any

cause), a history of recent head injury, past

meningitis, encephalitis, or a family history of

seizures. 

Clinicians should be aware that treatment of

the first seizure with benzodiazepines does

not prevent the likelihood of a second seizure

(D’Onofrio et al. 1999). Slower medication

tapers should be considered when this condition co­occurs with detoxification.

Lorazepam, which can be used in patients

with liver disease, has been suggested as

appropriate, but it and other short­acting

benzodiazepines may not prevent late­occurring withdrawal seizures (Shaw 1995).

Dosages of anticonvulsant medications should

be stabilized before sedative­hypnotic withdrawal begins. Adequate treatment with a

long­acting benzodiazepine is effective in preventing withdrawal seizures (Mayo­Smith and

Bernard 1995). D’Onofrio and colleagues

(1999) found that a one­time dose of the rela130 Chapter 5
tively shorter acting agent lorazepam also

reduced the risk of a subsequent seizure compared to placebo. However, in D’Onofrio’s

study doses were small and the results were

limited somewhat by use in an emergency

room setting.

Older, first­generation anticonvulsants have

limitations in that they have only been studied in mild to moderate withdrawal, on rare

occasions they can cause serious hepatic and

bone marrow toxicities, and they can interact

with other classes of medication. Newer

drugs, such as gabapentin (Neurontin) and

oxcarbazepine (Trileptal), do not appear to

have these liabilities, but sufficient studies to

show this have not yet been done. There is little evidence that long­term use of phenytoin is

helpful in the patient who does not have an

underlying seizure disorder (Kasser et al.

2000). Medications that may lower the seizure

threshold, including phenothiazines, such as

prochlorperazine (Compazine), and several

antidepressants, such as bupropion, should

be used with great caution in the patient with

a seizure history.

The use of anticonvulsants, such as valproic

acid and barbiturates, has been studied in

pregnant women. Valproic acid is associated

with several malformations in the fetus. The

use of any anticonvulsant medication should

be discussed with the pregnant patient and

risks and benefits explained (Robert et al.

2001).

Cerebrovascular accidents

Cerebrovascular accident (stroke) can be seen

in alcohol and cocaine use, coagulation impairment, and severe uncontrolled hypertension.

Patients with recent cocaine/amphetamine use

may present with headaches, which could

represent subarachnoid and/or intracerebral

bleed, and therefore should be appropriately

evaluated (Buxton and McConachie 2000).

Heavy alcohol consumption increases the risk

for all major types of stroke by a variety of

mechanisms (Hillbom and Numminen 1998).

There is a higher than normal incidence of

hemorrhagic stroke and other intracranial

bleeding among patients with heavy alcohol

use, and a particular association of strokes

within 24 hours of a drinking binge (Altura

1986).

Special considerations

Nifedipine and verapamil have been shown to

prevent alcohol­induced vasospasm, which suggests a possible therapeutic approach to hypertension and stroke in the patient with heavy

alcohol use (Altura 1986).

Polyneuropathy

Polyneuropathy frequently is seen in

nutritional deficien­ Treatment of the

first seizure with

benzodiazepines

does not prevent

the likelihood of a

second seizure.

cies that occur in the

patient with chronic

alcohol use.

Presenting signs and

symptoms include

lower extremity

pain, distal motor

loss, numbness or

tingling, and loss of

reflexes.

Polyneuropathy can

be seen in the

inhalation of h­hexane, methyl­n­butyl

ketone, and toluene

(Geller 1998).

Hepatic encephalopathy

Hepatic encephalopathy is a toxic brain syndrome that results from the accumulation of

unmetabolized nitrogenous waste products in

a patient with severe liver dysfunction.

Presenting signs and symptoms include an

alteration in consciousness and behavior,

fluctuating neurologic signs such as a flapping

tremor (asterixis), and an elevated serum

ammonia level. Clinicians should evaluate

Co­Occurring Medical and Psychiatric Conditions  131
patients for precipitating causes, which
 

include the following:
 

•GI hemorrhage

•Electrolyte imbalance (metabolic alkalosis)

•Infections

•Excessive diuresis (dehydration)

•Use of sedatives

•Increase of dietary protein intake

Those patients who are infected with
 

Helicobacter pylori may be more prone to
 

hepatic encephalopathy (Duseja et al. 2003). 

Special considerations

Clinicians should avoid the use of diuretics,

identify and treat factors that may have precipitated the
 

encephalopathy,
 

Immunocompromised

patients may not

react to the

tuberculin skin

tests.	 

decrease dietary
 

protein intake, and

use Lactulose to

decrease nitrogenous waste products via the GI

tract. Protocols

that use the benzodiazepines should

be adjusted to use

those specific medications that are

hepatically metabolized minimally or

not at all.

Infectious Diseases

The viral causes of hepatitis are multiple,

though the hepatitis B and C viruses are the

predominant causative agents. Hepatitis C

virus infection appears to be the most common form of infectious hepatitis in patients

with substance use disorders. At least 76 percent of patients who have used injection drugs

for less than 7 years are positive for hepatitis

C, while 25 percent of patients with alcohol

use disorders and those who do not inject

drugs show serologic evidence of infection

(Fingerhood et al. 1993; National Institute on

Drug Abuse 2000). Hepatitis B infections are

likely to present more often as a chronic

infection than as an acute­stage phenomenon.

Testing for chronic hepatitis B and C infection is appropriate during the detoxification

period.

Special considerations

Followup for hepatitis B and C should be

arranged for after discharge from the detoxification setting. Vaccination is recommended

for hepatitis A and B in the patient with hepatitis C. The vaccination schedule is over a 6­

month period, so it needs to be done after the

detoxification program. If significant liver

disease is present, use of shorter­acting medication with less liver metabolism should be

considered. For more on infectious disease

and substance abuse, see TIP 6, Screening

for Infectious Diseases Among Substance

Abusers (CSAT 1993c).

Endocarditis

Endocarditis is caused by the introduction of

various bacterial species into the vascular

system when the protective defense mechanisms of the skin are bypassed through injection. The patient frequently will present with

fever, cardiac murmur, anemia, enlargement

of the spleen, petechiae, and peripheral

embolic disease. The course can be subtle and

indolent to fulminant, and if untreated can

lead to a poor prognosis. In the patient who

uses drugs intravenously, the tricuspid valve

is affected in 70 percent of cases, followed by

effects on the aortic valve and the mitral

valve. Seventy­five percent of all cases are

caused by Staphylococcus aureus and up to

15 percent are caused by gram negative aerobic bacilli (Aragon and Sande 1994). 

Endocarditis always should be suspected in

the febrile patient who uses intravenous

drugs. Patients who use drugs intravenously

are 300 times more likely to die suddenly

from infectious endocarditis than patients

who use drugs nonintravenously (Burke et al.

1997). Patients who use cocaine intravenously

132	 Chapter 5
         

     

       

           

           

     

           

             

       

         

may have a higher rate of endocarditis as a

result of more frequent injections and the

reduced need to solubilize cocaine solutions

with heat (Chambers et al. 1987).

Bacterial pneumonia

Bacterial pneumonia can result from immune

system dysfunction, interference with normal

respiratory defense mechanisms (from alcohol

or smoked drugs), direct toxicity, or aspiration.

The treating physician should be aware that

the usual pathogens found in communityacquired pneumonia (i.e., Streptococcus

pneumoniae) may not be the causative agent

in pneumonias seen in patients dependent on

alcohol. Haemophilis influenzae, Klebsiella

pneumoniae, and other gram­negative

microorganisms must be suspected and treatment given until definitive culture results are

reported. Among patients who use parenteral

drugs, pneumonia is the most common reason

for admission to the hospital, accounting for

38 percent of all hospitalizations in this population (Marantz et al. 1987).

Special considerations

Careful use of respiratory depressants is recommended. Indications for hospitalization of

the patient with pneumonia (Neu 1994) include

the following:

•Old age

•Dehydration

•Vomiting and inability to take in oral fluids

and medications

•Multilobar disease

•Low white blood cell count

•Respiratory acidosis

•pO2 less than 55 mm Hg

•Significant concomitant diseases

•HIV

Tuberculosis

Tuberculosis (TB) is caused by acid­fast rod

(Mycobacterium tuberculosis). Transmission

is by droplets spread through the air. The

infected patient presents with complaints of

cough (most common finding), bloody sputum, chest pain, fever, and weight loss.

Recent immigrants from countries where TB

is prevalent, socioeconomically disadvantaged

populations, homeless persons, people who

use illicit drugs, incarcerated people, and

people who live in areas where infection with

HIV is prevalent, are at increased risk for

this disease and should be tested. Furthermore, new strains of multidrug­resistant TB

are appearing, especially among the homeless

population (Borgdorff et al. 2000; Moss et al.

2000).

TB is endemic in many areas of the world

(Asia, Africa, and South and Central

America) (Gupta et al. 2004). As a public

health concern, testing all patients is of the

utmost importance, even more so for patients

from regions where TB is endemic. It is

important to remember that immunocompromised patients may not react to the skin tests

(anergy). Diagnosis is made with tuberculin

skin testing, sputum smears and cultures, and

radiographic findings. For more information

on dealing with tuberculosis in detoxification

and treatment settings see TIP 18, The

Tuberculosis Epidemic: Legal and Ethical

Issues for Alcohol and Other Drug Abuse

Treatment Providers (CSAT 1995i).

Skin infections

Skin infections frequently are seen as a result

of the intravenous administration of drugs.

Staphylococcus aureus and Streptococcus

pyogenes are frequently the infectious agents.

The patient presents with tenderness,

swelling, pain, erythema, and warmth in the

injection area. The type and route of antibiotic is determined by the infecting organism

and the extent and severity of the infection.

Clinicians should remember that injection

sites can be found virtually any place on the

body where there is access to the venous system.

Patients who use drugs intravenously,

patients with peripheral vascular disease, and

Co­Occurring Medical and Psychiatric Conditions  133
             

           

             

           

         

             

         

           

     

         

             

         

             

           

           

         

         

         

patients with diabetes (particularly with

infections of the feet) should all be evaluated

carefully for skin disease.

Sexually transmitted 

diseases

Sexually transmitted diseases can be seen in the

form of urethritis, vaginitis, cervicitis, and genital lesions. These disorders are caused by a

variety of microorganisms, and a complete history and physical that includes examination of

the genitalia is indicated in all patients. The

clinical picture and cultures frequently can

guide the treatment protocols. Patients who use

drugs intravenously occasionally display a

false­positive serologic test for syphilis, possibly

due to a nonspecific reaction to repeated exposure of injected antigens (Hook 1992).

HIV/AIDS

HIV/AIDS is a serious and prevalent medical

condition among persons with substance use

disorders, especially those who inject drugs

and may share needles with other users.

Patients with AIDS can present with a spectrum of complaints and illnesses ranging from

an asymptomatic history to complaints of

fever, enlargement of the lymph nodes, difficulty swallowing, diarrhea, weight loss, skin

lesions, shortness of breath (due to

Pneumocystis carinii pneumonia), headaches

(due to Toxoplasma gondii), seizures, and

dementia. As a rule of thumb, no complaint

in the patient infected with HIV should be

dismissed as irrelevant. 

Gay men and patients who use drugs intravenously may be at higher risk for HIV/AIDS

than other groups; thus, testing or referral

for testing should be done and appropriate

counseling offered. All such patients should

be tested for HIV/AIDS or referred for testing. Some States, such as Colorado, require

that a risk assessment be administered to all

clients and that clients be advised of their

risk and referred for testing if they are at risk

for HIV/AIDS. Patients who decline HIV testing still should be educated about the risk

and prevention. 

Due to increased virulence of syphilis in

patients who are HIV positive, as well as

increased resistance to the treatments indicated in the usual treatment protocols, all such

patients should be tested for syphilis and all

patients who test positive for syphilis should

be sent for HIV testing (McNeil et al. 2004).

Special considerations

If methadone is being used in withdrawal protocols, or maintenance is being continued, the

clinician should be aware that certain HIV

medications can cause an increased metabolism

of methadone:

•Efavirenz (Sustiva)

•Nevirapine (Viramune)

•Lopinavir/ritonavir (Kaletra)

•Rifampin (a drug to prevent mycobacterium

avium complex, a serious bacterial infection,

in HIV­positive clients)

•Amprenavir (Agenerase)

•Abacavir

•Ritonavir

TIP 37, Substance Abuse Treatment for

Persons With HIV/AIDS (CSAT 2000e) provides further information about substance

abuse treatment for patients with HIV/AIDS. 

Other Conditions

Cancer

Cancer occurrence is increased in people with

substance use disorders due to the carcinogenicity of the drugs used. Cigarette smoking

is linked to lung, larynx, oral cavity, esophagus, stomach, bladder, and pancreatic cancer. Heavy alcohol consumption is associated

with an increased incidence of oral, pharyngeal, esophageal, laryngeal, respiratory tract,

and breast cancer (Polednak 2005).

Synergism is seen with alcohol and smoking

being associated with even higher risks of

cancer (Fagerstrom 2002). A history of weight

134 Chapter 5
loss could suggest many chronic diseases,

though cancer should be considered in the

differential. There may be an increase in

head and neck cancers in persons with heavy

cannabis use (Donald 1991). Liver cancer

may be seen in patients with hepatitis C and

those using anabolic steroids (Socas et al.

2005). There is a particular interrelationship

among alcohol intake, hepatitis C, and hepatocellular carcinoma (Yoshihara et al. 1998).

Diabetes

Patients who use drugs intravenously may

experience infections that affect diabetic control, though any infection in any detoxification

patient needs to be addressed both from an

infectious disease and diabetic viewpoint.

Special considerations

Several medications can lead to impaired glucose tolerance and an elevated serum glucose

(Garber 1994). Some examples include

•Thiazide diuretics

•Clonidine

•Glucocorticoids

•Haloperidol

•Lithium carbonate

•Phenothiazines

•Tricyclic antidepressants

•Indomethacin

•Olanzapine

•Risperdol

Antidiabetic agents in concert with alcohol may

produce hypoglycemia and lactic acidosis.

Diabetes mellitus also is seen in patients who

present with new­onset hyperglycemia (elevated

glucose) or with a history of diabetes and poor

control.

Acute trauma/fractures

Acute trauma/fractures can be seen in any

patient with a substance use disorder due to an

altered level of consciousness or impaired gait

when intoxicated. Patients with substance use

disorders appear to be particularly prone to

accidents of all kinds, with a spectrum of complications from head trauma to falls with fractures. Chronic pain frequently is seen in

patients as a result of trauma (treated or

untreated), poor health maintenance, or an

inability to deal with pain without drug use.

Chronic pain treatment and the issues of opioid

use have to be considered for each patient on

an individual basis.

The surgeon should

consider drug withdrawal in the differential diagnosis of

any physical or neurologic symptoms or Certain HIV

medications can

cause an increased

metabolism of

methadone.

signs that emerge

during the perioperative period. There

is a two­ to threefold

increase in postoperative morbidity in

patients with alcohol

use disorders, the

most frequent complications being
 

infections, bleeding,
 

cardiopulmonary
 

insufficiency, and
 

withdrawal complications (Tonnesen and Kehlet 1999).
 

Special considerations

Opioids may be used to control pain in the initial period of trauma. Detoxification protocols

should be started prior to anticipated surgery

and continued throughout the perioperative

period. Pain that causes an increased heart

rate, as well as postoperative temperature elevation, may impact the detoxification parameters.

Due to tolerance to opioids, the daily

methadone dose in a methadone­maintained

individual will not serve as an analgesic for

pain relief from surgical or other illnesses.

Full therapeutic doses of analgesic drugs

should be given to methadone­maintained

Co­Occurring Medical and Psychiatric Conditions  135
patients who have co­occurring painful conditions (CSAT 2005d; Ho and Dole 1979).

Since most medications for pain management

are drugs with a high abuse potential, programs may need to alter their policies regarding the use of such drugs. Pain patients do

not require detoxification from prescribed

medications unless they meet the criteria for

opioid abuse or dependence described in the

American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition. Treatments for

pain include physical therapy, transcutaneous

electrical nerve stimulation, and therapeutic

heat and cold.

Trials of nonsteroidal anti­inflammatory agents or

nerve block should

The effects of

drug toxicity and

withdrawal often

can mimic

psychiatric

disorders.	 

be considered prior

to the use of highly

addictive and abusable medications.

The use of

acetaminophen in

the patient with an

alcohol use disorder

always has been

questioned, especially if there is evidence of liver disease. However, a

review article of the

medical literature

showed that repeated ingestion of a therapeutic dose of

acetaminophen over 48 hours by patients with

severe alcoholism did not produce an increase

in hepatic aminotransferase enzyme levels or

any clinical manifestations as compared to a

placebo group (Dart et al. 2000).

Treatment of 

Co­Occurring

Psychiatric Conditions

Pharmacological agents can be used as indicated for co­occurring psychiatric conditions

in patients with substance use disorders.

Incidence of the co­occurrence of psychiatric

conditions and substance use disorders is

high; moreover, there is a higher rate of psychiatric conditions in patients dependent on

alcohol than that found in the general population (Kessler et al. 2003; Modesto­Lowe and

Kranzler 1999). 

Comorbidity of substance use and co­occurring mental disorders serves to complicate

diagnosis and treatment for patients (Salloum

and Thase 2000). It is difficult to accurately

access underlying psychopathology in a person undergoing detoxification. The effects of

drug toxicity and withdrawal often can mimic

psychiatric disorders. For this reason, it may

be best to conduct psychiatric evaluations

after several weeks of abstinence; however,

this should be weighed against the time an

individual has been in detoxification and

what treatment plan is set up for him. Some

patients also present to detoxification while

taking medications to treat underlying psychiatric disorders, such as depression and anxiety. The risk of not treating a severe comorbid psychiatric disorder predisposes the

patient to relapse; the decision needs to be

weighed against the risk of prescribing medications when the clinician is not entirely certain that a comorbid condition exists. If a

period of recent extended abstinence exists,

the patient’s mental condition when abstinent

can be better evaluated.

Although it is the philosophy of some physicians to discontinue all psychiatric medications upon entering a detoxification program,

this course of action is not always in the best

interest of the patient. Abrupt cessation of

psychotherapeutic medications may cause

withdrawal symptoms or the re­emergence of

the psychiatric disorder. As a general rule,

136	 Chapter 5
   

therapeutic doses of medications should be

continued through any withdrawal if the

patient has been taking the medication as prescribed. Decisions about discontinuing medications should be deferred until after the

individual has completed detoxification. If,

however, the patient has been abusing a medication or the psychiatric symptoms were

clearly caused by substance abuse, then the

rationale for discontinuing the medication is

strengthened. Finally, practitioners should

consider withholding medications that lower

the seizure threshold (e.g., bupropion or conventional antipsychotics) during the acute

alcohol withdrawal period, or at a minimum

prescribing a loading dose or scheduled taper

of benzodiazepine.

During detoxification, some patients decompensate and lapse into psychosis, depression,

or severe anxiety. In such cases, careful

observation of the withdrawal medication regimen is of paramount importance. If the

decompensation is a result of inadequate dosing with withdrawal medication, the appropriate response is to increase the dose of medication. If it appears that the withdrawal

medication is adequate, other medications

may be needed. Before choosing such an

alternative, it is important to take into

account additional considerations, such as the

side effects of the added medication and the

possibility of interaction with the withdrawal

medication. 

A patient with psychosis may need to take

neuroleptics. Medications that have a minimal

effect on the seizure threshold are recommended, particularly if the patient is being

withdrawn from alcohol or benzodiazepines.

Small, frequent doses of Haldol, such as 1mg

every 2 hours, may be used until the patient’s

symptoms of psychosis begin to disappear.

The case for emergency use of antidepressants is weaker than for other psychiatric

medications because of the 2­ to 3­week lag

time between initiation of medication and

therapeutic response. After detoxification,

the patient’s need for medication should be

reassessed. A trial without medications sometimes is the best way to assess the patient’s

need for the medication; however, it may not

be the best practice or in the best interest of

the patient, particularly for those with a serious mental illness. For more information on

working with patients with co­occurring substance use and mental disorders, see TIP 42,

Substance Abuse Treatment for Persons With

Co­Occurring Disorders (CSAT 2005c).

Treatment for Co­Occurring

Conditions

The treatment of substance use disorders can

be difficult without adequate treatment of any

co­occurring mental disorders. For instance,

a patient with schizophrenia who is hallucinating and delusional, but who also abuses

substances, cannot participate in substance

abuse treatment without adequate control

over the psychosis. Likewise, patients with

mania who are euphoric and delusional,

patients who are depressed, or patients with

agoraphobia who also have a substance use

disorder, will have difficulty cooperating with

substance abuse treatment. Treatment of the

substance use disorder is necessary to

improve the course of both the substance

abuse and co­occurring mental disorder.

Psychotherapy should serve as one aspect of

rehabilitation, initially focused around

relapse prevention (Aviram et al. 2001).

Highly effective treatment programs may

include a combination of therapeutic techniques. Programs should be long­term and

approach recovery in stages. Drake and colleagues (2001) suggest that treatment for cooccurring substance use and other mental disorders include skill building, illness management, cultural sensitivity, and support to

patients for the pursuit of practical goals. 

Limitations of pharmacological agents in persons with

substance dependence

Pharmacologic agents have limitations in the

population of persons with substance use disCo­Occurring Medical and Psychiatric Conditions  137
   

           

           

         

           

         

orders. Medications may impair cognition and

blunt feelings, sometimes subtly. Clinicians

treating substance use disorders advocate

that clients need clear thinking and access to

emotions in order to make fundamental

changes in themselves. A person recovering

from a substance use disorder must take an

active part in changing attitudes and abandoning a long­held belief that alcohol or other

drugs can “treat” life problems and uncomfortable psychological states. Although these

are potential risks, the intent of pharmacotherapy is to enhance a person’s ability to

sustain abstinence and benefit fully from concurrent psychosocial interventions and treatments. Still, many psychiatric disorders, if

untreated, result in mood, anxiety, or thought

disorders that prevent or retard the behavioral changes necessary to recover from substance use disorders.

Risks versus benefits of pharmacological

agents need to be considered carefully.

Untreated anxiety, mood, or thought disorders can be powerful relapse triggers, especially for people with a long­standing pattern

of relying on alcohol or other drugs to manage their symptoms. In many instances, the

benefits and reduced relapse risk that appropriate pharmacotherapy can provide far outweighs the risk of taking medications. Some

clinicians believe that the “no pain, no gain”

approach has far greater risk of interfering

with recovery than of promoting it. Symptoms

such as anxiety and depression in persons

recovering from substance use disorders

might be vital to recovery, and pharmacotherapy to treat such symptoms needs to be

considered carefully in this context.

Clinically, anxiety and depression can provide the motivation to change when the

patient otherwise has little awareness of the

need to alter behavior. 

Standard of Care for

Co­Occurring

Psychiatric Conditions

After detoxification and stabilization with

pharmacologic agents, the current treatment

of choice for substance use disorders is nonpharmacologic. Further, several studies have

shown that treating substance use disorders

with abstinence alone results in improvement

of the psychiatric syndromes associated with

the substance use (Anderson and Kiefer

2004). Severe syndromes induced by alcohol

that may otherwise meet criteria for major

depressive and anxiety disorders are best

classified as substance­induced disorders if

they resolve within days to weeks with abstinence. Likewise, manic syndromes induced by

cocaine resolve within hours to days, and

schizophrenia­like syndromes (e.g., hallucinations and delusions) induced by cocaine and

PCP often resolve within days to weeks with

abstinence.

Further studies are needed to confirm the

clinical experience that psychiatric symptoms

(including anxiety, depression, and personality disorders) respond to specific treatment of

the addiction. For example, cognitive–behavioral techniques employed in the 12­Step

treatment approach have been effective in the

management of anxiety and depression associated with addiction. Although challenging,

treatment of both addiction and co­occurring

psychiatric conditions has proven cost­effective in some studies (Goldsmith 1999).

Psychotropics for Co­Occurring

Psychiatric Conditions

General aspects

Because alcohol and other drugs can induce

almost any psychiatric symptom or sign or

mimic any psychiatric disorder, their effects

always must be considered before a co­occurring condition diagnosis is established or

treated.

138 Chapter 5
With an understanding of the interactions

between substance use and other mental disorders, a rational approach can be applied to

the use of pharmacologic therapies in cooccurring conditions. The use of medications

for psychiatric symptoms should begin only

after the knowledge of the natural history of

the addictive disorder and other psychiatric

disorders is clarified. Further, it is important

to be able to identify the respective roles of

substance use and other mental disorders in

the generation of psychiatric symptoms. 

Generally, substance­induced psychiatric

symptoms resolve within days to weeks of

abstinence. In many studies, the prevalence

rates for anxiety and affective disorders in

persons dependent on alcohol were not

greater than those for persons not dependent

on alcohol (Schneider et al. 2001).

A retrospective history of psychiatric symptoms often can lead to an inflated diagnosis of

these conditions because of rationalizations

regarding drinking and drug use by the individual. Typically, psychiatric symptoms are

emphasized by both the patient and the psychiatric examiner. 

Longitudinal observation frequently clarifies

the role of alcohol and other drugs in the production of anxiety, affective, psychotic, or

personality symptoms, particularly if objective criteria are relied on in addition to the

subjective report of the person who is addicted. Also, specific treatment of substance use

disorders can result in improvement of mood,

psychotic behavior, and personality disturbances if related to the alcohol or other drug

use. Mood lability and personality states can

be a manifestation of substance use disorders,

and treatment of the addictive disorder can

lead to stabilization of these psychiatric

symptoms. 

Furthermore, treatment plans and efficacy

may rely on the gender of the patient. Women

with a substance use disorder appear to have

higher rates of co­occurring mental disorders,

such as depression and anxiety, as well as

higher rates of physical and sexual abuse,

panic and phobia disorders, posttraumatic

stress disorder, victimization, and eating disorders. Deficits in the management of mood

disturbances may be self­medicated through

alcohol consumption in females. It has been

proposed that the outcomes of substance

abuse in women are different when compared

to those of men. For these reasons, the efficacy of treatment for substance use disorders

needs to be assessed independently for both

genders (Becker and Walton­Moss 2001;

Brady and Randall 1999).

Anxiety

Disorders Major depressive

and anxiety

disorders are best

classified as

substance­induced

disorders if they

resolve within

days to weeks with

abstinence.

General

approach

Prevalence rates for

the co­occurrence of

anxiety and substance use disorders

in the general population range from 5

to 20 percent in epidemiologic and clinical studies

(Merikangas et al.

1996).

Some antianxiety

agents can oversedate and dull the

individual’s reaction

to internal and external influences. Because

anxiety in recovery can be critically important for emotional growth, the individual will

feel a certain amount of anxiety to motivate

change in behavior, attitudes, and emotions.

(The expression “emotional growth” is related

to the anxiety or discomfort a recovering individual feels while undergoing the process of

change to reach a more mature state.) It is

important for the clinician to distinguish

between anxiety that can promote growth and

anxiety that can impair a person’s ability to

make change. Adapting behavior in response

to anxiety or other emotion requires coping

Co­Occurring Medical and Psychiatric Conditions  139
skills that may not be available to persons in

early recovery. A fully symptomatic anxiety

disorder may significantly limit a person’s

capacity to learn nonpharmacological coping

strategies. Medications with minimal addiction potential can be helpful and in some

cases necessary if patients are to make

progress in their recovery.

Depressants (e.g., alcohol) can produce anxiety during withdrawal, and stimulants (e.g.,

cocaine) can produce anxiety during intoxication. Because people with substance use disorders are in a relatively constant state of

withdrawal (it is

impossible to maintain a constant

blood level), they

regularly experiMedication is

indicated when

the anxiety is	 

preventing the

patient from

participating in

treatment.	 

ence anxiety as the

result of pharmacological withdrawal

from dependence.

As the substance

abuse becomes

more chronic, the

anxiety produced

by withdrawal from

pharmacologic

dependence can

become increasingly

severe. Relapse

and/or periods of

abstinence (sometimes prolonged—

for weeks or

months) should be

considered (confirm

abstinence with laboratory drug testing, if

necessary) before the effects of depressant or

stimulant drugs in inducing anxiety can be

ruled out. It can take weeks or months for

these effects to subside completely, although a

period of only a few days to weeks often is

sufficient in clinical practice. 

Treatment is indicated when the anxiety persists after adequate effort in a substance

abuse treatment program, or when the clinician suspects that anxiety is preventing the

patient from participating in treatment. A

thorough evaluation to assess whether the

individual is abstinent, involved in continuing

treatment, and/or attending self­help meetings

usually is necessary before a diagnosis of a

co­occurring psychiatric condition can be definitely established. After such an evaluation,

treatment of the anxiety disorder can proceed

separately from similar symptoms arising

from the addictive disorder. 

Pharmacologic therapies

The ideal medication works against abnormal

anxiety but not against the “normal” anxiety

needed for recovery. Some of the physical

symptoms of anxiety include sweating,

tremors, palpitations, muscle tension, and

increased urination. Psychological symptoms

include nervousness, feelings of dread or

impending doom, unpleasant tenseness, and

many more. 

The most common agents used in anxiety disorders are benzodiazepines and antidepressants. The benzodiazepines most frequently

used are alprazolam and lorazepam.

Diazepam and clonazepam are used less

often. Because the benzodiazepines can cause

significant problems in patients who are

addicted as well as in patients who are not

addicted, they generally are not recommended for people with substance use disorders or

for long­term treatment of anxiety or depressive disorders.

Antidepressants may be considered sooner if

depression is a known pre­existing condition

or historical experience and collateral information suggests a comorbid depression. Again

the risk of treating prematurely needs to be

weighed against the risk of not treating a condition that may prevent recovery from a substance use disorder. Antidepressants such as

imipramine and nortriptyline and selective

serotonin reuptake inhibitors (SSRIs) such as

fluoxetine (Prozac) have a low addiction

potential and can be used with relative safety.

They differ in their tendency to produce

sedation and anxiety and have a withdrawal

140	 Chapter 5
syndrome of their own. Because of its anticholinergic properties, imipramine is more

sedating, but nortriptyline and the SSRIs can

produce anxiousness in some individuals and

sedation in others. Not all individuals react

the same way to these medications. 

When medications are used, a specific target

symptom should be the focus. Also, medications should be tried in time­limited intervals,

such as weeks to months. A “drug holiday”

(i.e., a brief period where the patient stops

taking medications) should then be attempted

to see if the medication is still necessary. 

The patient should be instructed that the

medications will not “cure” the addiction,

that treatment of anxiety will not control the

addiction, and that treatment of the addiction

will not necessarily ameliorate the anxiety disorder. In essence, the substance use disorder

must be treated independently of the anxiety

disorder and vice versa.

Depressive Disorders

General approach

Prevalence rates for the co­occurrence of

depressive and addictive disorders range

from 5 to 25 percent in epidemiologic and

clinical studies. Depressive disorders include

major depressive and dysthymic disorders,

which can occur independently with addictive

disorders, or similar depressive symptoms

can be induced by substance use disorders.

Major depressive disorder is more common in

older individuals and in women and can be

difficult to distinguish from substanceinduced depression.

Depression can be viewed as protective and

can be associated with “healing” in many conditions involving emotions. For example, a

grief reaction is an expected experience after

loss, with depression an essential emotion in

this process. Recovery from a substance use

disorder has been compared to a grief reaction because of losses (e.g., of the substance

or relationships based on substance use) suffered by the patient with an addictive disorder. Likewise, and analogous to the role of

anxiety, depression also is a part of the healing process that the patient with a substance

use disorder experiences during recovery.

Depressant drugs (e.g., alcohol) can produce

depression during intoxication which often

resolves following abstinence. A survey of 69

adults with alcohol use disorders showed a

strong correlation between the reduction in

cravings for alcohol over 2 weeks of abstinence and the lifting of depressive mood. The

patients’ cravings were assessed with the

Obsessive­Compulsive Drinking Scale (OCDS)

and their depressive symptoms measured with

the Self­rating Depressive Scale (SDS).

Between day 1 and day 14, their cravings

score dropped nearly a third, while the scores

for severity of depression fell by about one

fourth. The correlation between the reduction

in cravings and the lifting of depression persisted after controlling for sex, age, duration

and extent of alcohol abuse, and the amount

of clomethiazole administered (Anderson and

Kiefer 2004).

Stimulant drugs (e.g., cocaine) can produce

depression during withdrawal. These effects

may be prolonged with certain drugs that

linger in the body (i.e., are stored in fat),

such as cannabis and benzodiazepines. These

drugs can produce depression or anxiety that

is indistinguishable from other psychiatric

causes of depression. Therefore, they must be

considered causative whenever depression is

present, and the possibility of addiction needs

to be assessed when these drugs are identified. While depression may persist for weeks

or months, it often resolves within days with

abstinence from these drugs. 

Pharmacologic therapies

The use of medication is recommended if the

depression persists beyond a few weeks of

drug withdrawal or arises during confirmed

abstinence (laboratory drug testing may be

necessary to confirm abstinence). The risk of

suppressing normal depressive processes durCo­Occurring Medical and Psychiatric Conditions  141
   

ing recovery versus the benefit from suppressing depression that is interfering with

function should be weighed, as is the case

with anxiety disorders.

Antidepressants are the main treatment for

depression. The target symptoms are a sad

mood, tearfulness, appetite and sleep disturbances, and other neurovegetative symptoms.

Depression can be found in many conditions,

including a variety of psychiatric and medical

conditions. SSRIs are the drug of choice for

many physicians treating depressed patients

with substance use disorders. Although some

are costly, they provide adequate treatment

of depression with fewer side effects than

other medications commonly used (Thase et

al. 2001).

Depressive disorders are thought to have a

significant biological component, including

deficiencies in such central nervous system

neurotransmitters as serotonin, norepinephrine, and dopamine. Interestingly,

these neurotransmitters are also affected by

substances of abuse. These agents are thought

to act by increasing the activity of these neurotransmitters, ultimately alleviating depression and stabilizing mood. 

Bipolar Disorders

General approach

Prevalence rates for the co­occurrence of

bipolar and addictive disorders range from 30

to 60 percent, depending on the population

studied, in epidemiologic and clinical studies

(Chen et al. 1998; Sallom and Thase 2000;

Sonne and Brady 1999; Strakowski and

DelBello 2000).

Mania is a condition associated with elevated

mood, grandiosity, hyperactive behavior,

poor judgment, and lack of insight. The

patient with mania will show excess such as

spending sprees, sexual promiscuity, intrusiveness, and abnormal alcohol and drug use.

A manic episode can follow, precede, or alternate with depressive moods.

Bipolar disorder may be complicated by the

influence of substances (Sonne and Brady

1999). The manic state can be produced by

stimulants (e.g., cocaine) during intoxication,

and from depressants (e.g., alcohol) during

withdrawal. A period of confirmed abstinence

usually is necessary before mood­stabilizing

drugs are started. Generally, a period of a

week or two may be required for the role of

drugs in inducing manic symptoms to be

properly assessed.

Pharmacologic therapies

Mood stabilizers control bipolar disorders in

patients with or without co­occurring substance use disorder. These medications can

control either the manic or depressed phase,

or both. 

Manic episodes can occur cyclically, alternatively, and concurrently with depressive

episodes. One theory of the pathogenesis of

bipolar disorder involves the neurotransmitter norepinephrine (i.e., excessive in mania

and deficient in depression).

Lithium is a natural salt, available in the carbonate form and slow release preparations.

Its exact mechanism of action is unknown,

but it can be effective in reducing or preventing the recurrence of manic and depressive

episodes. Lithium carbonate must be taken

daily in doses of 600 to 2,400mg to achieve

plasma levels in the 0.5 to 1.5­m equiv/L

range. It should be noted that studies have

shown that lithium has no conclusively positive effect on rates of abstinence in either

depressed or nondepressed patients.

Anticonvulsant mood stabilizers, such as

divalproex sodium and carbamazepine, can

be effective in controlling mania and, some

evidence suggests, in co­occurring addictive

conditions as well. Carbamazepine is known

to be as effective as some benzodiazepines in

inpatient treatment of alcohol withdrawal

and, because of its anticonvulsant properties,

it may be a good choice for treating those

patients at high risk of withdrawal seizures

142 Chapter 5
(Malcolm et al. 2001). One theoretical explanation for the mechanism of action for carbamazepine involves suppression of mood centers in the limbic system that act like seizure

foci. In this context, a “kindling” model has

been proposed for both mood and addictive

disorders (Gelenberg and Bassuk 1997).

Psychotic Disorders

General approach

Prevalence rates for co­occurrence of

schizophrenic and addictive disorders range

from 40 to 80 percent, depending on the population studied, in epidemiologic and clinical

studies.

Schizophrenia is a chronic illness characterized by bizarre thinking and behavior.

Hallucinations and delusions are “positive”

symptoms of the psychotic process, while

symptoms such as social withdrawal and

poverty of emotions are “negative” symptoms

(or deficit syndrome). Conventional neuroleptics are more effective for positive symptoms,

whereas behavioral, group, and individual

psychotherapy are more effective for negative

symptoms. New agents such as clozapine and

risperidone may be more effective in treating

both the positive and negative symptoms. 

Psychosis can be caused by stimulant drug

use during intoxication and depressant

drug/alcohol use during withdrawal. A period

of weeks or months may be necessary to

assess the effects of substances of abuse, but

as with anxiety, depression, or mania, medications can be started at almost any time as

the psychosis is persistent and waiting is not

possible. Moreover, the greater the number of

psychiatric admissions, the greater the probability of a chronic mental disorder associated

with the co­occurring psychiatric disorder.

High­ or moderate­potency neuroleptics (e.g.,

haloperidol or atypical agents) generally are

the agents of choice in the treatment of

schizophrenia. The clinical potency correlates

with the drug’s ability to block the action of

the neurotransmitter dopamine at its postsynaptic receptor sites.

Adverse

Effects

Antianxiety A period of

confirmed

abstinence usually

is necessary

before moodstabilizing drugs

are started.

agents

While benzodiazepines are useful

in the short term,

their efficacy wanes

with long­term use,

probably because of

the development of

pharmacologic tolerance and dependence. It should be

noted that benzodiazepines can be

addicting, particularly in those already

addicted to other

substances.

Antipsychotic agents 

Antipsychotics can produce sedation and

hypotension (at times causing lightheadedness

in some individuals), particularly with postural changes. Conventional neuroleptics produce acute extrapyramidal reactions, which

include pseudoparkinsonism, dystonia, and

akathisia. Dystonia usually responds to treatment with anticholinergic drugs such as benztropine or diphenhydramine. Akathisia is

the subjective feeling of anxiety and tension,

causing the patient to feel compelled to move

about restlessly. This symptom usually

requires beta blocker, as a decrease in the

antipsychotic dose does not have the desired

effect. Alternatively, switching to risperidone

may accomplish the intended effect while

avoiding intolerable neurologic syndromes. 

Co­Occurring Medical and Psychiatric Conditions  143
     

         

           

               

         

             

     

Antidepressants

Antidepressants, particularly the tricyclics,

can produce sedation, hypotension, syncope,

and other anticholinergic effects. The SSRIs

can produce anxiousness, sedation, insomnia,

and gastrointestinal upset. A withdrawal syndrome also has been reported with most

antidepressant medications.

The SSRIs are preferred in patients with

addiction and co­occurring psychiatric conditions because of their reduced side effect profile and low risk of dangerous drug interactions; for example, there are no anticholinergic effects on the senses and no risk of lethal

effects from overdose.

Cognitive State in Recovery

A person recovering from a substance use disorder must have a clear mind and a stable

mood. Medications have a tendency, sometimes subtly and other times obviously, to dull

the senses and thinking and blunt or disrupt

the emotions. People with substance use disorders must eventually change and control

feelings to remain abstinent and also to comply with psychiatric management. The ability

of a person with a substance use disorder to

use the 12 steps of Alcoholics Anonymous

(AA) and to accept psychiatric advice will

depend on clear thinking and emotional balance, which is stressed as central to the

recovery process in AA. In other cases—such

as patients with traumatic brain injuries—

treatment venues should be adaptable to their

cognitive abilities. 

Accordingly, the use of medications should be

conservative, taking into consideration the

pros and cons of their expected positive and

negative effects. Unfortunately, few psychiatric medications are totally free of moodaltering properties. However, the cognitive

state of individuals who have a serious mental

illness often is more distorted when not medicated appropriately. The very nature of their

illness is a disruption to their cognitive processes.

Dosing

Because of inherent susceptibility to drug

effects by people with substance use disorders,

it is important to use the lowest effective doses

possible. Also, the intervals for administration

should be selected to reduce effects on cognition and feelings.

144 Chapter 5
In This
 Chapter...
 

Preparing and
 

Developing a
 

Program
 

Working in
 

Today’s Managed
 

Care Environment
 

Preparing for the
 

Future
 

6 Financing and

Organizational

Issues

Preparing and Developing a

Program

Developing a detoxification program is a major financial challenge,

whether the program requires building an entirely new organization

or is part of an existing treatment entity. The process of program

development requires careful planning, especially to ensure adequate

financial support for the operation. The decision to develop a detoxification program should be based on a well­developed strategic planning process (see chapter 2) and a clear understanding of what a

detoxification program entails. Because the new program will incur

major costs for office space, furniture, staff, computers, and other

equipment before clients can be provided with services and payment

can be received, significant amounts of initial capital may be needed.

As soon as the administrator or planner identifies a market need for

detoxification services, potential fiscal support and other resources

should be identified and checked to see if such support is likely and

sufficient. Both implementation and initial operating costs must be

covered. It may be possible to find strategic partners who will provide

resources, work with the program planner, provide office space, or

help obtain funding. Community organizations that see a need for

establishing detoxification and treatment services are likely partners.

Locally based foundations and businesses also may be approached for

assistance with developing a program, especially if a case can be made

to the potential funder that ongoing costs can be covered from operations. 

It is important to have documented assurance from major referral

and payment sources that they will refer patients with information on

payment sources; that is, by the referral source, by a third party, or

145
   

         

         

           

           

           

           

           

           

         

   

           

     

           

by patients who have the documented financial resources to pay for detoxification treatment themselves. Signed contracts with

expected payors may be useful to ensure adequate cash flow and to establish a budget for

the new program’s fee structure. 

Identifying and recruiting strategic partners

is one of the most important steps in the program development process. Before and during

the program development process, administrators and planners should work closely with

potential referral and payment sources to

determine their needs and to see if the detoxification program will fit those needs.

Programs also will need to learn whether

referral sources are open to new partners, the

types of contracts they utilize, their timeframes for reimbursement, and the process

for negotiating a contract. Among useful tactics to employ is holding focus groups and

strategy meetings with individuals from

potential referral sources; these groups can

suggest the types of services they need and for

which they will reimburse. Potential referral

sources will be more invested in the program

if they are involved throughout the planning

process. All potential stakeholders should be

informed regularly of the developing plans

and milestones achieved. 

Program planners should follow up on all

potential leads for both funding sources and

potential referral sources. Relationships with

referral sources are important to build and

maintain. Obviously, referral sources need to

be carefully assessed to ensure that they can

provide patients who have needs and

resources appropriate for the services the

program will provide. Leads for potential

sources of funding and referrals may include

the contacts made during a focus group process, public system payors and planners, private insurance plans, contracting agents for

private insurance (e.g., managed care organizations [MCOs]), and local employers large

enough to have employee assistance programs

(EAPs) or managed behavioral health plans

that cover detoxification services. Direct contact with the EAPs or managed behavioral

health plans may be necessary to ensure both

private sector demand for services and

appropriate reimbursement of the services.

Forming strategic alliances with other components of the treatment environment can be

both an important source for referrals and a

resource for clients with needs other than

detoxification. Vertical alliances facilitate

referrals up and down the continuum of care.

An alliance with a larger organization can

increase leverage when negotiating with an

MCO. 

The Dramatically Changing

Pattern of Utilization of

Detoxification Services

The settings for detoxification services have

changed dramatically over the last decade, as

have patients’ primary substances of abuse. As

the setting for detoxification services has shifted from inpatient to outpatient, the primary

substance abuse problem of clients has shifted

from alcohol and cocaine/crack to heroin and

other opioids. This shift has created significant

opportunities in the market for detoxification

services for community­based and

entrepreneurial providers that are not part of

hospitals, or for freestanding detoxification

facilities that are owned by hospitals.

Changes in practice patterns and in the epidemiology of substance abuse in the last

decade have been dramatic. Between 1993

and 2000, the number of admissions to hospital inpatient settings for detoxification of

patients with a primary problem of alcohol

abuse declined by 79.6 percent. During the

same period, the total admissions to inpatient

hospital detoxification services declined by

69.3 percent, from 23.5 percent of total

detoxification admissions in 1993 to 8.8 percent of total detoxification admissions in

2000, while admissions to 24­hour free­standing detoxification units increased by the same

14.7 percentage points, from 60.5 percent of

total admissions in 1993 to 75.1 percent of

total admissions for detoxification services in

146 Chapter 6
2000. During this same period, the number of

alcohol admissions to free­standing clinics

decreased by 32.0 percent and the number of

cocaine/crack admissions decreased by 42.5

percent. Concurrently, heroin admissions (to

free­standing clinics) increased substantially

from just under a quarter of total detoxification admissions in 1993 to just over a third of

total admissions in 2000. 

Of course, these statistics reflect national

trends and regional differences in patterns of

both practice and substance abuse. Changes

in specific geographic areas will vary.

Prospective programs should carefully

research their own local market for detoxification services and should obtain data on

current utilization of and demand for detoxification in their local area before proceeding

with program development.

Funding Streams and Other

Resources in the Substance

Abuse Treatment Environment

Substance abuse treatment and detoxification

services in the United States are financed

through a diverse mix of public and private

sources, with substantially more being spent

by the public sector. Public sources account

for 64 percent of all substance abuse treatment spending, a much higher percentage

than public expenditure for the rest of health

care (Coffey et al. 2001). The existence of

diverse funding streams presents both management challenges and opportunities for program independence and stability. However, a

program with only one major funding source

is financially and clinically vulnerable to

changes in its major source’s budget and priorities, and this situation should be avoided.

Diversification of funding sources should be a

major goal for detoxification programs.

Usually, each funding stream has different

approval and reporting requirements.

Because of this, any new or existing detoxification program requires a fairly sophisticated

management and accounting system to meet

the reporting needs and performance requirements of each purchaser, to provide information that meets their requirements, and to

generate the appropriate bills/invoices.

Detoxification program administrators must

be knowledgeable about efficient business

practices, the use of data­based performance

measures, accounting, budgeting, financing,

and financial and clinical reporting.

It also is important to reach out to other

potential sources of support such as foundations, board members, and local or

national corporate Identifying and

recruiting

strategic partners

is one of the most

important steps in

the program

development

process.

donation programs

for any assistance

that will help to

reduce costs,

increase revenue, or

improve productivity

and effectiveness

and aid in the success of the organization. Searching for

support does not end

with ensuring initial

funding. Planners

must make good use

of the Internet to

uncover potential

cash and in­kind

donations that can

supplement major funding sources, discussed

below. 

Entrepreneurial, for­profit programs may be

able to attract private capital. Not­for­profit

entities that are similarly entrepreneurial

may be able to take advantage of this potential source of funding through establishment

of a for­profit subsidiary. Detoxification programs in particular, as opposed to some other

areas of substance abuse treatment, may be

attractive candidates for private financing

because of their potential to serve privately

insured and self­pay patients. However,

acceptance of private capital usually carries

with it requirements for rapid growth in revFinancing and Organizational Issues 147
enues and profitability that may be difficult

to meet and may limit operational flexibility,

at least in the short term. In the longer term,

successful detoxification programs may be

able to generate profits. 

Funding streams associated with public and

private health insurance often provide benefits to covered individuals that vary according

to whether or not the services are facilitybased and according to the level or

setting of care. The Substance

Abuse Prevention

and Treatment

Block Grant

program is the

cornerstone of

Federal funding

for substance

abuse treatment

and detoxification

programs.

Complexity arises

because coverage

and reimbursement

depend both on

whether a service is

considered to be a

medical service or a

substance abuse

treatment service

and whether a service is facility

based.

Many public and

private benefit

plans still classify

substance abuse

detoxification as a

medical rather than

a substance abuse

treatment service.

In general, and

especially for

employer­based

coverage, benefits under a medical plan are

provided at higher reimbursement rates with

fewer limits and restrictions than are benefits

for substance abuse treatment (Merrick et al.

2001). Requirements for out­of­pocket payments by those covered under these plans

typically are lower under the medical portion

of a plan than under the substance abuse

treatment portion. However, it is important

to note that benefit plan features are but one

component of coverage; utilization management procedures continue to play a very

important role in a patient’s access to specific

services. Any episode of detoxification may be

denied reimbursement under a plan if medical necessity is not demonstrated to the satisfaction of the plan or if the service is provided at a higher level of care than is judged

medically necessary.

It is important to decide whether to make a

new detoxification program hospital­based,

facility­based, or office­based. Services that

are considered hospital­ or facility­based, like

those in hospital outpatient departments,

often are eligible for higher payment rates

than office­based services to reflect their

greater capital and other overhead costs.

Similarly, hospital inpatient services often are

reimbursed at a higher payment rate than

outpatient services, but medical necessity

determinations also require patients to need

more intensive services. Sometimes, patient

copayments or coinsurance rates may be

higher for office­based services than facilitybased services. This is true for Medicare as

well as for other health insurance plans.

Detoxification programs that are parts of hospitals, affiliated with a hospital, or considered as a licensed facility themselves may be

eligible for higher rates of reimbursement

than are those that are considered to be outpatient programs with no facility license.

However, utilization management criteria to

authorize payment for admission to and continued stay in a hospital inpatient setting

require a significantly greater severity of

patient diagnosis than do criteria for admission and continued stay in a freestanding or

outpatient program. On the other hand, often

there are high barriers to obtaining a facility

license to open a freestanding 24­hour facility

or licensed outpatient detoxification facility.

Programs that are part of or affiliated with

hospitals also must contend with overhead

cost allocations from the hospital as well as

with oversight from hospital administrators

who may know little about substance abuse

treatment or detoxification. In addition, some

health insurance plans actually exclude coverage for hospital­based or freestanding facility­based detoxification programs and others

may subject admissions to such programs to

148 Chapter 6
more intensive review than admissions to

non–facility­based detoxification programs.

Program planners should consider carefully

all alternatives; decisions concerning affiliation with a hospital or pursuit of a facility

license have far­reaching financial and political ramifications and should be made with as

much information as possible.

Following is a discussion of the key funding

streams and resources that are available for

programs providing detoxification services.

SAPT Block Grant

The Substance Abuse Prevention and

Treatment (SAPT) Block Grant program is

the cornerstone of Federal funding for substance abuse treatment and detoxification

programs. These funds are sent to the State’s

Single State Agency (SSA) for substance

abuse for distribution to counties, municipalities, and designated programs. Some of the

funds are subject to required set­asides for

special populations. Each program should

check to see if the clients it intends to serve

are eligible for block grant funding, either for

set­asides or for other funds. Each State

maintains its own criteria for eligibility and

the criteria and definitions vary greatly

among States. Multistate providers will need

to check specifically in each State in which

they operate.

The Substance Abuse and Mental Health

Services Administration (SAMHSA) provides

funding for substance abuse treatment and

prevention through the block grants as well as

a large variety of other mechanisms, including both discretionary grants and contracts.

A portion of the SAMHSA Web site is devoted

to various funding opportunities.

The most recent available data indicate that

the SAPT Block Grant accounts for approximately 40 percent of public funds nationally

expended for prevention and treatment of

substance abuse (U.S. Department of Health

and Human Services 2003). Funds from the

block grant may come directly from the SSA

or be channeled through regional or county

intermediary agencies. Services may be paid

for through grants, contracts, fee­for­service,

and/or managed care arrangements. The

Children’s Health Act of 2000 mandated a

gradual transition from SAPT Block Grants

to Performance Partnership Grants (PPGs).

Providers should follow developments

through their SSA, which include

•Changes in reimbursement. Treatment

purchasing systems may evolve over time;

managed care arrangements and requirements are increasingly common. 

•Performance outcome data. In accordance

with Federal legislation, PPGs eventually

will replace SAPT Block Grants and will

provide more flexibility for States as well as

require more accountability based on outcome and other performance data.

Substance Abuse and Mental Health

Services Administration (SAMHSA) and the

States are establishing performance outcome measures for funding programs under

the block grants. All data for core measures

are collected from States receiving PPG

dollars.

Medicaid

Medicaid, administered by the Centers for

Medicare and Medicaid Services (CMS) in

conjunction with the States, provides financial assistance to States to pay for medical

care of specifically defined eligible persons.

Medicaid is being used by many States as a

vehicle for experimentation with public sector

managed care in an effort to expand medical

coverage to the uninsured. About 2 percent of

total Medicaid expenditures nationally are for

substance abuse treatment services (Mark et

al. 2003a) but Medicaid supports about 20

percent of national expenditures for substance abuse services (Coffey et al. 2001). The

level of expenditure varies greatly by State.

Medicaid is an entitlement program with several distinct eligible groups: low­income children, pregnant women, the elderly, and people who are blind or disabled, all or some of

whom can be enrolled in a detoxification program population. Some substance abuse

treatment programs will want to target proFinancing and Organizational Issues 149
         

         

           

     

         

           

           

         

             

           

           

       

           

           

   

           

           

         

           

           

     

           

       

           

       

             

grams to the Medicaid population; if the

State’s coverage and payment rates are minimal, however, other funders should be

explored in greater depth.

The reason for substantial variation in State

Medicaid expenditures and coverage is that

substance abuse treatment and rehabilitation

is an optional benefit under Medicaid that

States have the discretion to include or not

include in their Medicaid program. Medicaid

may pay for substance abuse treatment either

directly through fee­for­service arrangements

or through a managed behavioral health care

or other MCO with which it contracts. More

than one type of arrangement may exist within the same State. Rates of payment/reimbursement are determined by each State independently and may vary within the State

among the various coverage arrangements. If

a State decides to include benefits for substance abuse treatment in its Medicaid program, it can choose the precise services and

levels of care that will be reimbursed. The

services provided under managed care may

differ from those under fee­for­service

arrangements. Although most States offer

some coverage for detoxification services

under their Medicaid program (Office of the

Inspector General 1998), not all types or settings for detoxification programs are covered

in those States that do provide coverage.

Therefore, a State Medicaid program may

cover certain substance abuse treatment services but not cover detoxification services.

For more information, readers should contact

their State Medicaid office. 

An important distinction of the Medicaid benefit structure since its inception has been the

exclusion of coverage for services provided in

an Institute for Mental Disorders (IMD),

defined as a facility with more than 16 beds

that treats mental disorders, including substance abuse, for individuals between the ages

of 21 and 64 (Rosenbaum et al. 2002).

Although services furnished by outpatient

detoxification programs are not excluded,

detoxification programs should be aware of

the IMD exclusion in their program planning

process.

The Medicaid Early Periodic Screening

Detection and Treatment (EPSDT) mandate

requires States to screen all children and adolescents on Medicaid for physical and behavioral health disorders. Further, EPSDT

requires that any needed medical treatment is

provided to children, even if the service is not

in the State’s Medicaid plan submitted to

CMS. Although the procedures and screening

tools vary by State, and there is significant

variation in their identification of substance

abuse issues, the EPSDT program is an

important entrance to substance abuse treatment for children and adolescents (Semansky

et al. 2003).

When available, Medicaid coverage offers the

following advantages:

•It can provide significant treatment funding

for certain high­risk groups, such as lowincome mothers and adolescents.

•Client copays traditionally have not been

required so the program receives the entire

negotiated fee without having to collect funds

from clients. (However, some States have

changed this provision due to budget crises.)

•A Medicaid contract can provide a useful

lower limit for rate negotiations with commercial payors by essentially prohibiting

acceptance of contract terms with any other

purchaser at rates lower than those established for Medicaid.

•Certification as a Medicaid provider also can

position the program to receive patients from

other public sector referral sources, making

it possible to obtain patients from sources

such as social services, indigent care funds,

and criminal justice systems.

•The criminal justice and juvenile justice systems and drug court administrators typically

favor providers that are eligible for Medicaid

reimbursement because treatment of some

offenders can then be billed to Medicaid in

some States.

150 Chapter 6
Medicaid link to

Supplemental Security

Income

Supplemental Security Income (SSI) is a program financed through general tax revenues.

SSI recipients are one of the mandated populations for Medicaid, but specific provisions

vary by State. SSI disability benefits are

payable to adults or children who are blind

or have certain other disabilities that make it

impossible for them to work, who have limited income and resources, who meet the living

arrangement requirements, and who are otherwise eligible. Congress has excluded a primary diagnosis of substance abuse as a qualifying disability under the Social Security

Administration’s programs, but if there is

another primary disability that qualifies the

person for SSI, a secondary substance abuse

diagnosis remains acceptable. Many SSI

recipients with a mental disorder diagnosis

have a co­occurring substance abuse 

diagnosis.

Medicare

Medicare provides coverage to individuals

over age 65, people under the age of 65 with

certified disabilities, and people with endstage renal disease. Medicare supports about

8 percent of national expenditures for substance abuse treatment services. Medicare

may provide Part A coverage to clients in

detoxification programs that are based in hospitals certified by Medicare. However, detoxification programs that provide only a structured environment, socialization, and/or

vocational rehabilitation are not covered by

Medicare. Medicare imposes very strict

review requirements for detoxification programs based in hospitals and detoxification

programs that are considered to be partial

hospitalization programs, and for patients in

those detoxification programs. Alternatively,

Medicare may provide Part B coverage to

clients in detoxification programs with

Medicare­certified medical practitioners;

however, clients whose services are reimbursed under Part B are required to pay 50

percent of Medicare­approved amounts. For

more information, contact the Social Security

Administration, Medicare provider enrollment

department, or State Medicare services.

Medicare link to Social

Security Disability Insurance

The Social Security Administration provides

Social Security Disability Insurance (SSDI) to

individuals and certain members of

their family if they Medicaid supports

about 20 percent

and Medicare

supports about

8 percent
 

of national
 

expenditures for
 

substance abuse

treatment

services.

have worked long

enough and paid

Social Security

taxes. Recipients of

SSDI benefits are

covered by Medicare

following a 2­year
 

waiting period. SSDI
 

is a program

financed with Social
 

Security taxes paid

by workers, employers, and selfemployed persons.
 

In order to be eligible for a Social

Security benefit, the

worker must earn

sufficient credits

based on taxable

work. Disability

benefits are payable

to disabled workers, disabled widow(er)s, or

adults disabled since childhood, who are otherwise eligible. A substance abuse diagnosis

was excluded by Congress as a qualifying disability for SSDI, but a secondary substance

abuse diagnosis is acceptable if the person is

qualified by another primary diagnosis, such

as mental illness, which often co­occurs. 

Financing and Organizational Issues 151
State Children’s Health
 

Insurance Program
 

The State Children’s Health Insurance

Program (SCHIP) provides funds for substance abuse treatment of children and adolescents in many States. This program provides low­cost health insurance for children

of low­income families who are not eligible for Medicaid. Substance abuse

treatment and

detoxification	 

services in the

United States are

funded through a

diverse mix of

public and private	 

sources.	 

States have the

option of providing

SCHIP benefits

under their existing

Medicaid program

or designing a separate children’s

health insurance

program entirely

separate from

Medicaid. If the

program is part of

Medicaid, then the

substance abuse

benefits will mirror

those under

Medicaid. If the

State designs its

own program, CMS

has promulgated a

set of rules to

ensure that coverage meets minimum standards. A State’s Alcohol and Drug Abuse

Agency also may be able to provide information on resources available for treatment of

transition­age youth who have exceeded the

maximum age for the SCHIP program in the

State. For more information see the State

SCHIP program office.

TRICARE

TRICARE is a regionally managed health

care program for active duty and retired

members of the uniformed services and their

families and survivors. TRICARE supplements the healthcare resources of the Army,

Navy, and Air Force with networks of civilian

healthcare professionals. TRICARE consists

of TRICARE Prime, where Military

Treatment Facilities are the principal source

of health care; TRICARE Extra, a preferred

provider option; and TRICARE Standard, a

fee­for­service option that replaced the program formerly known as CHAMPUS. The

TRICARE Extra and Standard benefits

include treatment for substance abuse, subject to preauthorization requirements, but

programs will need to check to see if detoxification programs are eligible or preauthorized

under TRICARE managed care arrangements. TRICARE is run by managed care

contractors, each of whom may have different

authorization procedures. 

Indian Health Service

The Indian Health Service (IHS) is an agency

within the Department of Health and Human

Services that operates a comprehensive health

service delivery system for approximately 1.6

million of the Nation’s estimated 2.6 million

American Indians and Alaska Natives. Most

IHS funds are appropriated for American

Indians who live on or near reservations.

Congress also has authorized programs that

provide some access to care for Indians who

live in urban areas. IHS services are provided directly and through tribally contracted

and operated health programs. Health services also include health care purchased from

more than 9,000 private providers annually.

The IHS behavioral health program supports

alcoholism and other drug dependency treatment, detoxification, rehabilitation, and prevention services for individuals and their

families.

Department of Veterans

Affairs

The Department of Veterans Affairs provides

the Civilian Health and Medical Program of the

Veterans Administration to eligible beneficia152	 Chapter 6
         

           

           

           

         

         

         

         

         

           

       

         

             

           

ries. Medically necessary treatment of substance abuse is a covered benefit; beneficiaries

are entitled to three substance use disorder

treatment benefit periods in their lifetimes.

Social Services

Funding for substance abuse treatment,

which may include detoxification services,

also may be available through arrangements

with agencies funded by the U.S. Departments of Labor, Housing and Urban

Development (HUD), and Education (ED).

Some Federal sources of funding for substance abuse treatment under these programs

may prohibit use of funds for “medical” services. However, services performed by those

not in the medical profession (e.g., counselors, technicians, social workers, psychologists) and services not provided in a hospital

or clinic (including 24­hour care programs)

may be considered nonmedical. The precise

definition of “medical” under some of these

Federal programs may be determined by each

State individually, so administrators need to

check with their State authorities to determine exactly which services may be funded

through these sources. Even if funding for

detoxification services is not available

through these programs, programs may be

able to link their clients to them for support

for services that enable them to initiate and

complete treatment successfully. Opportunities include the following:

•Temporary Assistance to Needy Families

(TANF). Under the TANF programs, each

State receives a Federal block grant to fund

treatment for eligible unemployed persons

and their children, usually women with

dependent children. Services that overcome

barriers to employment (e.g., substance

abuse treatment) are eligible for formula

grants—with one quarter of the money allocated to local communities through a competitive grant process. The funding channels vary by State. Funds may be directed

through Private Industry Councils,

Workforce Investment Boards, Workforce

Development Boards, and similar bodies at

the State and community levels. Although

States may not use TANF funds for “medical” services, States have considerable latitude in the definition of “medical,” and

have used TANF funds to support the following substance abuse treatment services:

screening/assessment, detoxification, outpatient treatment, non­hospital residential

treatment, case management, education/

prevention, housing, employment services,

and monitoring (Rubinstein 2002). Even if

these funds are not available for substance

abuse treatment in a State or program, the

program’s clients may be able to access this

source of assistance for employment training, child care, and other support needs. 

•Social Services Block Grant. Under Title

XX of the Social Security Act, the

Administration for Children and Families

provides a block grant to each State for the

purpose of furnishing social services. Funds

may not be used for medical services

(except initial detoxification of an individual who is alcohol or drug dependent). In

2002, these funds provided close to $8 million for substance abuse treatment in 14

States (Administration for Children and

Families 2002).

•Public housing. HUD funds substance

abuse treatment of public housing residents

under the Public Housing Drug Elimination

Program. HUD awards grants to public

housing authorities, tribes, or tribally designated housing entities to fund treatment.

Funds are channeled to local public housing

authorities, which contract with service

providers. In addition, special housing programs are available for people who are homeless and have substance use disorders.

•Vocational rehabilitation. Federal ED

funds support services that help people with

disabilities participate in the workforce.

Treatment of substance use disorders is eligible for funding. Funds are channeled to

Financing and Organizational Issues 153
       

         

             

         

         

             

               

         

           

           

         

             

         

   

         

           

           

           

               

           

         

             

           

       

         

           

    

the State agencies responsible for vocational

rehabilitation. 

•Children’s protective services. Title IV of

the Social Security Act provides funding

for foster care and services to prevent child

abuse and neglect. Eligible services include

substance abuse treatment for parents who

are ordered by a court to obtain treatment

and are at risk for losing custody of their

children. Medicaid also covers these children, as they are a mandatory eligibility

group.

•Ryan White. The Federal Ryan White

CARE Act, enacted in 1990, provides

health care for people with HIV disease.

Under Title I of the Ryan White CARE Act,

which provides emergency assistance to

Eligible Metropolitan Areas that are most

severely affected by the HIV/AIDS epidemic, funds are available for substance abuse

treatment. Over 500,000 people are served

through this program each year. 

Criminal justice/juvenile 

justice (CJ/JJ) systems

Both State and local CJ/JJ systems purchase

substance abuse treatment services. The manner in which these systems work varies across

locales. The following are common components

of these systems:

•State corrections systems may provide

funds for treatment of offenders who are

returning to the community, through parole

offices, halfway houses, or residential correctional facilities.

•Community corrections systems may

include a system of presentence diversion or

parole services, including drug court, that

may mandate substance abuse treatment in

lieu of incarceration.

•Community drug courts may send low­risk,

nonviolent offenders to substance abuse

treatment in lieu of incarceration—programs can be under contract to provide this

treatment.

•Correctional residential facilities serve

offenders returning from a State correctional system; the programs may extend contracts for substance abuse treatment to prevent relapse of treated offenders. 

•Juvenile court systems may provide contracts to programs with expertise in treating

adolescents to treat juvenile offenders in

correctional facilities or who are otherwise

involved in the criminal justice system.

Providers should understand the culture, values, and needs of the CJ/JJ system so they

can develop responsive services for this special needs population. For more information,

see TIP 21, Combining Alcohol and Other

Drug Abuse Treatment With Diversion for

Juveniles in the Justice System (CSAT

1995b), TIP 30, Continuity of Offender

Treatment for Substance Use Disorders From

Institution to Community (CSAT 1998b), and

TIP 44, Substance Abuse Treatment for

Adults in the Criminal Justice System (CSAT

2005b).

Byrne Formula Grant

Program

The Byrne Formula Grant Program awards

grants to States to improve the functioning

of the criminal justice system. Grants may

be used to provide rehabilitation of offenders who violate State and local laws. One of

the 26 Byrne Formula Grant purpose areas

is providing programs that identify and

meet the treatment needs of adult and juvenile offenders who are drug and alcohol

dependent. However, the availability of

Byrne Formula Grant funds depends on

annual Congressional appropriations and

declines have been proposed for funding in

recent years.

154 Chapter 6
County and local 

governments

County and local governments often contract

for the delivery of substance abuse treatment

services using locally available funds. The

annual availability of these funds depends in

part on State fiscal conditions.

Schools

Local public schools may be a source of funding for assessments; however, they rarely pay

for ongoing treatment. Some services may be

reimbursable under the special entitlements for

children with disabilities.

Private Payors

Private sources of revenue include a range of

entities from large MCOs to local or selfinsured national employers. Most health

plans offered by large employers operate

under managed care arrangements.

Sometimes, a health plan may cover some

substance abuse treatments under the mental

health benefit portion of their plan; others

may provide coverage through the medical

component. In many cases, substance abuse

treatment benefits, when offered, are provided through Managed Behavioral Healthcare

Organizations (MBHOs) (see “Working In

Today’s Managed Care Environment,” p.

157, for a more detailed discussion of managed care arrangements). Because substance

abuse coverage is a minor cost to employers,

accounting for about 0.4 percent of the cost

of health insurance overall (Schoenbaum et

al. 1998), it may be difficult to get employers’

attention, despite the high profile that substance abuse problems sometimes present. In

general, three broad categories of private

funding may be distinguished:

•Contracts with health plans, MCOs, and

MBHOs.

•Direct service contracts with local employers.

Local employers may contract directly with

substance abuse services providers if the benefits offered by their health plans are inadequate.

•Contracts with EAPs. Some employers have

EAPs that can provide direct service contracts for a particular detoxification program.

Contributions

By developing relationships with people in the

community, an administrator can find new

sources for support of capital and operations.

Even if a source is reluctant to provide funds to

support treatment

services directly,

other aspects of program development, Many public and

private benefit

plans still classify

detoxification as a

medical rather

than a substance

abuse treatment

service.

organizational

growth, and operations or equipment

may be eligible for

support. A variety of

support may be

available from

sources in the community, ranging from

financial support to

donations of time,

expertise, used or

low­cost furniture

and equipment, and

space for a variety of

activities. Some

potential sources

include

•Fundraisers. People who do fundraising

can help the program develop a campaign.

Many States and the District of Columbia

require that charitable organizations register and report to a governmental authority

before they solicit contributions in their

jurisdiction.

•Foundations and local charities. A program may qualify as a recipient of funds for

capital, operations, or other types of support such as board development from foundations, the Community Chest, United Way,

or other charities. 

Financing and Organizational Issues 155
             

     

         

           

         

           

         

     

   

           

     

         

     

           

       

       

           

             

           

           

           

•Alumni. Graduates from a program may

donate money to the program or provide

support for clients.

•Internships. Local colleges and universities

may need internship slots for their students

who are planning careers in human services.

•Volunteers. Some programs use volunteers

in various capacities. Sources include local

retirement organizations and faith­based

agencies. 

•Community groups. Faith­based agencies

and community centers may let the program

use rooms for meetings, alumni groups,

recovery support groups, or classes.

Community groups can contribute reading

materials, clothes, toys for clients’ children,

furniture, or computers.

•Local stores and vendors. Local businesses

may contribute useful supplies such as

snacks, office supplies, or even computers.

Research funding

In addition to SAMHSA’s other roles, such as

technical assistance, helping communities use

research findings to implement effective treatment programs, and funding of prevention and

treatment, the institutes of the National

Institutes of Health conduct research on best

practices in substance abuse treatment.

The Research Assistant

(http://www.theresearchassistant.com) may be

a helpful source for information. For current

funding opportunities, visit the National

Institute on Drug Abuse Web site

(http://www.nida.nih.gov) and the National

Institute on Alcohol Abuse and Alcoholism Web

site (http://www.niaaa.nih.gov).

Grants

Government agencies and private foundations

offer funding through competitive grants.

Grant money usually is designated for discrete

projects, such as creating a videotape on family

issues, providing childcare services in a program for women, enhancing the cultural competence of staff members, or treating underserved populations.

Writing grant applications requires special

skills. A program can hire a consultant to

write the application or use its own planning

or research staff, if available. Successful

grant applications address areas of genuine

need, propose ideas worthy of support,

express these ideas well, and explicitly follow

the requirements of the request for application or proposal. To design a fundable project, the program may need to establish links

with other resources. Each donor agency or

foundation has its own application format

and requirements that should be followed

exactly. It is especially important when using

a consultant to have program staff closely

involved in the process of developing a grant

application to ensure that affirmations in the

application are completely aligned with agency capabilities. Programs that fail to involve

their own staff in the grant application process risk falling into the “implementation

trap” when a grant is awarded for projects

they are not prepared to perform. SAMHSA

offers a variety of resources to assist community­based organizations and others in developing successful grant applications. See the

text box on page 157 for sources of information on grants for treatment and detoxification programs.

Self­pay patients

Some patients pay for some or all of a course

of treatment themselves, without seeking

reimbursement from a third­party payor.

These patients may have no or inadequate

third­party coverage for substance abuse

treatment and are not eligible for public payment sources. Some patients who have coverage may prefer to pay out of their own pockets due to concerns about the confidentiality

of their information with their employer or

others. 

156 Chapter 6
Working in Today’s

Managed Care

Environment

All healthcare providers, including those who

provide substance abuse treatment services,

increasingly operate in a world in which care

is managed in all sectors, both public and private. Among individuals covered by employer-sponsored benefits in 2003, 95 percent

were covered under managed care arrangements (Kaiser Family Foundation and Health

Research and Educational Trust 2003). The

penetration of managed care into employersponsored health plans is relatively new; as

recently as 1993, 46 percent were covered by

indemnity plans. It is estimated that more

than 160 million Americans have their behavioral health care (treatment for substance use

and mental disorders) covered by a managed

behavioral health care organization (Oss and

Clary 1999). Although managed care penetration is lower in public programs than in

employer-sponsored programs, it is still significant; in 2002, 58 percent of the Medicaid

population was enrolled in managed care

arrangements (CMS 2002). Many States also

operate MCOs not connected with Medicaid

for provision of substance abuse treatment

services. 

Behavioral health care carve-outs, so named

because management of substance abuse

treatment and mental health benefits are separated (carved out) from the provision and

management of other healthcare services, are

now the dominant approach to managed care

for mental health treatment. However, this is

not the case for substance abuse; many

behavioral health carve-outs retain substance

abuse coverage in the medical MCO. The

“carve-in” approach, which theoretically

integrates traditional medical services with

services for substance use and other mental

disorders, is re-emerging but as of 2004 was

still relatively rare. Even when health plans

carve-in substance abuse services, they often

use a subcontracted specialty vendor or a

separate internal division with specialty

expertise to manage the carve-in benefits.

MCOs are becoming more prevalent in the

public sector. In 2002, 51 percent of all substance abuse treatment facilities had contracts with MCOs and even 39 percent of

facilities owned by State and local governments had such contracts (Office of Applied

Studies 2002b). By 1998, all but four States

had implemented some form of managed

behavioral health care in their public sector

treatment programs. However there is wide

variation among States and large counties in

the extent and form of reliance on managed

Financing and Organizational Issues 157

Where To Get Information on Grants

•SAMHSA provides information about the grants it provides at http://www.samhsa.gov/grants/block-grants.

Information on grants throughout the Federal government is available from http://www.grants.gov.

•The Web site http://www.cybergrants.com provides information about corporate foundations.

•The National Center on Addiction and Substance Abuse at Columbia University’s Web site at

http://www.casacolumbia.org provides links to several helpful sites.

•The Substance Abuse Funding Week provides public and private funding announcements for alcohol,

tobacco, and drug abuse programs. It is available by subscription in print.

•The Grantsmanship Center at http://www.tgci.com offers some useful information.

•The Non-Profit Resource Center, http://www.nprcenter.org/, has information on a variety of funding

sources.
care and in the vendors who operate such

programs on behalf of government or private

entities.

A distinct terminology has evolved in the

managed care industry—terms such as capitation, network, or staff­model as well as a

host of acronyms. 

Contracts Are Primary Tools

Managed care arrangements have four fundamental aspects with which all program administrators should be

familiar. First, an

arrangement begins

It is estimated that

more than 160

million Americans

have their

behavioral health

care (treatment

for substance use

and mental

disorders) covered	 

by a managed

behavioral health

care organization.

with a managed

care contract that

specifies the obligations of each party.

It should be noted

that small community providers may

have little or no

negotiating leverage

in the contracting

process; their only

decision may be

whether or not to

accept what is

offered, including

the rate of payment

and all other contract provisions.

Nevertheless, a

clear and detailed

understanding of

the contract is

required to ensure

successful performance. One key

aspect of any managed care contract

is the financial arrangement between the parties, including the basis for payment and the

amount of risk assumed by each party, if any.

Of course, some managed care contracts are

not risk­based. It is important to have someone with expertise and experience in managed

care contracts and financing examine any

proposed contract and make certain that the

financial components of the arrangement are

well understood by the program staff who

have financial responsibilities. 

Secondly, by negotiating and signing a managed care contract, a detoxification program

or its parent agency becomes a member of

that MCO’s managed care network. MCOs

generally have a network of contracted and

credentialed providers who supply services at

a negotiated rate to members who are

enrolled in the plans. Each organizational

member of the network must satisfy the

MCO’s minimum requirements for licensure

of staff, programs, and facilities to be eligible

for a managed care contract. 

The third fundamental aspect of managed

care arrangements is the requirement for performance measurement and reporting. All

MCOs apply a wide range of standard performance measures to each of their contracted

providers and may have financial or referral

incentives or disincentives associated with

measured performance.

Finally, the fourth aspect involves utilization

management and case management. These

tasks generally are performed by MCO staff,

typically nurses or social workers, with

supervision from Ph.D. clinicians or physicians. The staff makes a determination of

what services are “medically necessary” and

therefore eligible for health plan reimbursements. Utilization management compares a

provider’s proposed treatment plan with similar or expected plans for individuals with similar conditions and diagnoses. The utilization

management approach may vary not just by

MCO but by MCO customer, with some customers preferring that utilization be highly

scrutinized and meet the test of medical

necessity and others preferring that the MCO

use a light touch in managing utilization. If a

treatment plan from a detoxification program

does not meet criteria for medical necessity, it

is likely to be denied and referred to a higher

level clinician for review, delaying approval

and payment. It makes sense to obtain each

MCO’s protocols, as well as any specific

158	 Chapter 6
       

   

         

         

       

             

       

           

           

           

arrangements and benefit plans for customers

whose employees or enrollees are in the

detoxification program’s client population. 

Case management programs operated in the

private sector often are utilization review

programs rather than the clinical case management programs typical in the public sector. Moreover, the process of case management in the private sector often differs from

the one found in traditional public sector

mental health or substance abuse treatment

agencies. Instead, it primarily involves telephone contact, usually with a nurse, in highrisk or high­cost cases. Case management

usually is not performed onsite or in person

in MCOs unless under contract to a public

agency that requires this. If a detoxification

program client has a public sector and a managed care case manager, the detoxification

program will have to interact with both to

obtain initial and continuing approvals of

treatment in what is called a case or utilization management program. 

In general, programs will be required to

obtain utilization management approval

and/or case management approval for any

proposed treatment plan before they can bill

the MCO. Programs will have to bear the cost

of pursuing denials and requesting exceptions

as well. The more the program’s staff can

develop a relationship with the MCO’s utilization management and case management staff,

the more they will learn about the internal

criteria and protocols that drive approval or

denial decisions and the more latitude they

will have to request special arrangements for

a particular client. Most MCOs and MBHOs

have Web sites with provider portals. Once a

program identifies the name of the managed

care plan from which payment is to be

requested staff should be sure to check its

Web site. Some managed care plans offer

electronic data interchange with network

providers to facilitate claims submission. 

Elements of Financial Risk in

Managed Care Contracts

Cost of services

To assess and negotiate a managed care contract and to monitor a program’s performance under that contract, it is imperative to

know what it costs the detoxification program

to provide each unit of service that is produced. The cost of services includes staff time

spent with clients, administrative time spent

on meetings and paperwork, and capital and

operating expenses. Only when the actual cost

of delivering a unit of a particular service is

known can an agency negotiate a reasonable

rate for specific services when negotiating

contracts and a fiscally prudent arrangement.

Determining the cost of services often entails

many challenges but is absolutely essential in

the current environment of accountability.

See the text box on page 160 for a list of

resources from the literature. Following are

the recognized but evolving cost methodologies developed specifically for substance

abuse services:

•The first systematic cost data collection

method, the Drug Abuse Treatment Cost

Analysis Program (DATCAP) (French 2003a,

b), was developed in the early 1990s by

economists at Research Triangle Institute

(French et al. 1997). The Treatment Services

Review used with DATCAP provides unit service costs (French et al. 2000).

•The Uniform System of Accounting and

Cost Reporting for Substance Abuse

Treatment Providers is a cost estimation

method developed about the same time by

CSAT (1998d).

•Another estimation approach has been

developed by Yates (1996, 1999): the

Cost–Procedure–Process–Outcome

Analysis. 

•Anderson and colleagues (1998) have developed a cost of service methodology. 

Financing and Organizational Issues 159
Resources on Service Costs

Anderson, D.W., Bowland, B.J., Cartwright, W.S., and Bassin, G. Service­level costing of drug abuse

treatment. Journal of Substance Abuse Treatment 15(3):201–211, 1998.

Center for Substance Abuse Treatment. Measuring the Cost of Substance Abuse Treatment Services: An

Overview. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998.

Center for Substance Abuse Treatment. Uniform System of Accounting and Cost Reporting for

Substance Abuse Treatment Providers. Rockville, MD: Substance Abuse and Mental Health Services

Administration, 1998.

Center for Substance Abuse Treatment. Summary Report on Assessment and Measurement of

Treatment Costs. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000. 

Dunlap, L.J., and French, M.T. A comparison of two methods for estimating the costs of drug abuse

treatment. Journal of Maintenance in the Addictions 1(3):29–44, 1998.

Flynn, P.M., Porto, J.V., Rounds­Bryant, J., and Kristiansen, P.L. Costs and benefits of methadone

treatment in DATOS—Part 1: Discharged versus continuing patients. Journal of Maintenance in the

Addictions 2(1/2):129–150, 2003.

French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): Program Version. 8th ed.

Miami, FL: University of Miami, 2003. 

French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): User’s Manual. 8th ed. Miami,

FL: University of Miami, 2003.

French, M.T., Dunlap, L.J., Zarkin, G.A., and Karuntzos, G.T. The costs of an enhanced employee

assistance program (EAP) intervention. Evaluation and Program Planning 21(2):227–236, 1998.

French, M.T., Dunlap, L.J., Zarkin, G.A., McGeary, K.A., and McLellan, A.T. A structured instrument for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost

Analysis Program (DATCAP). Journal of Substance Abuse Treatment 14(5):445–455, 1997.

French, M.T., Roebuck, M.C., McLellan, A.T., and Sindelar, J.L. Can the Treatment Services Review

be used to estimate the costs of addiction and ancillary services? Journal of Substance Abuse

12(4):341–361, 2000.

French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefit­cost analysis of a

modified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning

25(2):137–148, 2002.

French, M.T., Salome, H.J., and Carney, M. Using the DATCAP and ASI to estimate the costs and benefits of residential addiction treatment in the State of Washington. Social Science & Medicine

55(12):2267–2282, 2002.

Yates, B.T. Analyzing Costs, Procedures, Processes, and Outcomes in Human Services. Applied social

research methods series v. 42. Thousand Oaks, CA: Sage, 1996.

Yates, B.T. Measuring and Improving Cost, Cost­Effectiveness, and Cost­Benefit for Substance Abuse

Treatment Programs: A Manual. NIH Publication No. 99­4518. Rockville, MD: National Institute on

Drug Abuse, 1999. 

Zarkin, G.A., and Dunlap, L.J. Implications of managed care for methadone treatment. Findings from

five case studies in New York State. Journal of Substance Abuse Treatment 17(1­2):25–35, 1999.

Zarkin, G.A., Dunlap, L.J., and Homsi, G. The substance abuse services cost analysis program (SASCAP): A new method for estimating drug treatment services costs. Evaluation and Program Planning

27(1):35–43, 2004.

160 Chapter 6
•The Substance Abuse Services Cost Analysis

Program (Zarkin et al. 2004) is an emerging

treatment services cost estimation method.

•Variants of these methods have been applied

to several treatment studies (Flynn et al.

2003; Koenig et al. 1999; Mojtabai and

Zivin 2003).

Three major categories of financial arrangements may be distinguished in managed care

contracts: (1) fee­for­service agreements, (2)

capitation agreements, and (3) case rate

agreements. Program administrators need to

understand the differences among these types

of arrangements so they can manage financial

risk. Sometimes, administrators may think

that the contract itself is the goal. However,

the existence of a contract is no guarantee of

a referral; it only enables referrals that are

medically necessary. The closer the relationship the program staff can develop with a

given MCO, the easier it will be for them to

understand their clinical criteria, to obtain

more than intermittent referrals, and to negotiate a financial arrangement for the program

that is reasonable and fair.

Managed care contracts vary according to two

principal dimensions: (1) the method of payment and the corresponding type of risk

assumed by the provider, and (2) the amount

of payment. Each of the three major types of

financial arrangements or methods of payment (described in Figure 6­1, p. 162) is associated with major financial risks that

providers should be aware of in negotiating

each type. Risk, of course, is a continuous

variable, so that no arrangement is devoid of

any risk whatsoever. The key is to ensure that

a program has the tools and capabilities to

manage the risks it assumes. Many managed

care systems rely on fee­for­service arrangements with providers, so that most providers

are paid on a discounted fee­for­service basis,

based on a schedule of fees described in the

contract. Capitation agreements usually are

reserved for very large networks of

providers, who in turn pay individual

providers on a fee­for­service basis. 

For more information on managed care purchasing and negotiation from the perspective

of a purchaser, see TAP 22, Contracting for

Managed Substance Abuse and Mental Health

Services: A Guide for Public Purchasers

(CSAT 1998c). 

Networks, Accreditation, and

Credentialing

To join an MCO’s network of providers and

negotiate a contract specific MCO minimum

standards for staff credentials and program

accreditation must be met. These minimum

standards generally are not negotiable

because they have their basis in that MCO’s

accreditation requirements. The provider

credentialing requirements vary by MCO and

by customer within the MCO and often

include primary verification of specific academic degrees or specific levels of licensure

for staff, as well as verified minimum levels of

malpractice insurance. Some MCOs may use

what are called independent Credentialing

Verification Organizations (CVOs) for this

process. These CVOs verify the credentials of

providers on behalf of MCOs to ensure, for

example, that their licenses are valid and up

to date.

MCOs sometimes are not familiar with substance abuse treatment and, moreover, typically include only those types of providers

that are licensed by a given State to engage in

private practice in their provider networks.

Usually such providers are licensed in psychology, nursing, medicine, or social work.

MCOs explain that this has to do with malpractice insurance issues. This credentialing

practice has a disproportionate impact on

those substance abuse treatment providers

that do not have as many staff with these credentials as do mental health providers, by

presenting an obstacle to contracting with

these MCOs. However, it is not an insurmountable obstacle. Substance abuse treatment providers often must help MCOs understand the substance abuse treatment environment, the types of providers that deliver serFinancing and Organizational Issues 161
   

       

   

       

       

Figure 6­1

Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Fee­for­Service Agreement. Fee­for­service programs are the least risky to providers. They generally require precertification and utilization

management for some or all procedures and services. The client’s benefit plan document or the

public payor’s contract dictate the services that

may be approved. In a fee­for­service contract, a

rate is received for the services provided; typically, a standard program session with specific services bundled in. This is referred to as an “allinclusive rate.”

Some common bundled services are urine drug

screens and group, family, and individual counseling. Thus the payment rate for one visit may

include a 50­minute group counseling session and

a urine drug screen. The rate for a day of treatment could include, for example, one­fifth of a 25­

minute psychologist visit, one­half of a urine drug

screen, one­half of a vocational training session,

and two sessions of group counseling. The

assumption is that these services will occur at a

specified frequency during the course of the

client’s treatment. Psychiatric services can be

incorporated into the bundled services, but usually they are negotiated separately and treated as an

additional service.

When negotiating a fee­for­service contract, an

administrator needs to ensure that the rate is sufficient to cover the actual costs to a program of

providing the specified services. During negotiations, the MCO has the option of saying that it will

not pay for some of the bundled services. All services should be costed out prior to negotiation, so

actual costs of treatment components are known

and can be compared to the reimbursement

offered. Programs must understand that even if a

fee­for­service contract is successfully negotiated,

referrals may or may not follow. 

vices, and the qualifications and standards

they must meet so that the MCO can modify

its policies appropriately. MCOs often are

more willing to contract with organizations

that have a facility license from their State

than with individual substance abuse treatment providers who may not possess credentials that meet the MCO’s licensure criteria.

Many managed care plans have separate

provider networks for behavioral health services. It is important for detoxification

providers to participate in both medical and

behavioral health networks, given that detoxification benefits may be considered either

medical or behavioral benefits.

In addition to the credentials of the staff and

practitioners, the program itself may have to be

accredited by one of the major national healthcare accrediting organizations. These include

the Commission on Accreditation of

Rehabilitation Facilities, the National

Committee for Quality Assurance and the Joint

Commission on Accreditation of Healthcare

Organizations. In general, accreditation from

CARF is considered most important by substance abuse treatment providers for their

162 Chapter 6
       

Figure 6­1 (continued)

Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Capitation Agreement. A managed care company

may establish a stipulated dollar amount to cover

treatment costs for a group of people using one

per­person rate for everyone, which is the MCO’s

capitation rate. The MCO may then subcapitate a

stipulated dollar amount to a treatment provider

or organization, and the MCO and the treatment

provider negotiate an agreement in which the

provider is paid a fixed amount per subscriber

per month, rather than billing on a fee­for­service

basis. The provider agrees to provide all or some

of the treatment services for an expected number

of managed care “covered lives” (e.g., for 100,000

subscribers). Usually only large service providers

have the assets and volume of services to engage in

capitated agreements.

The two critical elements are the per member/per

month (pm/pm) rate and the utilization rate. If

many more people than are predicted require

treatment, the provider may not be able to cover

service delivery costs, much less make a profit/surplus. The key is to have reliable information on

the historical use rates of a given managed care

plan’s enrollees. If the provider bears in mind

these caveats, this regular, guaranteed payment

can be an excellent arrangement but carries with it

the risks of both “overutilization” (when compared to the assumption used in developing the

rate) and the need for a greater intensity of treatment than the capitation rate can cover. In some

cases a program may want to accept a somewhat

speculative capitation rate in order to join a panel

and then renegotiate that rate after the program

has collected data that show that it needs a higher

rate to cover its costs. In any case, it is crucial to

track actual dollars against the budget in real time

to avoid unexpected deficits.

Case Rate Agreement. The case rate is a fixed

rate per client paid for delivery of specific services to specified types of consumers. For this fee,

a provider such as a clinic covers all the services

that a client requires for a specific period. In

essence, the MCO is saying, “You provide the

client what he needs from this set of services and I

will pay you this set amount.” What usually distinguishes case rate from capitation is that essentially all of the case rate clients are anticipated to

be receiving some service; that is, at least case

management. Usually those receiving services

under capitation are a small minority of those

covered. The case rate may be “risk­adjusted” to

compensate for the higher costs of serving clients

who predictably need more services than average.

A case rate agreement removes some of the utilization risk from the service provider. However, the

risk remains that clients will need services more

frequently or at higher levels than the case rate

covers. It is essential that programs track costs by

specific client in order to assess the adequacy of a

proposed case rate. However, it is a mistake to

consider a case rate as a cap for any specific

patient; the goal is to ensure that the average cost

per case is lower than the negotiated case rate, not

that the cost for each case is less than the negotiated rate. Once again, it is crucial to track actual

average dollars per case against the contracted

case rate in real time to avoid unexpected deficits.

Financing and Organizational Issues 163
     

       

           

         

           

         

         

         

             

         

           

             

           

         

         

           

           

       

           

         

           

         

           

                 

           

         

           

         

             

             

             

           

       

           

           

   

           

           

           

               

         

         

           

           

   

programs. However, providers that wish to

offer inpatient detoxification services generally must obtain accreditation from JCAHO to

meet the requirements of most MCOs.

Organizational Performance

Measurement

Performance measurement is becoming an

increasingly important component of managed and fee­for­service care in both the

public and private sectors. SAMHSA’s SAPT

Block Grants now require the collection of

measures of program performance and outcomes. MCOs have their own performance

measures established by the agencies that

accredit them, such as the NCQA. Their customers, employers, or public purchasers may

use adequacy of performance on these measures in their decisions to acquire or retain

their plans for their employees. NCQA has

established a set of measures specifically

relating to substance abuse and mental

health treatment services for all the MCOs

that it accredits, including new measures of

the identification of enrollees with substance

abuse diagnoses, the rate of initiation of

treatment, and a measure of treatment

engagement. Programs will be asked to participate in measuring these indicators and

report that information to the MCO, and

doing so will likely be a condition of the contract. The MCO may reward good performance with an additional fee.

Similarly, MCOs evaluate the performance of

the members of their provider network. Each

MCO has its own measures and procedures

for implementation, some of which are prescribed by the organizations that accredit

them. Not all MCOs are diligent about this

provider evaluation process. Only a few

MCOs have implemented sophisticated measurement systems, and some of the methods

used today may be crude but they still are

required. Nevertheless, regardless of how

simple or complex they may be, the results of

external performance measures implemented

by MCOs can be extremely important to a

program’s financial and organizational success, affecting a program’s ability to remain a

viable, respected network provider. Some

performance management systems implemented by MCOs also use financial incentives

and/or disincentives keyed to performance.

Regardless of the specific measures implemented by particular MCOs, well­managed

organizations will also develop and use their

own internal performance measures and constantly strive to improve their own performance. Among these should be measures of

both process and outcomes, such as 

•The percentage of clients who complete a

defined treatment regimen that meets their

individual needs

•The percentage of clients who drop out of

treatment in the first 7 days following treatment initiation

•The percentage of clients who remain in documented but less intensive treatment 30 days

after discharge from the program

•The percentage of clients who are employed

or attending school 6 months after discharge

from the program

When using performance measures, it is important for programs to account for differences

among clients that may affect measured results,

such as a client’s previous history of abuse or

medical conditions. Nevertheless, it is equally

important to recognize that employing measurement is an integral component of external

and internal accountability as well as continuous clinical improvement.

One of the primary independent entities

involved in the construction of national performance measures for substance abuse treatment is the Washington Circle Group.

NCQA’s new substance abuse performance

measures on identification and initiation of

treatment and treatment engagement were

developed by the WCG over a 4­year period.

164 Chapter 6
They have identified four major “domains”

for substance abuse treatment measures:

1.	 Prevention/Education

2.	 Recognition or Identification of Substance

Abuse

3.	 Treatment

•Initiation of alcohol and other plan services

•Linkage of detoxification and alcohol and

other drug plan services 

•Treatment engagement

•Use of interventions for family members

and significant others 

4.	 Maintenance of Treatment Effects

These and other substance abuse performance

measures are now used in NCQA’s MCO

accreditation process. The WCG and others

have defined a variety of such measures and

administrators should think of these measures

as ways to improve their own performance, as

an essential element in the reporting system,

and as a means for documenting success to

their customers and other stakeholders.

Performance measurement is becoming

increasingly important outside of managed care

contracts as well as inside them. For example,

as mentioned in the previous section on funding, SAMHSA began integrating performance

measurement into the SAPT Block Grant as of

fiscal year 2004. Each State will expect programs to understand and be able to measure

the required indicators accurately and in a

timely way.

One of the most important performance measures in the future for detoxification programs

is likely to be linkages to substance abuse treatment following detoxification (Mark et al.

2002). Research has shown that patients who

receive continuing care following detoxification

have better outcomes in terms of drug abstinence and readmission rates than those who do

not receive continuing care. This focus on linkages is a likely result of research indicating that

many people who undergo detoxification do not

receive subsequent substance abuse services

from the formal treatment system and that the

lack of substance abuse treatment following

detoxification has been getting worse instead of

better (Mark et al. 2002). It is incumbent on

providers of detoxification services to ensure

that clients are linked to substance abuse treatment following detoxification.

Recordkeeping and management information systems

Like indemnity insurers, MCOs also require

detailed records of

services provided to

clients in order for

them to pay for ser­ Performance

measurement is

becoming an

increasingly

important component of managed

and fee­for­service

care in both the

public and private

sectors.

vices received. The

program’s accounting system needs to

track counselors’

time spent on the

phone, on paperwork, and directly

with clients. Clinical

records should

reflect accurately

the claims records

submitted to the

MCO. Periodically,

payors and MCOs

may audit the clinical records to

ensure that the services billed for actually have been provided. Failure to
 

adequately document clinical services can result in nonpayment and put a contract in jeopardy. On the other hand, individuals’ private information and identity must
 

be handled in a confidential manner pursuant
 

to the Health Insurance Portability and
 

Accountability Act (HIPAA) and Federal confidentiality requirements for persons with
 

substance abuse.
 

Financing and Organizational Issues 165
Managing multiple contracts requires sophisticated management, a fiscal management

information system (MIS), and constant

scrutiny. The need for information is even

more crucial for capitation­based arrangements that place risk on the service provider

than it is for fee­for­service arrangements. In

essence, the MIS needs to be capable of twoway information transfer between the MCO

and the program. Data such as membership,

benefits, copays, deductible amounts, and

other financial information must be passed

between the program and the

Successfully	 

addressing the

needs of the

utilization and

case management

staff at MCOs is a

critical element in

the relationship

with an MCO.

insured entity or

payor. The MIS

also should be able

to analyze key performance data for

internal and external reports. The

MIS must pass useful data to staff

members responsible for managing

benefits and providing services. 

Program data will

need to meet State

data requirements

as well as requirements by each

payor, while

respecting confidentiality.

Managing payment from
 

multiple funding streams
 

Especially in the public arena, multiple contracts with and grants from several funding

streams and payors may be used to support

services for a single client. These contracts

will specify order of payment. The provider

needs to manage the funds carefully and

appropriately to be in compliance with contracts and grants. For example, a contract

with a drug court may specify that Medicaid

should be billed as payor number one and the

drug court as payor number two. Any unpaid

portion might then be billed to the block

grant agency as payor of last resort, if it is an

eligible service under the block grant. Some

providers have successfully used the strategy

of first using the reimbursement of those payors with the most restrictive array of services;

later, the more flexible funds can be used to

cover the remaining services. A clearly documented strategy for managing payment that is

communicated effectively to the accounts

payable staff is critical and will help programs be successful in this important area.

Utilization and Case

Management

All MCOs use methods to manage the service

utilization of their members and ensure that

they are receiving the most appropriate array

of services in the most appropriate environment or level of care for the appropriate

length of time. Although technically, utilization management focuses on a single type of

service and case management focuses on the

coordination of the appropriate array of services needed by a specific individual, in practice the same individual professionals may be

responsible for both types of management.

Utilization and case management staff at an

MCO authorize specific services for purposes

of payment. A wide variety of specific criteria

and protocols may be used to determine

whether services may be authorized for substance abuse, typically including the

American Society of Addiction Medicine

(ASAM) patient placement criteria (ASAM

2001) and other level of care or diagnosisbased criteria sets. 

Successfully addressing the needs of the utilization and case management staff at MCOs

responsible for authorizing care is a critical

element in the relationship with an MCO and

in maintaining the program’s clinical and

financial viability. To do so, program staff

must understand what their counterparts do

and be well trained in conducting professional

166	 Chapter 6
   

         

         

           

           

     

         

         

           

                 

       

relationships over the telephone, be familiar

with the criteria and protocols employed by

the MCOs with which the program has contracts, and have easy access to the multitude

of clinical and service information required

by an MCO to help them complete a review

and authorize services. Excellent records are

essential. Program staff also should be familiar with each MCO’s appeal or exceptions

process for those occasions when the outcome

of a first­level review is unsatisfactory. 

Utilization management cannot proceed if the

program is not recognized as an eligible network provider; the program will have to

ensure that it is an accepted network

provider before it can participate in the utilization management or case management

process. 

Strengthening the Financial

Base and Market Position of a

Program

The following strategies may strengthen the

market position of a detoxification program to

facilitate both larger numbers of patients and

greater revenues per patient:

•Achieve recognition for the quality and

effectiveness of services. If a program has

a reputation for providing effective care,

then managed care enrollees and other

potential clients will want to use it. A program can be of value to a client, a purchaser, and/or an MCO if it can reduce repeated

detoxification, repeated treatment, and readmissions, and thus manage unnecessary

costs and interventions. Effective substance

abuse treatment provided promptly may

reduce medical care and hospitalization

costs in the long run. A program that effectively manages the care of high­utilization

substance abuse clients by also providing

psychiatric treatment, case management,

and housing support is a good candidate for

“preferred” or “core” status with one or

several MCOs or MBHOs. Of course, the

additional costs of these services need to be

a component of a program’s rate and contract. Having highly reputable, recognized,

and efficient providers is a major marketing

and regulatory advantage for the health

plan, as well as for the program. All these

program characteristics can be marketing

advantages. Programs also may apply to

SAMHSA’s National Registry of Evidencebased Programs and Practices, which recognizes model, effective, and promising programs. Check SAMHSA’s Web site to find

out how to apply for this status, which is a

major achievement and marketing asset.

•Serve specific populations. Providing lowcost, high­quality treatment to a population

no other program serves (e.g., adolescents,

clients with HIV/AIDS, clients with cooccurring mental disorders, pregnant

women, women with young children, clients

who are deaf) also is a possible marketing

advantage. Treating these clients can result

in client referrals from a larger geographic

area and multiple sources. Such clients may

bring with them higher reimbursement rates

too, but this also may simply reflect higher

costs to provide care to the population.

Using special capabilities to attract clients is

a good idea, but not at the cost of inadequate payment for services.

•Develop economies of scale. Adding clinic

sites or increasing the number of branch

clinics may permit spreading some fixed

costs (e.g., management, information,

financial systems, executive staff) among a

larger number of patients, thus driving

down a program’s per capita costs.

However, larger size requires greater

administrative coordination, which itself

can be costly.

•Gain community visibility and support.

Having governmental, community agency

executives, or political figures (e.g., the

mayor, council members) as board members

raises the program’s profile in the community. Of course, programs should be sure to

include board members who have specific

Financing and Organizational Issues 167
skills and connections that will advance the

purposes of the detoxification program.

•Form alliances with other treatment

providers. Setting up coalitions to compete

with or work with MCOs and other purchasers such as Medicaid may be useful.

However, consultation with an attorney is

strongly advised prior to developing such a

coalition or other collaboration with local

treatment providers as the laws regarding

antitrust and other matters related to such

relationships are complex. For programs

serving publicly funded clients, technical

assistance may be available through 

SAMHSA; the SSA can provide details.

Preparing for the

Future 

Major forces that shape and limit provider

financing are unlikely to change substantially

in the near future. 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 an MCO, a health plan, other purchasers, or with another agency or group of

agencies depends on day­to­day interactions

in which staff members serve as informed,

professional advocates for their clients and

the program.

168 Chapter 6
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Appendix B: Common

Drug Intoxication

Signs and Withdrawal

Symptoms

Cocaine Alcohol Heroin Cannabis 

(marijuana)

Intoxication

Action Stimulant Sedative Sedative, euphoriant, analgesic

Euphoriant, at

high doses may

induce hallucinations

Characteristics of

intoxication

D BP, HR, temp, 

Denergy, 

Dparanoia,

Dfatigue,

bappetite, 

move bowels/

urinate

•

•

Sedation,

brespiration,

Depresses CNS

system, can

result in coma,

death

Drowsiness, “nodding,” euphoria

(happy giddiness)

bBP, DHR,

bintraocular pressure (pressure in

the eyes) 

conjunctival injection (reddening of

the eyes) 

Withdrawal

Onset Depends upon

type of cocaine

used: for crack

will begin within

hours of last use

24–48 hours after

blood alcohol level

drops

Within 24 hours

of last use

Some debate

about this, may be

a few days

Duration 3–4 days 5–7 days 4–7 days May last up to

several weeks

223
Cocaine Alcohol Heroin Cannabis 

(marijuana)

Characteristics Sleeplessness or

excessive restless

sleep, appetite

increase, depression, paranoia,

decreased energy

DBP, DHR, 

Dtemp,

nausea/vomiting/ 

diarrhea, 

seizures, delirium,

death

Nausea, vomiting,

diarrhea, goose

bumps, runny

nose, teary eyes,

yawning

Irritability,

appetite disturbance, sleep disturbance, nausea,

concentration

problems, nystagmus, diarrhea

Medical/ Stroke, cardiovas­ Virtually every During withdrawal

psychiatric issues cular collapse,

myocardial and

other organ infarction, paranoia,

violence, severe

depression, suicide

organ system is

affected (e.g., cardiomyopathy, liver

disease, esophageal

and rectal

varices); fetal alcohol syndrome and

other problems

with fetus

individual may

become dehydrated

224 Appendix B
                   

                   

                 

                       

                     

             

                 

                 

       

       

Appendix C: Screening

and Assessment

Instruments

Please note that this list of screening and assessment instruments has

been divided into two sections. The first section comprises those instruments used for patients with suspected alcohol abuse or dependence

only; the second lists instruments used to screen and assess for abuse of

or dependence on any substances. Thus those tools that screen for all

substances of abuse are listed in section II.

Section I: Screening and

Assessment for Alcohol Abuse

This section of the appendix lists common screening and assessment

instruments specifically used in cases where abuse of or dependence

upon alcohol is in question.

The Alcohol Use Disorders Identification Test

(AUDIT)

Purpose: The purpose of the AUDIT is to identify persons whose alcohol consumption has become hazardous or harmful to their health.

Clinical utility: The AUDIT screening procedure is linked to a decision process that includes brief intervention with heavy drinkers or

referral to specialized treatment for patients who show evidence of

more serious alcohol involvement.

Groups with whom this instrument has been used: Adults, particularly primary care, emergency room, surgery, and psychiatric patients;

DWI offenders; offenders in court, jail, and prison; enlisted men in

the armed forces; workers receiving help from employee assistance

programs and in industrial settings.

225
Norms: Yes, heavy drinkers and people with

alcohol use disorders

Format: A 10-item screening questionnaire

with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 on problems caused by alcohol.

Administration time: Two minutes

Scoring time: One minute

Computer scoring? No

Administrator training and qualifications:

The AUDIT is administered by a health professional or paraprofessional. Training is required

for administration. A detailed user’s manual

and a videotape training module explain proper administration, procedures, scoring, interpretation, and clinical management.

Fee for use: No

Available from: Department of Mental Health

and Substance Dependence, World Health

Organization, CH-1211 Geneva 27,

Switzerland; request document

WHO/MSD/MSB/01.6a.

Brief Michigan Alcoholism

Screening Test (BMAST)

Purpose: Used to screen for alcoholism with a

variety of populations.

Clinical utility: The BMAST can save clinicians time when integrated with instruments

used to screen for other behavioral health

problems (Pokorny et al. 1972).

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: Ten-item questionnaire; interview or

paper-and-pencil

Administration time: Five minutes

Scoring time: Two to 3 minutes

Computer scoring? No

Administrator training and qualifications: No

training required.

Fee for use: No

Available from: Can be downloaded from

Project Cork Web site: 

http://www.projectcork.org

CAGE Questionnaire

Purpose: Used to detect alcoholism.

Clinical utility: The CAGE Questionnaire is a

very useful bedside, clinical desk instrument

and has become the favorite of many family

practice and general internists and among

nurses.

Groups with whom this instrument has been

used: Adults and adolescents (over 16 years

old)

Norms: Yes

Format: Very brief, relatively nonconfrontational questionnaire for detection of alcoholism, usually directed “have you ever” but

may be focused to delineate past or present

use. 

Administration time: Less than 1 minute

Scoring time: Instantaneous

Computer scoring? No

Administrator training and qualifications: No

training required for administration; it is

easy to learn, easy to remember, and easy to

replicate. 

Fee for use: No

Available from: Can be downloaded from

Project Cork Web site: 

http://www.projectcork.org

226 Appendix C
Clinical Institute Withdrawal

Assessment (CIWA-Ar)

Purpose: Converts DSM-III-R items into

scores to track severity of withdrawal; measures severity of alcohol withdrawal.

Clinical utility: Aid to adjustment of care

related to withdrawal severity.

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: A 10-item scale for clinical quantification of the severity of the alcohol withdrawal syndrome.

Administration time: Two minutes 

Scoring time: Four to 5 minutes

Computer scoring? No

Administrator training and qualifications:

Training is required; the CIWA-Ar can be

administered by nurses, doctors, research

associates, and detoxification unit workers.

Fee for use: No

Available from: Center for Substance Abuse

Treatment. A Guide to Substance Abuse

Services for Primary Care Clinicians.

Treatment Improvement Protocol (TIP)

Series 24. HHS Publication No. (SMA) 97-

3139. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 1997.

Michigan Alcoholism

Screening Test (MAST)

Purpose: Used to screen for alcoholism with a

variety of populations.

Clinical utility: A 25-item questionnaire

designed to provide a rapid and effective

screen for lifetime alcohol-related problems

and alcoholism.

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: Consists of 25 questions 

Administration time: Ten minutes

Scoring time: Five minutes

Computer scoring? No

Administrator training and qualifications: No

training required.

Fee for use: Fee for a copy, no fee for use

Available from: Can be downloaded from

Project Cork Web site: 

http://www.projectcork.org

TWEAK

Purpose: Screens for heavy drinking and

alcohol dependence in the past year in male

and female samples of the general household

population and hospital clinic outpatients

(Chan et al. 1993).

Clinical utility: The TWEAK provides a

quick and easy method of targeting outpatients and inpatients in need of more thorough assessments of their alcohol use patterns

and problems to determine whether treatment

is needed. The TWEAK has also been used to

screen for periconceptional risk drinking

among obstetric outpatients (Russell et al.

1994), which may improve pregnancy outcome among high-risk drinkers. 

Groups with whom this instrument has been

used: Adults

Norms: Yes

Format: Five items; pencil and paper selfadministered, administered by interview, or

computer self-administered.

Administration time: Less than 2 minutes

Scoring time: Approximately 1 minute

Computer scoring? No

Screening and Assessment Instruments 227
Administrator training and qualifications: No

training required.

Fee for use: No

Available from: Can be downloaded from

Project Cork Web site: 

http://www.projectcork.org

Section II: Screening

and Assessment for

Alcohol and Other

Drug Abuse

This section of the appendix lists common

screening and assessment instruments used in

cases where abuse of or dependence upon substances (including alcohol) is in question.

Addiction Severity Index (ASI)

Purpose: The ASI is most useful as a general

intake screening tool. It effectively assesses a

client’s status in several areas, and the composite score measures how a client’s need for

treatment changes over time. 

Clinical utility: The ASI has been used extensively for treatment planning and outcome

evaluation. Outcome evaluation packages for

individual programs or for treatment systems

are available.

Groups with whom this instrument has been

used: Designed for adults of both sexes who

are not intoxicated (on illicit drugs or alcohol)

when interviewed. It is also available in

Spanish.

Norms: The ASI has been used with males

and females with substance use disorders in

both inpatient and outpatient settings. 

Format: Structured interview

Administration time: Fifty minutes to 1 hour

Scoring time: Five minutes for severity rating 

Computer scoring? Yes

Administrator training and qualifications: A

self-training packet is available as well as

onsite training by experienced trainers.

Fee for use: No cost; minimal charges for

photocopying and mailing may apply

Available from:

A. Thomas McLellan, Ph.D.

Building 7

PVAMC 

University Avenue 

Philadelphia, PA 19104 

Phone: (800) 238-2433

Cocaine Selective Severity

Assessment (CSSA)

Purpose: Measures early cocaine abstinence

signs and symptoms.

Clinical utility: The CSSA is able to predict a

patient’s response to treatment and could be

used to identify patients at greater risk for

treatment failure so that these patients could

be targeted for additional interventions. This

instrument could also be used to evaluate the

effectiveness of medications intended to treat

cocaine abstinence symptoms.

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: Eighteen items

Administration time: Less than 10 minutes

Scoring time: N/A

Computer scoring? No

Administrator training and qualifications:

Requires little training; clinician-administered 

Available from: Kampman, K.M., Volpicelli,

J.R., McGinnis, D.E., Alterman, A.I.,

Weinrieb, R.M., D’Angelo, L., and

Epperson, L.E. Reliability and validity of the

228 Appendix C
   

   

     

     

Cocaine Selective Severity Assessment.

Addictive Behaviors 23(4):449–461, 1998.

Objective Opiate Withdrawal

Scale (OOWS)

Purpose: Used to record symptoms of opiate

withdrawal.

Clinical utility: Allows staff to share information about a client’s withdrawal, especially

objective signs observed by staff.

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: Thirteen manifestations of withdrawal; observer scores

Computer scoring? No

Administrator training and qualifications:

Staff must be familiar with withdrawal signs

(e.g., registered nurse, physician) or trained.

Available from: Handelsman, L., Cochrane,

K.J., Aronson, M.J., Ness, R., Rubinstein,

K.J., and Kanof, P.D. Two new rating scales

for opiate withdrawal. American Journal of

Alcohol Abuse. 13:293–308, 1987.

Structured Clinical Interview

for DSM­IV Disorders (SCID)

Purpose: Obtains Axis I and II diagnoses

using the DSM­IV diagnostic criteria for

enabling the interviewer to either rule out or

to establish a diagnosis of “drug abuse” or

“drug dependence” and/or “alcohol abuse” or

“alcohol dependence.”

Clinical utility: A psychiatric interview

Groups with whom this instrument has been

used: Psychiatric, medical, or communitybased normal adults.

Norms: No

Format: A psychiatric interview form in

which diagnosis can be made by the examiner

asking a series of approximately 10 questions

of a client.

Administration time: Administration of Axis I

and Axis II batteries may require more than 2

hours each for patients with multiple diagnoses. The Psychoactive Substance Use

Disorders module may be administered by

itself in 30 to 60 minutes.

Scoring time: Approximately 10 minutes

Computer scoring? No. Diagnosis can be

made by the examiner after the interview. 

Administrator training and qualifications:

Designed for use by a trained clinical evaluator at the master’s or doctoral level, although

in research settings it has been used by bachelor’s level technicians with extensive training.

Fee for use: Yes

Available from:
 

American Psychiatric Publishing, Inc.
 

1400 K Street, N.W.
 

Washington, DC 20005
 

Stages of Change Readiness

and Treatment Eagerness

Scale (SOCRATES)

Purpose: Designed to assess client motivation

to change drinking­ or drug­related behavior.

Consists of five scales: precontemplation, contemplation, determination, action, and maintenance. Separate versions are available for

alcohol and illicit drug use.

Clinical utility: The SOCRATES can assist

clinicians with necessary information about

client motivation for change, an important

predictor of treatment compliance and outcome, and aid in treatment planning.

Groups with whom this instrument has been

used: Adults

Screening and Assessment Instruments 229
   

Norms: N/A

Format: Forty items; paper­and­pencil

Administration time: Five minutes

Computer scoring? No

Administrator training and qualifications: No

training required.

Fee for use: No

Available from: Center for Substance Abuse

Treatment. Enhancing Motivation for Change

in Substance Abuse Treatment. Treatment

Improvement Protocol (TIP) Series 35. HHS

Publication No. (SMA) 99­3354. Rockville,

MD: Substance Abuse and Mental Health

Services Administration, 1999.

Subjective Opiate Withdrawal

Scale (SOWS)

Purpose: Used to record client’s impressions

or complaints of opiate withdrawal symptoms.

Groups with whom this instrument has been

used: Adults

Norms: N/A

Format: Sixteen­item questionnaire; interview

or paper­and­pencil

Computer scoring? No

Available from: Handelsman, L., Cochrane,

K.J., Aronson, M.J., Ness, R., Rubinstein,

K.J., and Kanof, P.D. Two new rating scales

for opiate withdrawal. American Journal of

Alcohol Abuse. 13:293–308, 1987.

University of Rhode Island

Change Assessment (URICA)

Purpose: The URICA operationally defines

four theoretical stages of change (precontemplation, contemplation, action, and maintenance), each assessed by eight items. 

Clinical utility: Assessment of stages of

change/readiness construct can be used as a

predictor, and for treatment matching and

determining outcome variables. 

Groups with whom this instrument has been

used: Both inpatient and outpatient adults

Norms: Yes, for an outpatient alcoholism

treatment population

Format: The URICA is a 32­item inventory

designed to assess an individual’s stage of

change located along a theorized continuum

of change.

Administration time: Five to 10 minutes to

complete 

Scoring time: Four to 5 minutes

Computer scoring? Yes, using computer

scannable forms

Administrator training and qualifications:

N/A

Fee for use: No—the instrument is in the

public domain 

Available from: Center for Substance Abuse

Treatment. Enhancing Motivation for Change

in Substance Abuse Treatment. Treatment

Improvement Protocol (TIP) Series 35. HHS

Publication No. (SMA) 99­3354. Rockville,

MD: Substance Abuse and Mental Health

Services Administration, 1999.

230 Appendix C
Appendix D: 

Resource Panel

231

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Brad Austin 

Public Health Advisor 

Division of State and Community Assistance PPG Program Branch 

Center for Substance Abuse Treatment

Rockville, Maryland

Christina Currier 

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 

Rockville, Maryland 

Herman Diesenhaus 

Public Health Analyst 

Scientific Analysis Branch

Office of Evaluation, Scientific Analysis and Synthesis 

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

Hendree E. Jones, M.A., Ph.D. 

Assistant Professor 

CAP Research Director 

Department of Psychiatry and Behavioral Sciences 

Johns Hopkins University Center

Baltimore, Maryland 
Robert Lubran, M.S., M.P.A. 

Director 

Division of Pharmacologic Therapies 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health

Services Administration 

Rockville, Maryland
 

James J. Manlandro, D.O., FAOAAM,

FACOFP 

Medical Director 

Family Addiction Treatment Services, Inc.

Somers Point, New Jersey

Carol Rest­Mincberg 

State Project Officer 

Center for Substance Abuse Treatment

Substance Abuse and Mental Health

Services Administration
 

Rockville, Maryland 

Dennis Scurry, M.D. 

Chief Medical Officer 

Addiction of Prevention and Recovery

Administration 

Government of the District of Columbia 

Department of Health

Washington, DC

Alan Trachtenberg, M.D., M.P.H. 

Medical Officer 

Division of Pharmacologic Therapies 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health

Services Administration 

Rockville, Maryland 

232 Appendix D
Appendix E: 

Field Reviewers

Karen C.O. Batia, M.A., Ph.D. 

Senior Director 

Mental Health and Addiction Services 

Heartland Health Outreach

Chicago, Illinois 

Thomas P. Beresford, M.D. 

Professor 

Department of Psychiatry 

University of Colorado School of Medicine

Denver, Colorado 

Barry Blood, LCPC 

Addiction Counselor 

Family Service Foundation

Columbia, Maryland

Patricia T. Bowman 

Probation Counselor 

Fairfax Alcohol Safety Action Program

Fairfax, Virginia

Barry S. Brown, M.S., Ph.D. 

Adjunct Professor 

University of North Carolina at Wilmington

Carolina Beach, North Carolina 

233

Note: The information given indicates each participant's affiliation during the time the review was conducted and may no longer reflect the individual's current affiliation.
David A. Chiriboga, Ph.D. 

Professor 

Department of Aging and Mental Health 

Florida Mental Health Institute 

University of South Florida

Tampa, Florida 

Carol J. Colleran, CAP, ICADC 

Director of Primary Programs 

Center of Recovery for Older Adults 

Hanley­Hazelden Center

West Palm Beach, Florida

Joy Davidoff 

Coordinator of Addiction Medicine 

New York State Office of Alcoholism and

Substance Abuse Services 

Albany, New York 

John P. de Miranda, Ed.M. 

Executive Director 

National Association on Alcohol, Drugs

and Disability, Inc.
 

San Mateo, California 

B.J. Dean 

Executive Director 

Island Grove Regional Treatment Center,

Inc. 

Greeley, Colorado 

Ralph W. Edwards, M.P.H., M.P.A. 

Director 

Office of Citizen Leadership 

Massachusetts Department of Mental

Health and Retardation 

Boston, Massachusetts 

Michael I. Fingerhood, M.D. 

Associate Professor of Medicine 

Johns Hopkins Bayview Medical Center

Baltimore, Maryland

Michael M. Galer, D.B.A. 

Chair 

Graduate School of Business 

University of Phoenix Greater Boston

Campus
 

Braintree, Massachusetts 

Robert Holden, M.A. 

Program Director 

Partners in Drug Abuse Rehabilitation

Counseling 

Washington, DC 

Kyle M. Kampman, M.D. 

Associate Professor of Psychiatry 

Medical Director 

Treatment Research Center 

University of Pennsylvania

Philadelphia, Pennsylvania 

Michael Warren Kirby, Jr., M.A., Ph.D. 

Chief Executive Officer 

Arapahoe House, Inc.

Thornton, Colorado 

James J. Manlandro, D.O., FAOAAM,

FACOFP 

Medical Director 

Family Addiction Treatment Services, Inc.

Somers Point, New Jersey 

Ethan Nebelkopf, Ph.D., MFCC 

Director 

Family and Child Guidance Clinic 

Native American Health Center

Oakland, California

Robert E. Olson, M.S. 

Project Director 

California Alcohol, Drug and Disability

Technical Assistance Project 

National Association on Alcohol, Drugs

and Disability, Inc.

Belmont, California 

Christopher Pond 

Director of Adult Services 

Arapahoe House, Inc.

Thornton, Colorado 

Anthony B. Radcliffe, M.D. 

Chief of Addiction Medicine 

Fontana SCPMG 

Kaiser Permanente/CDRP

Fontana, California 

234 Appendix E
Jay Renaud 

Member/Editor 

J & M Reports 

Guidepoints: Acupuncture in Recovery

Vancouver, Washington

Joseph P. Reoux, M.D. 

Assistant Professor 

Department of Psychiatry and Behavioral

Sciences 

VA Puget Sound Health Care System 

University of Washington School of

Medicine
 

Seattle, Washington
 

Timothy M. Scanlan, M.D. 

Medical Director 

Addiction Specialists of Kansas 

Wichita, Kansas

Lawrence Schonfeld, Ph.D. 

Professor 

Louis de la Parte Florida Mental Health

Institute 

Department of Aging and Mental Health 

University of South Florida

Tampa, Florida 

Steven Shevlin 

Executive Director 

Signs of Sobriety, Inc.

Ewing, New Jersey

Carla Shird, M.A., CSC­AD 

Counselor 

Mental Health Center 

Gallaudet University Kellogg Conference

Center
 

Washington, DC
 

Mickey J.W. Smith, M.S.W. 

Senior Policy Associate, Behavioral Health 

Program, Policy & Practice Unit 

Division of Professional Development &

Advocacy 

National Association of Social Workers
 

Washington, DC 

Leslie R. Steve, M.A. 

Native American Coordinator 

Center for the Application of Substance

Abuse Technologies 

University of Nevada
 

Reno, Nevada 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders and

Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences

Services 

Department of Veterans Affairs
 

Washington, DC
 

Nancy R. VanDeMark, M.S.W. 

Director 

Research and Program Evaluation 

Arapahoe House, Inc.

Thornton, Colorado

Melvin H. Wilson, M.B.A., LCSW­C 

Baltimore HIDTA Coordinator 

Maryland Department of Parole and

Probation
 

Clinton, Maryland
 

Ann S. Yabusaki, M.Ed., M.A., Ph.D. 

Substance Abuse Director 

Psychologist 

Substance Abuse Programs and Training 

Coalition for a Drug­Free Hawaii

Kaneohe, Hawaii 

Field Reviewers 235
           

           

               

         

           

         

     

Index
 

Because the entire volume is about detoxification and substance abuse treatment, the use

of these terms as entry points has been minimized in this index. Commonly known

acronyms are listed as main headings. Page

references for information contained in figures appear in italics

A

acupuncture, 103–104, 113
 

acute care inpatient settings, 19–20
 

adolescents, 30–31, 118
 

and club drugs, 97
 

Adult Detoxification levels of care, 13
 

adults, older, 109–110
 

African Americans, 113–115
 

aggressive behavior, 27
 

strategies for de­escalating, 28
 

alcohol withdrawal

and benzodiazepine treatment, 58–61

contraindications to using benzodiazepines

during, 61
 

management with medication, 57–58
 

management without medication, 55
 

medical complications, 54
 

and seizures, 64–65
 

signs and symptoms, 52–54
 

alternative treatment, 34, 103–104

and disabilities, 113
 

American Indians, 116–117
 

American Medical Association, position on 

alcoholism, 3
 

Americans With Disabilities Act, 110
 

amphetamines. See stimulants
 

anabolic steroid withdrawal, 96
 

management, 97
 

medical complications of, 96–97
 

patient care and comfort, 97
 

signs and symptoms, 96
 

anticonvulsants, 62
 

antipsychotics, 62
 

anxiety disorders, 139–141
 

antianxiety agents, 143
 

Asians and Pacific Islanders, 115–116
 

assessment
 

and determining rehabilitation plans, 40
 

of psychosocial needs, 39
 

of severity of nicotine dependence, 86–87
 

audience for this TIP, 2
 

B

barbiturates, 61–62

barriers to treatment
 

access, 43–44
 

administrative, 39
 

benzodiazepine
 

contraindications, 61
 

limitations in outpatient treatment, 60–61
 

and phenobarbital withdrawal equivalents, 77
 

and pregnant women, 106, 108
 

symptom­triggered therapy, 58–59
 

tapering dosages, 59
 

and treatment of alcohol withdrawal, 58–61
 

benzodiazepine withdrawal
 

management with medication, 75–76
 

medical complications of, 75
 

signs and symptoms, 74–75
 

biochemical markers, 48
 

biomedical evaluation domains, 25
 

bipolar disorders, 142–143
 

blood alcohol content, 48–49
 

breath alcohol levels, 50
 

buprenorphine
 

and opioid withdrawal, 71–72

and pregnant women, 107
 

bupropion, 92
 

Byrne Formula Grant Program, 154
 

C

carve­outs, 157
 

case management, 44
 

case studies, 48, 102
 

CDT levels, 51
 

central nervous system depression, 66
 

children’s protective services, 154
 

Civilian Health and Medical Program of the
 

Veterans Administration, 152–153
 

client advocates, 33
 

clinically managed residential detoxification, 17
 

Clinical Practice Guidelines for Detoxification of
 

Chemically Dependent Inmates, 119
 

clonidine
 

detoxification, 72
 

and opioid withdrawal, 70–71
 

and pregnant women, 107
 

and rapid detoxification, 73
 

club drugs, 97
 

ecstasy, 99–100
 

GHB, 98–99
 

hallucinogens, 98
 

Index 237
 
ketamine and PCP, 100–101
 

and pregnant women, 109
 

cocaine. See stimulants
 

Commission on Accreditation of Rehabilitation 

Facilities, 17, 27
 

Community Reinforcement and Family Training 

(intervention), 34
 

complementary medicine. See alternative 

treatment
 

confidentiality, 28, 165
 

confrontation, 35
 

Contracting for Managed Substance Abuse and 

Mental Health Services: A Guide for 

Public Purchasers, 161
 

contracts, managed care, 158–159
 

co­occurring medical conditions, 24–26, 26, 

110–113
 

acute trauma, 135
 

cancer, 134–135
 

cardiovascular disorders, 125–127
 

diabetes, 135
 

gastrointestinal disorders, 122–125
 

general principles of care, 122
 

hematologic disorders, 127–128
 

infectious disease, 132–134
 

neurologic system effects, 129–132
 

pulmonary disorders, 128–129
 

co­occurring psychiatric conditions, 27–28, 

136–137
 

anxiety disorders, 139–141
 

bipolar disorders, 142–143
 

depressive disorders, 141–142
 

and pharmacologic agents, 137–138
 

psychotic disorders, 143
 

and psychotropic medications, 138–139
 

substance induced, 139
 

cost methodologies, 159–161
 

criminal justice systems, 118–119, 154
 

cultural competence, 32–33, 44
 

questions to guide practitioners, 32
 

D

decisional balancing strategies, 37
 

definitions, 6
 

detoxification, 4
 

disabilities, 111
 

evaluation, 4
 

fostering entry to treatment, 5
 

maintenance, 6
 

regarding disabilities, 111
 

social detoxification, 17
 

stabilization, 4
 

substance, 5
 

substance intoxication, 5
 

substance­related disorder, 5
 

substance withdrawal, 5
 

treatment/rehabilitation, 5–6
 

delirium, 63–66
 

delirium tremens, 63
 

depressive disorders, 27, 141–142
 

antidepressants, 144
 

detoxification
 

building a program, 145–146
 

clinically managed residential, 17
 

definition of, 4
 

as distinct from substance abuse treatment, 4
 

history of services, 2–3
 

inpatient versus outpatient programs, 20, 21
 

linkage with substance abuse treatment, 8
 

medical model of, 3
 

outpatient, 13
 

principles for care during, 24
 

rapid, ultrarapid, 73
 

service setting changes, 146
 

social model of, 3, 55
 

strengthening market position of program,
 

167–168
 

disabilities, 110–113, 112
 

definitions, 111
 

locating expert assistance, 114
 

domestic violence, 31
 

Drug Addiction Treatment Act of 2000, 72
 

drug­free environment, maintaining, 34
 

E

ecstasy, 99–100
 

enhancing motivation, 34
 

ERs, and urgent care facilities, 15
 

evaluation
 

definition of, 4
 

initial, 24
 

F

Fetal Alcohol Syndrome, 108, 117
 

fostering entry to treatment, definition of, 5
 

freestanding substance abuse treatment 

facility, 16–17
 

funding issues, 147–148, 155, 162–163
 

grant funding, 156, 157
 

multiple funding streams, 166
 

G

gays and lesbians, 117–118
 

GGT levels, 51
 

GHB, 98–99
 

grant funding, 156, 157
 

guiding principles, 7
 

238 Index
H

hallucinogens, 98
 

hepatitis, and GGT levels, 51
 

Hispanics/Latinos, 117
 

history of detoxification services, 2–3
 

HIV/AIDS, 134
 

detoxification as a means to inhibit spread 

of, 3
 

homeless patients, 43
 

I
 

incarcerated persons, 118–119
 

Indian Health Service, 152
 

infectious disease, 26–27, 132–134
 

inhalant/solvent withdrawal
 

management with medication, 83
 

management without medication, 82
 

medical complications of, 82
 

patient care and comfort, 83–84
 

signs and symptoms, 82
 

inhalants/solvents, commonly abused, 83–84

inpatient detoxification programs, versus 

outpatient programs, 20, 21
 

instruments, for dependence and withdrawal, 49
 

intensive outpatient programs, 18–19
 

interventions
 

Community Reinforcement and Family 

Training, 34
 

Johnson Intervention, 35
 

intoxication, signs and symptoms, 52, 53
 

J

Johnson Intervention, 35
 

Joint Commission on Accreditation of 

Healthcare Organizations, 17, 27
 

K

ketamine, 100–101
 

kindling effect, 54, 56
 

L

least restrictive care, 12
 

levels of care, 39
 

acute care inpatient settings, 20
 

Adult Detoxification, 13
 

ambulatory detoxification, 14
 

clinically managed residential 

detoxification, 17
 

intensive outpatient programs, 18–19
 

medically monitored inpatient 

detoxification, 17
 

urgent care facilities and ERs, 16
 

linkages
 

to followup medical care, 45
 

to ongoing psychiatric services, 44
 

to treatment and maintenance activities, 42
 

M

malnutrition, 28
 

managed care

accreditation, 161–162

contracts, 158–159

financial risk in, 159–161

performance measurement, 164–165

recordkeeping, 165–166

marijuana, 95
 

and pregnant women, 109
 

market position, strengthening, 167–168
 

MCV levels, 51
 

Medicaid, 149–150
 

medically monitored inpatient detoxification, 17
 

medical model of detoxification, 3
 

Medicare, 151
 

methadone
 

detoxification, 72
 

and opioid withdrawal, 69–70
 

and pregnant women, 106
 

motivational enhancements, 34
 

N

nicotine, 84–85
 

assessing severity of dependence, 86–87
 

Fagerstrom Test for Nicotine Dependence, 87
 

Glover­Nilsson Smoking Behavioral
 

Questionnaire, 88
 

and pregnant women, 108–109
 

Treating Tobacco Use and Dependence: 

Clinical Practice Guidelines, 90, 93
 

nicotine replacement therapy, 91–92
 

combining, 93–94
 

and pregnant women, 109
 

nicotine withdrawal, 86
 

effects of abstinence on blood levels of 

psychiatric medications, 90
 

interventions, 90–91, 91
 

management with medication, 91–94
 

management without medication, 89–90
 

medical complications of, 87–89
 

patient care and comfort, 94
 

signs and symptoms, 85–86, 89
 

nutrition

deficits, 29–30

evaluation, 28–29

Index 239
 
O

office­based detoxification. See detoxification,
 

outpatient
 

older adults, 109–110
 

opioid withdrawal
 

and buprenorphine, 71–72
 

and clonidine, 70–71
 

management with medication, 68–69
 

management without medication, 68
 

and methadone, 69–70
 

signs and symptoms, 66–68, 67
 

outpatient programs, versus inpatient 

programs, 20, 21
 

P

parents, 31
 

partial hospitalization programs. See intensive
 

outpatient programs
 

patient care and comfort, 66, 73–74
 

anabolic steroid withdrawal, 97
 

inhalant/solvent withdrawal, 83–84
 

nicotine withdrawal, 94
 

stimulant withdrawal, 81
 

patient education, 33
 

Patient Placement Criteria, ASAM, 12–13, 39
 

performance measurement, 164–165
 

pharmacotherapy
 

and anxiety disorders, 140–141
 

and bipolar disorders, 142–143
 

and depressive disorders, 141–142
 

nonnicotine, 92–93
 

phenobarbital withdrawal
 

and benzodiazepine, 77
 

and sedative­hypnotics, 78
 

physicians, and preparing patients to enter
 

detoxification, 13
 

placement matching, challenges to, 11–12
 

polydrug abuse, 101–102
 

prioritizing substances of abuse, 102–103
 

pregnant women, 43, 105–106
 

and alcohol, 106
 

and marijuana, 109
 

and nicotine, 108–109
 

and opioids, 106–108
 

and solvents, 108
 

and stimulants, 108
 

principles for care during detoxification, 24
 

Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, 

and Transgender Individuals, A, 118
 

psychiatric services, linkages to, 44
 

psychosocial evaluation domains, 25
 

psychotic disorders, 143
 

public housing, 153

public intoxication, prior to 1970s, 2–3

R

rapid detoxification, 73
 

recordkeeping, 165–166
 

referral sources, 146
 

Rehabilitation Act of 1973, 110
 

reimbursement systems, 8
 

relapse
 

chronic, 33
 

prevention, 62–63
 

research funding, 156
 

rohypnol, 101
 

Ryan White CARE Act, 154
 

S

scope of this TIP, 2
 

sedative­hypnotics, and phenobarbital 

withdrawal equivalents, 78
 

seizures, 63–66
 

alcohol withdrawal, 64–65, 130
 

what to do in the event of, 65
 

self­pay patients, 156
 

service costs, resources on, 160
 

service delivery, pitfalls of, 8
 

social detoxification, 3, 17, 55–57
 

Social Security Disability Insurance, 151
 

social services, 153–154
 

Social Services Block Grant, 153
 

solvents, and pregnant women, 108
 

stabilization, definition of, 4
 

staffing issues
 

acute care inpatient settings, 20
 

inpatient detoxification programs, 18
 

intensive outpatient programs, 19
 

in outpatient detoxification, 14
 

stages of change, 35–37, 36
 

State Children’s Health Insurance Program, 152
 

steroids, anabolic, 96
 

stimulants, 76
 

and pregnant women, 108
 

stimulant withdrawal
 

management with medication, 81
 

management without medication, 80
 

medical complications of, 80, 81
 

patient care and comfort, 81
 

symptoms, 79–80
 

substance
 

changing patterns of use, 3
 

definition of, 5
 

dependence, chronic, 45
 

­induced psychiatric conditions, 139
 

240 Index
intoxication, definition of, 5
 

­related disorder, definition of, 5
 

withdrawal, definition of, 5
 

substance abuse epidemiology, 146–147

Substance Abuse Prevention and Treatment
 

Block Grant, 149
 

substance abuse treatment
 

as distinct from detoxification, 4
 

funding issues, 147–148, 155, 156, 157,
 

162–163
 

linkage with detoxification, 8
 

suicide, 27
 

Supplemental Security Income, 151
 

support systems, 33–34

symptom­triggered benzodiazepine therapy, 

58–59

T

tapering dosages, benzodiazepine, 59
 

Temporary Assistance to Needy Families, 153
 

THC abstinence syndrome, 95
 

therapeutic alliance, 37–38
 

and clinician characteristics, 38
 

TIPs cited
 

Clinical Guidelines for the Use of
 

Buprenorphine in the Treatment of Opioid
 

Addiction (TIP 40), 71
 

Combining Alcohol and Other Drug Abuse
 

Treatment With Diversion for Juveniles in
 

the Justice System (TIP 21), 119, 154
 

Comprehensive Case Management for
 

Substance Abuse Treatment (TIP 27), 44, 45
 

Continuity of Offender Treatment for
 

Substance Use Disorders From Institution to
 

Community (TIP 30), 119, 154
 

Detoxification From Alcohol and Other Drugs
 

(TIP 19), 1
 

Enhancing Motivation for Change in Substance
 

Abuse Treatment (TIP 35), 34, 35
 

Improving Cultural Competence in Substance 

Abuse Treatment (in development), 7, 44,
 

114, 116, 117
 

Medication­Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs
 

(TIP 43), 58, 69, 107
 

Role and Current Status of Patient Placement
 

Criteria in the Treatment of Substance
 

Use Disorders, The (TIP 13), 13, 41
 

Screening and Assessing Adolescents for
 

Substance Use Disorders (TIP 31), 31, 118
 

Screening for Infectious Diseases Among 

Substance Abusers (TIP 6), 132
 

Substance Abuse Among Older Adults (TIP 26),
 

110
 

Substance Abuse: Clinical Issues in Intensive 

Outpatient Treatment (in development), 19
 

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (in development),
 

39, 106, 108, 109
 

Substance Abuse Treatment and Domestic 

Violence (TIP 25), 32
 

Substance Abuse Treatment for Adults in the
 

Criminal Justice System (TIP 44), 119, 154
 

Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues (TIP 36), 44
 

Substance Abuse Treatment for Persons With
 

Co­Occurring Disorders (TIP 42), 27, 45, 93,
 

112, 121, 137
 

Substance Abuse Treatment for Persons With
 

HIV/AIDS (TIP 37), 134
 

Substance Abuse Treatment: Men’s Issues (in
 

development), 39
 

Substance Use Disorder Treatment for People
 

With Physical and Cognitive Disabilities (TIP
 

29), 44, 110
 

Treatment of Adolescents With Substance Use
 

Disorders (TIP 32), 31, 118
 

Tuberculosis Epidemic: Legal and Ethical Issues
 

for Alcohol and Other Drug Abuse
 

Treatment Providers, The (TIP 18), 133
 

transtheoretical model. See stages of change
 

Treating Tobacco Use and Dependence: Clinical 

Practice Guidelines, 90, 93
 

treatment
 

definition of, 5–6
 

initiation of, 42
 

settings, 41
 

TRICARE, 152
 

U

ultrarapid detoxification, 73
 

Uniform Alcoholism and Intoxication Treatment
 

Act, 3
 

urgent care facilities, and ERs, 15
 

urine drug screens, 50
 

utilization and case management, 166–167
 

V
 

violence, 27
 

domestic, 31
 

vocational rehabilitation, 153–154

Index 241
 
W

Washington Circle Group, 4, 164
 

Web sites
 

American Cancer Society, 94
 

American Lung Association, 94
 

Byrne Formula Grant Program, 154
 

children’s protective services, 154
 

Civilian Health and Medical Program of the
 

Veterans Administration, 152–153
 

Commission on Accreditation of
 

Rehabilitation Facilities, 17, 20, 21, 27, 162
 

grant funding sources, 157
 

Health Insurance Portability and
 

Accountability Act, 165
 

Indian Health Service, 152
 

Joint Commission on Accreditation of
 

Healthcare Organizations, 17, 20, 21, 27, 162
 

legal aspects of prescribing buprenorphine, 72
 

Medicaid, 150
 

Medicare, 151
 

model programs, 167
 

National Committee for Quality Assurance, 

162
 

National Institute on Alcohol Abuse and
 

Alcoholism, 156
 

National Institute on Drug Abuse, 156
 

Patient Placement Criteria, ASAM, 166
 

public housing, 153
 

Research Assistant, The, 156
 

Ryan White CARE Act, 154
 

SAMHSA funding opportunities, 149
 

Social Security Disability Insurance, 151
 

State Children’s Health Insurance Program,152
 

Temporary Assistance to Needy Families, 153
 

TRICARE, 152
 

vocational rehabilitation, 154
 

Washington Circle Group, 164
 

withdrawal, 24–26, 33. See also alcohol withdrawal; anabolic steroid withdrawal; benzodiazepine withdrawal; inhalant/solvent withdrawal; nicotine withdrawal; opioid withdrawal;

stimulant withdrawal

women, pregnant, 43, 105–106

wraparound services, 43
 

Z

Zyban, 92
 

242 Index
243

SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,

program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs

are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept

within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by

TIP 43

TIP 2 Pregnant, Substance-Using Women—Replaced by

TIP 51

TIP 3 Screening and Assessment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed Infants

TIP 6 Screening for Infectious Diseases Among Substance

Abusers—Archived

TIP 7 Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and Other

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine- Abusing

Methadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53

TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use

Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians

TIP 14 Developing State Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse Treatment

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized

Trauma Patients 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 17 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues

for Alcohol and Other Drug Abuse Treatment

Providers—Archived

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution Therapy—Replaced by TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the

Justice System 

 Quick Guide for Clinicians and Administrators 
244

TIP 22 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing 

 Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for Primary

Care Clinicians 

 Concise Desk Reference Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic Violence 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 26 Substance Abuse Among Older Adults 

 Substance Abuse Among Older Adults: A Guide for

Treatment Providers 

 Substance Abuse Among Older Adults: A Guide for

Social Service Providers 

 Substance Abuse Among Older Adults: Physician’s

Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 27 Comprehensive Case Management for Substance

Abuse Treatment

 Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers 

 Case Management for Substance Abuse Treatment: A

Guide for Administrators 

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by

TIP 49

TIP 29 Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities

 Quick Guide for Clinicians

 

 KAP Keys for Clinicians 

 Quick Guide for Administrators 

TIP 30 Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 31 Screening and Assessing Adolescents for Substance

Use Disorders

 See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance Use

Disorders 

 

 

 

 

 

Quick Guide for Clinicians 

 

 

 KAP Keys for Clinicians 

TIP 33 Treatment for Stimulant Use Disorders

Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 34 Brief Interventions and Brief Therapies for Substance

Abuse 

Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 35 Enhancing Motivation for Change in Substance Abuse

Treatment

 Quick Guide for Clinicians 

 

 

 

 

 

 

 

 

 

 

 

 

 KAP Keys for Clinicians 

TIP 36 Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 Helping Yourself Heal: A Recovering Woman’s Guide to

Coping With Childhood Abuse Issues 

 Also available in Spanish

 Helping Yourself Heal: A Recovering Man’s Guide to

Coping With the Effects of Childhood Abuse 

 Also available in Spanish

TIP 37 Substance Abuse Treatment for Persons With

HIV/AIDS

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide 

 Also available in Spanish

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for

African Americans

TIP 38 Integrating Substance Abuse Treatment and

Vocational Services

 

 

 

 

 

 

Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family Therapy

Quick Guide for Clinicians

 Quick Guide for Administrators

 Family Therapy Can Help: For People in Recovery

From Mental Illness or Addiction
245

TIP 40 Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction

 

 

 

 

Quick Guide for Physicians 

 

 

 

 

 

 

 

 KAP Keys for Physicians 

TIP 41 Substance Abuse Treatment: Group Therapy

Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons With CoOccurring Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs

Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 44 Substance Abuse Treatment for Adults in the

Criminal Justice System

Quick Guide for Clinicians

 KAP Keys for Clinicians 

TIP 45 Detoxification and Substance Abuse Treatment

Quick Guide for Clinicians

 Quick Guide for Administrators

 KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in

Outpatient Treatment

 

 

 

 Quick Guide for Administrators

TIP 47 Substance Abuse: Clinical Issues in Outpatient

Treatment

Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 48 Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery

TIP 49 Incorporating Alcohol Pharmacotherapies Into

Medical Practice

 

 

 

Quick Guide for Counselors 

 Quick Guide for Physicians 

KAP Keys for Clinicians 

TIP 50 Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment

 

 

 

 

 

 

Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 51 Substance Abuse Treatment: Addressing the Specific

Needs of Women

KAP Keys for Clinicians

Quick Guide for Clinicians

 Quick Guide for Administrators

TIP 52 Clinical Supervision and Professional Development

of the Substance Abuse Counselor

 Quick Guide for Clinical Supervisors

 Quick Guide for Administrators

TIP 53 Addressing Viral Hepatitis in People With Substance

Use Disorders

 

 

 

 

 

 

 

Quick Guide for Clinicians and Administrators

 KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 You Can Manage Your Chronic Pain To Live a Good

Life: A Guide for People in Recovery From Mental

Illness or Addiction

TIP 55 Behavioral Health Services for People Who Are

Homeless

TIP 56 Addressing the Specific Behavioral Health Needs of

Men 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 57 Trauma-Informed Care in Behavioral Health

Services 

 

 

 Quick Guide for Clinicians

KAP Keys for Clinicians

TIP 58 Addressing Fetal Alcohol Spectrum Disorders

(FASD)

TIP 59 Improving Cultural Competence
This TIP is a revision of TIP 19, Detoxification From Alcohol and

Other Drugs, and was created by a panel of experts with diverse

experience in detoxification services—physicians, psychologists,

counselors, nurses, and social workers. This revision provides upto-date information about changes in the role of detoxification

in the continuum of services for patients with substance use disorders, increased knowledge of the physiology of withdrawal,

pharmacological advances in the management of withdrawal,

patient placement procedures, and new issues in the management of detoxification services within comprehensive systems of

care. It also expands on the administrative, legal, and ethical

issues commonly encountered in the delivery of detoxification

services and suggests performance measures for detoxification

programs.

Collateral Products

Based on TIP 45

Quick Guide for Clinicians

KAP Keys for Clinicians

Detoxification and

Substance Abuse Treatment

HHS Publication No. (SMA) 15-4131

Printed 2006

Revised 2008, 2012, 2013, and 2015

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration