Detoxification and 

Improvement 

Protocol 

Substance Abuse Treatment 

DETOXIFICATION 

DXt

A Treatment 

TIP 

45 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

KAP KEYS Based on TIP 45 

Detoxification and Substance 

Abuse Treatment 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

KnowledgeApplicationProgram

KAP Keys
 

For Clinicians 

Based on TIP 45 

Detoxification and 

Substance Abuse 

Treatment 

DETOXIFICATION 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Introduction
 

KAP Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) Series published by the Center for 

Substance Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration (SAMHSA). These KAP 

Keys are based entirely on TIP 45 and are designed to meet 

the needs of the busy clinician for concise, easily accessed 

“how-to” information. 

Other Treatment Improvement Protocols (TIPs) 

that are relevant to these KAP Keys: 

TIP 33: Treatment for Stimulant Use Disorders BKD289 

TIP 35: Enhancing Motivation for Change in Substance Abuse 

Treatment BKD342 

TIP 40: Clinical Guidelines for the Use of Buprenorphine in the 

Treatment of Opioid Addiction BKD500 

TIP 43: Medication-Assisted Treatment for Opioid Addiction in 

Opioid Treatment Programs BKD524 
Symptoms and Signs of Conditions 1 

That Require Immediate Medical 

Attention 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

• Change in mental status 

• Increasing anxiety and panic 

• Hallucinations 

• Seizures 

• Insomnia 

• Changes in responsiveness of pupils 

• Significant increases and/or decreases in blood pressure 

and heart rate 

• Abdominal pain 

• Upper and lower gastrointestinal bleeding 

• Temperature greater than 100.4°F (these patients should be 

considered potentially infectious) 

• Heightened deep tendon reflexes and ankle clonus, a reflex 

beating of the foot when pressed rostrally (i.e., toward the 

mouth of the patient), indicating profound central nervous 

system irritability and the potential for seizures 
Intoxication and Withdrawal From 2 

Cocaine, Methamphetamine, and 

Other Stimulants 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Fast Facts: 

• Cocaine and amphetamines (such as methamphetamine) 

are the most frequently abused central nervous system 

stimulants. 

• Stimulants are intensely rewarding and are actually selfadministered by laboratory animals to the point of death. 

Symptoms of Cocaine and Other Stimulant Intoxication 

• Dilated pupils 

• Profuse sweating, often with chills 

• Elevated blood pressure 

• Elevated temperature 

• Increased heartbeat 

• Slowed heart action 

• Teeth grinding 

• Tremors 

• Seizures—mostly for cocaine users 

Withdrawal Symptoms of Cocaine and Other Stimulants 

• Depression 

• Hypersomnia or insomnia 

• Fatigue 

• Anxiety 

• Psychomotor retardation (slow reflexes) 

• Paranoia 

• Drug craving 

Management of Withdrawal From Cocaine, Methamphetamine, 

and Other Stimulants 

• No medication has been developed for treating stimulant 

withdrawal. 

• The most effective means of treating stimulant withdrawal 

involves establishing a period of abstinence from these 

agents. 

• Stimulant withdrawal is not usually associated with medical 

complications. 

• Amantadine may help reduce cocaine use in patients with 

more severe withdrawal symptoms. 

• Modafinil, an anti-narcolepsy agent with stimulant-like action, 

is currently under investigation by one research group as a 

cocaine detoxification agent. 

• Antidepressants, such as selective serotonin reuptake 

inhibitors, can be prescribed for the depression that often 

accompanies methamphetamine or other amphetamine 

withdrawal. 
Intoxication and Withdrawal From 3

Alcohol 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Fast Facts: 

• The clinical presentation of intoxication from alcohol varies 

widely depending in part on blood alcohol level and level of 

previously developed tolerance. 

• Since the elimination rate of alcohol from the body generally 

is 10mg to 30mg percent per hour, the goals for the treatment of alcohol intoxication are to preserve respiration and 

cardiovascular function until alcohol levels fall into a safe 

range. 

Symptoms of alcohol intoxication 

Blood alcohol level is 20mg100mg percent 

• Mood and behavioral 

changes 

• Reduced coordination 

• Impairment of ability to 

drive a car or operate 

machinery 

Blood alcohol level is 101mg200mg percent 

• Reduced coordination of 

most activities 

• Speech impairment 

• Trouble walking 

• General impairment of 

thinking/judgment 

Blood alcohol level is 201mg300mg percent 

• Marked impairment of 

thinking, memory, and coordination 

• Marked reduction in level of 

alertness 

• Memory blackouts 

• Nausea and vomiting 

Blood alcohol level is 301mg400mg percent 

• Worsening of above symptoms with reduction of body 

temperature and blood 

pressure 

• Excessive sleepiness 

• Amnesia 

• Nausea and vomiting 

Blood alcohol level is 401mg800mg percent 

• Difficulty waking the patient 

(coma) 

• Serious decreases in pulse, 

temperature, blood pressure, and rate of breathing 

• Urinary and bowel incontinence 

• Death 

Continued on back 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Alcohol Withdrawal Symptoms 

• Restlessness, irritability, anxiety, agitation 

• Anorexia, nausea, vomiting 

• Hallucinations (auditory, visual, or tactile) 

• Insomnia, intense dreaming, nightmares 

• Grand mal seizures 

• Hyperthermia 

• Increased sensitivity to sound, light, and tactile sensations 

• Delusions, usually of paranoid or persecutory varieties 

• Tremor, elevated heart rate, increased blood pressure 

• Poor concentration, impaired memory and judgment 

• Delirium/disorientation with regard to time, place, person, 

and situation; fluctuation in level of consciousness 

Management of Withdrawal From Alcohol 

• The course of alcohol withdrawal is unpredictable; it is hard 

to tell who will or will not experience life-threatening complications. 

• Deciding whether or not to use medical management for 

alcohol withdrawal requires that patients be separated into 

three groups: 

1.	 Clients who have a history of the most extreme forms of 

withdrawal, that of seizures and/or delirium. The medication treatment of this group should proceed as quickly as 

possible. 

2. Patients who are already in withdrawal and demonstrating 

moderate symptoms of withdrawal also require immediate 

medication. 

3. The third group includes patients who may still be intoxicated, or who have, at the time of admission, been abstinent for only a few hours and have not developed signs or 

symptoms of withdrawal. A decision regarding medication 

treatment for this group should be based on advancing 

age, number of years with alcohol dependence, and the 

number of previously treated or untreated severe withdrawals. 

• The major goal of medical detoxification is to avoid seizures 

and a special state of delirium called delirium tremens (DTs) 

with aggressive use of the primary detoxification drug. 

• Several medications used in the treatment of alcohol withdrawal are: benzodiazepine, barbiturates, anticonvulsants, 

beta blockers/alpha adrenergic agonists, antipsychotics, 

relapse prevention agents. 
Intoxication and Withdrawal 

From Heroin and Other Opioids 

4 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Fast Facts: 

• Opioids are highly addicting. 

• Chronic use of opioids leads to withdrawal symptoms that, 

although not medically dangerous, can be highly unpleasant 

and produce intense discomfort. 

Signs and Symptoms of Opioid Intoxication 

Opioid Intoxication Signs 

• Slow pulse 

• Low body temperature 

• Pinpoint pupils 

• Slurred speech 

• Low blood pressure 

• Sedation 

• Slowed movement 

• Head nodding 

Opioid Intoxication Symptoms 

• Euphoria 

• Pain-killing effects 

• Calmness 

Signs and Symptoms of Opioid Withdrawal 

Opioid Withdrawal Signs 

• Fast pulse 

• High body temperature 

• Enlarged pupils 

• Sweating 

• Increased respiratory rate 

• Yawning 

• High blood pressure 

• Insomnia 

• Abnormally heightened reflexes 

• Gooseflesh 

• Tearing (as in crying) 

• Runny nose 

Opioid Withdrawal Symptoms 

• Abdominal cramps 

• Vomiting 

• Nausea 

• Diarrhea 

• Anxiety 

• Bone and muscle pain 

Continued on back 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Management of Withdrawal From Heroin and Other Opioids 

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

• The management of opioid withdrawal with medication is 

most commonly achieved through the use of methadone. 

• The initial dose requirements for methadone are determined 

by estimating the amount of opioid use and gauging the 

patient’s response to administered methadone. 

• Methadone can be given once daily and generally tapered 

over 3 to 5 days in 5 to 10mg daily reductions. 

• Clonidine can also be used to treat opioid withdrawal, but it 

is usually ineffective for common symptoms such as insomnia, muscle aches, and drug craving. 
Intoxication and Withdrawal From 5

Cannabis (Marijuana) 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Fast Facts: 

• Marijuana and hashish are the two substances containing 

THC (delta-9-tetrahydrocannabinol) commonly used today. 

• The THC abstinence syndrome usually starts within 24 hours 

of cessation. The amount of THC that one needs to ingest in 

order to experience withdrawal is unknown. It can be 

assumed, however, that heavier consumption is more likely 

to be associated with withdrawal symptoms. 

Symptoms of Cannabis Intoxication 

• Impaired short-term memory 

• Impaired attention, judgment, and other cognitive functions 

• Impaired coordination and balance 

• Increased heart rate 

Cannabis Withdrawal Symptoms 

• Anxiety 

• Restlessness 

• Irritability 

• Sleep disturbance 

• Change in appetite 

• Tremor 

• Sweating 

• Elevated heart rate 

• Nausea, vomiting, diarrhea 

Management of Withdrawal From Cannabis 

• There are no medical complications of withdrawal from THC, 

and medication is generally not required to manage withdrawal. 

• Screening the patient for suicidal ideation or other mental 

health problems is warranted. 

• The patient should be encouraged to maintain abstinence 

from THC as well as other addictive substances. 
Intoxication and Withdrawal From 

Other Drugs: An Overview 

KAP KEYS Based on TIP 

Detoxification and Substance Abuse Treatment 

6 

Nicotine 

Two issues regarding tobacco smoking merit consideration by 

staff of substance abuse detoxification programs. The first is 

the program management’s desire to establish a smoke-free 

treatment environment to comply with workplace ordinances 

and to safeguard the health and comfort of patients from exposure to second hand smoke. The second issue is the patient’s 

dependence on nicotine as a drug of abuse. 

Drugs That Do Not Produce a Withdrawal Syndrome 

Chronic use of PCP can cause toxic psychosis that takes days 

or weeks to clear; however, PCP does not have a withdrawal 

system. LSD and ecstasy do not produce physical dependence. 

Polydrug Use 

People who abuse substances rarely use just one substance. 

Typical combinations and preferred modes of treatment are as 

follows: 

• Alcohol and stimulant: Treat alcohol abuse. 

• Cocaine and opiate: Treat opiate dependence. 

• Cocaine and amphetamine: No detoxification protocol is 

known. 
Initial Evaluation Domains 7 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Biomedical 

General Health History What is the patient’s medical 

and surgical history? Are 

there any psychiatric or medical conditions? Are there 

known medication allergies? 

Is there a history of seizures? 

Mental Status Is the patient oriented, alert, 

cooperative? Are thoughts 

coherent? Are there signs of 

psychosis or destructive 

thoughts? 

General Physical 

Assessment 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. 

Continued on back 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Psychosocial 

Demographic Features Gather information on gender, 

age, ethnicity, culture, language, and educational level. 

Living Conditions Is the patient homeless or living in a shelter? What is the 

living situation? Are significant 

others in the home (and, if so, 

can they safely supervise)? 

Violence, Suicide Risk Is the patient aggressive, 

depressed, or hopeless? Is 

there a history of violence? 

Transportation Does the patient have adequate means to get to 

appointments? Do other 

arrangements need to be 

made? 

Financial Situation Is the patient able to purchase medications and food? 

Does the patient have adequate employment and 

income? 

Dependent Children Is the patient able to care for 

children, provide adequate 

child care, and ensure the 

safety of children? 

Legal Status Is the patient a legal resident? 

Are there pending legal matters? Is treatment court 

ordered? 

Physical, Sensory, or 

Cognitive Disabilities 

Does the client have disabilities that require consideration? 
Recommended Areas for 

Assessment to Determine 

Appropriate Rehabilitation Plans 

8 

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

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, substance-free friends, involvement in support groups 

Co-Occurring 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 co-occurring 

disorders should include a 

determination of any psychiatric medications that the 

patient may be taking for the 

condition) 

Continued on back 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Domain Description 

Dependent Children Custody of dependent children or caring for noncustodial children and options for 

care of these children during 

rehabilitation 

Trauma and Violence Current domestic violence 

that affects the safety of the 

living environment, co-occurring posttraumatic stress disorder or trauma history that 

might complicate rehabilitation 

Treatment History Prior successful and unsuccessful rehabilitation experiences that might influence 

the decision about type of 

setting indicated 

Cultural Background Cultural identity, issues, and 

strengths that might influence 

the decision to seek culturally 

specific rehabilitation programs, culturally driven 

strengths or obstacles that 

might dictate level of care or 

setting 

Strengths and Resources Unique strengths and 

resources of the client and 

his or her environment 

Language Language or speech issues 

that make it difficult to communicate, or require an interpreter familiar with substance 

abuse 
Commonly Abused Inhalants 9

KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Type Examples Chemicals in 

Inhalant 

Adhesives Airplane glue Toluene, ethyl 

acetate 

Other glues Hexane, toluene, 

methyl chloride, 

acetone, methyl 

ethyl ketone, 

methyl butyl ketone 

Special cements Trichloroethylene, 

tetrachloroethylene 

Aerosols Spray paint Butane, propane 

(U.S.), fluorocarbons, toluene, 

hydrocarbons, 

“Texas shoe shine” 

(a spray containing 

toluene) 

Hair spray Butane, propane 

(U.S.), chlorofluorocarbons (CFCs) 

Deodorant; air 

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 

Continued on back 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Type Examples Chemicals in 

Inhalant 

Cleaning agents Dry cleaning Tetrachloroethylene, 

trichloroethane 

Spot remover Xylene, petroleum 

distillates, chlorohydrocarbons 

Degreaser Tetrachloroethylene, 

trichloroethane, 

trichloroethylene 

Solvents and gases Nail polish 

remover 

Acetone, ethyl 

acetate 

Paint remover Toluene, methylene 

chloride, methanol 

acetone, ethyl 

acetate 

Paint thinner Petroleum distillates, 

esters, acetone 

Correction fluid 

and 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, R.L. The pharmacology of inhalants. In: 

Graham, A.W., Schultz, T.K., Mayo-Smith, M.F., Ries, R.K., and 

Wilford, B.B., eds. Principles of Addiction Medicine. 3d ed. 

Chevy Chase, MD: American Society of Addiction Medicine, 

2003. pp. 295–304. 

Continued on next page 
KAP KEYS Based on TIP 45 

Detoxification and Substance Abuse Treatment 

Management of Withdrawal From Inhalants 

• It is crucial to provide the patient with an environment of 

safety that removes him or her from access to inhalants. 

• Patients presenting with only inhalant withdrawal are unusual; clinicians should promptly ascertain if the patient has 

been abusing other substances and proceed with appropriate detoxification as clinically indicated. 

• No systemic detoxification protocol has been established for 

inhalant abuse. 
Ordering Information
 

TIP 45 

Detoxification and Substance 


Abuse Treatment
 

Three Ways to Obtain Free Copies 

of All TIPs Products 

1.	 Call SAMHSA’s National Clearinghouse for Alcohol and 

Drug Information (NCADI) at 800-729-6686, 

TDD (hearing impaired) 800-487-4889. 

2. 	Visit NCADI’s Web site at www.ncadi.samhsa.gov. 

3. 	You can also access TIPs online at: 

www.kap.samhsa.gov. 

Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of 

Communications, Substance Abuse and Mental Health 

Services Administration, U.S. Department of Health and 

Human Services. 

DHHS Publication No. (SMA) 06-4224 

Printed 2006