Detoxification and
 

Substance Abuse Treatment
 

Training Manual
 

Based on
 

A Treatment 


Improvement 


Protocol
 

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 
Detoxification
 

and Substance Abuse 


Treatment Training Manual
 

Based on
 

A Treatment
 

Improvement
 

Protocol
 

TIP
 

45
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Acknowledgments 

Numerous people contributed to the development 

of this training manual based on Treatment 

Improvement Protocol (TIP) 45: Detoxification and 

Substance Abuse Treatment. This publication 

was produced under the Central East Addiction 

Technology Transfer Center (ATTC), under grant 

number TI 13427, for the Center for Substance 

Abuse Treatment (CSAT), Substance Abuse and 

Mental Health Services Administration (SAMHSA), 

U.S. Department of Health and Human Services 

(HHS). Eric B. Broderick, D.D.S., M.P.H., served 

as the SAMHSA Acting Administrator. H. Westley 

Clark, M.D., J.D., M.P.H., CAS, FASAM, served as 

the CSAT Director. Catherine D. Nugent, LCPC, 

served as the CSAT Government Project Officer 

(GPO) for the ATTCs. Thomas G. Durham, Ph.D., 

served as Project Director. Donna Ruscavage, 

M.S.W., is primary author for the inservice training 

manual. Thomas G. Durham, Ph.D., and Cynthia 

Moreno Tuohy, N.C.A.D.C. II, are coauthors. 

Deborah Petska, M.A., is managing editor. Yen-Wen 

Chau, M.F.A., provided graphic design and layout 

assistance. Clifton Coles, M.F.A., provided editorial 

services. 

The Knowledge Application Program (KAP), 

contract number 270-04-7049, a Joint Venture of 

The CDM Group, Inc., and JBS International, Inc. 

(JBS), provided production assistance. Christina 

Currier served as the CSAT KAP GPO. Lynne 

MacArthur, M.A., A.M.L.S., served as the JBS KAP 

Executive Project Co-Director, and Barbara Fink, 

RN, M.P.H., served as the JBS KAP Managing 

Project Co-Director. 

Disclaimer 

The views, opinions, and content expressed 

herein are those of the expert panel and do not 

necessarily reflect the views, opinions, or policies 

of CSAT, SAMHSA, or HHS. No official support of or 

endorsement by CSAT, SAMHSA, or HHS for these 

opinions or for particular instruments, software, or 

resources is intended or should be inferred. 

Public Domain Notice 

All materials appearing in this volume except 

those taken directly from copyrighted sources are 

in the public domain and may be reproduced or 

copied without permission from SAMHSA/CSAT or 

the authors. 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 downloaded or ordered 

at http://www.samhsa.gov/shin. Or, please 

call SAMHSA’s Health Information Network at 

1-877-SAMHSA-7 (1-877-726-4727) (English 

and Español). The document and accompanying 

PowerPoint slides can be downloaded from the 

KAP Web site at http://www.kap.samhsa.gov. 

Recommended Citation 

Center for Substance Abuse Treatment. 

Detoxification and Substance Abuse Treatment 

Training Manual. HHS Publication No. (SMA) 09­

4331. Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 2008; reprinted 

2009. 

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) 09-4331 

Printed 2008 

Reprinted 2009 
Contents
 

TIP 45: Detoxification and Substance Abuse Treatment Training and Manual Overview . . . . . . . 1
 

TIP 45 Training Purpose...................................................................... 

................................................ 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

........................................................................ 

..................................................................... 

...................................................................... 

............................................................. 

................................... 

..............................................

 . . . . . . . . . . . . . . . . . . . . . . . .

.........................

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1
 

Background on Treatment Improvement Protocols 1
 

TIP 45 Training Rationale 2
 

TIP 45 Training Goals 3
 

TIP 45 Training Overview 3
 

Training Manual Design 7
 

Trainer’s Role and Responsibilities 8
 

Modules 

1. Overview, Essential Concepts, and Definitions in Detoxification 9
 

2. Settings, Levels of Care, and Patient Placement 21
 

3. An Overview of Psychological and Biomedical Issues During Detoxification 29
 

4. Physical Detoxification Services for Withdrawal From Specific Substances 49
 

5. Co-Occurring Medical and Psychiatric Conditions 71
 

6. Financing and Organizational Issues 77
 

iii 

 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

TIP 45: Detoxification 

and Substance Abuse 

Treatment Training and 

Manual Overview 

I . TIP 45 Training Purpose 

The purpose of this training is to provide instruction to substance abuse 

treatment staff and related professionals and service providers about the 

Treatment Improvement Protocol (TIP) 45: Detoxification and Substance 

Abuse Treatment. 

This TIP is a revision of TIP 19: Detoxification from Alcohol and Other 

Drugs, published in 1995. 

The complete text of TIP 45 can be found on line at http://www.ncbi.nlm. 

nih.gov/books/bv.fcgi?rid=hstat5.chapter.85279 along with an extensive 

bibliography and appendices that include common drug intoxication signs 

and withdrawal symptoms and screening and assessment instruments for 

alcohol and drug abuse. 

A complete list of the individuals involved in the production of TIP 45 is 

also included in its appendices. 

II . Back ground on Treatment Improvement 

Protocols (TIPs) 

A . What is a TIP? 

Treatment Improvement Protocols, or TIPs, are best-practice guidelines 

for the treatment of substance use disorders developed by the Center for 

Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental 

Health Services Administration (SAMHSA). 

The CSAT TIP Series has been in production since 1991. There are 

currently 47 TIPs available on a wide variety of topics that are timely and 

important for the advancement of substance abuse treatment. 

Overview 1 
TIP 45: Detoxification and Substance Abuse Treatment 

B . How is a TIP Developed? 

Topics for TIPs are generated through collaboration with State Alcohol and 

Drug Abuse Directors and CSAT’s Knowledge Application Program (KAP) 

and are based on the field’s current needs for information and guidance. 

Once a topic is selected, CSAT forms a Resource Panel comprising staff 

from pertinent Federal agencies and national organizations to make 

recommendations regarding focus areas and resources to be used for 

the TIP. 

Resource Panel recommendations are shared with a non-Federal, peernominated Consensus Panel composed of experts on the particular topic 

of the TIP. These experts represent diverse backgrounds and include 

clinical researchers, clinicians, counselors, psychologists, social workers, 

program administrators, and client advocates. 

The Consensus Panel participates in a series of intensive discussions to 

review and debate relevant research findings, demonstration experience, 

and implementation requirements until it reaches consensus on best 

practices. 

The Consensus Panel’s work is then reviewed and critiqued by expert field 

reviewers across the United States, and a final TIP is produced. 

C . How to Access the TIP Series 

There are currently 47 TIPs available, accessible through the Internet on 

the KAP Web site, http://www.kap.samhsa.gov/products/manuals/tips/ 

index.htm. 

Copies of the TIPs can also be obtained by calling SAMHSA’s Health 

Information Network at 1-877-726-4727. 

III . TIP 45 Training Rationale 

The integration of detoxification and substance abuse treatment has 

become an increasingly important part of the continuum of care for 

individuals undergoing supervised withdrawal from substances of 

dependency, because 

■ Individuals undergoing detoxification are in the midst of a personal 

and a medical crisis that can facilitate a real window of opportunity 

for them to acknowledge their substance abuse problem and 

become willing to consider and seek treatment. 

■ Research indicates that detoxification is often followed by reduced 

drug use and increased treatment-seeking behavior. 

■ Detoxification staffers are in a unique and key position to not 

only ensure a safe and humane withdrawal from substances of 

dependency, but also facilitate a patient’s entry into treatment. 

2 Overview 
TIP 45: Detoxification and Substance Abuse Treatment 

While detoxification is a highly valued key service, it is but one component 

in the continuum of health care services required for substance-related 

disorders. Research has shown that large numbers of people each year 

receiving detoxification services do not receive follow-up treatment. 

Today, due to individuals entering treatment at different points of care, 

there is a special and urgent need for nontraditional settings, such as 

emergency rooms, hospital medical/surgical wards, and acute care 

clinics, to be prepared to help detoxification patients seek treatment 

services as quickly as possible. 

This training will provide staff in both traditional and nontraditional 

settings with valuable information for providing detoxification services and 

ensuring linkages to follow-up treatment services. 

IV . TIP 45 Training Goals 

Upon completion of this training, participants will have a basic 

understanding of the complex issues and the required resources to 

develop and/or refine successful strategies for detoxification and 

substance abuse treatment services. 

Participants will have, at the training’s end, an increased understanding 

of the 

■		Essential concepts and definitions in detoxification. 

■		Different treatment settings and the role they play in delivery of 

detoxification and substance abuse treatment services. 

■		Psychosocial and biomedical issues during detoxification. 

■		Physical detoxification services for withdrawal from specific 

substances, including alcohol, opioids, sedative hypnotics, 

stimulants, nicotine, anabolic steroids, and “club drugs.” 

■		Co-occurring medical and psychiatric conditions and their impact on 

detoxification. 

■		Financing and organizational issues, including program 

development and working in a managed care environment. 

V . TIP 45 Training Overview 

A . Modular Approach 

This six-module training program is intended to be a forum for increasing 

linkages between detoxification and substance abuse treatment services. 

The training will provide participants with up-to-date information and 

practical tools. The training includes the following six modules: 

■		Module 1: Overview, Essential Concepts, and Definitions in 

Detoxification 

Overview 3 
 

 

 

 

 

 

 

 

 

 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Module 2: Settings, Levels of Care, and Patient Placement 

■		Module 3: An Overview of Psychosocial and Biomedical Issues 

During Detoxification 

■		Module 4: Physical Detoxification Services for Withdrawal From 

Specific Substances 

■		Module 5: Co-Occurring Medical and Psychiatric Conditions 

■		Module 6: Financing and Organizational Issues 

B . Target Audience 

TIP 45 and this training manual are designed for use by a varied target 

audience, including: substance abuse treatment counselors; administrations 

of detoxification programs; Single State Agency (SSA) directors; psychiatrists 

and physicians working in the field; other primary care providers, such as 

nurse practitioners, physician assistants, and nurses; social workers; staff of 

managed care and insurance carriers; policymakers; and others involved in 

planning, evaluating, and delivering detoxification services. 

C . Training Delivery Options 

The content of each of the modules builds on the information in the 

preceding modules. Learning objectives for each module are sequential, 

moving from more general concepts and definitions to more specific 

information on and tools for detoxification and substance abuse 

treatment services. 

It is suggested that these modules be delivered in the order in which they 

are presented. The training can be conducted in one day, or the sessions 

can be spread out over time. It is strongly recommended to allow no 

more than a 2-week period to deliver this training. If the training extends 

over a longer period, participants may forget basic information, and the 

continuity of the program could be lost or significantly compromised. 

The training process includes brief didactic presentations, facilitated 

large-group discussions, and small-group activities; these are all based on 

content-specific information contained in TIP 45. Trainers are encouraged 

to have participants use their own agency experiences as examples for 

discussions and exercises. 

The training manual has been developed so that the modules can be 

individually tailored to the needs of the participating trainees. Modules 

1, 2, and 6 are each created for 1-hour sessions that can be extended 

depending on the participants’ needs. Module 5 will take 30 minutes to 

complete. Modules 3 and 4 will take longer than Modules 1, 2, 5, and 6 to 

deliver because they cover more material. Suggested times for all exercises 

within a module are included. Trainers will need to develop their own 

agendas for the entire training and for each training module given their 

individual time and training constraints and participant training needs. 

4 Overview 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

Training time can be used more efficiently and effectively if the 

participants are given TIP 45 and any module handouts to read before 

the training. If the training is being delivered over an extended period, 

then, beginning with the introductory session, handouts for the next 

training module and reading assignments in TIP 45 can be distributed to 

participants at the end of each session as “homework.” 

Participant attendance at each module is important, both for the 

individual participant and for the functioning of large-group discussions 

and small-group activities. The requirement for full attendance must be 

clearly stated to participants at the beginning of the training. 

The option of providing certificates of training completion and/or 

Continuing Education Units (CEUs) will depend primarily on professional 

and/or State requirements. If this training meets professional and/or 

State continuing education guidelines, attendance records will need to be 

maintained to document participant attendance. 

Trainers can use training or module sign-in sheets to reinforce full 

participation whether or not they provide Certificates of Completion or 

CEUs to trainees. 

D . Trainer-to-Participant Ratio and Trainer 

Qualifications 

The optimal trainer-to-participant ratio is one trainer for each 10 to 15 

participants. This ratio will enable the trainer to provide individualized 

attention and coaching during the training. This training is most effective 

as a small-group training with no more than 30 participants at a time. 

Because of the complex medical and psychosocial content of the training, it 

is recommended to have two trainers deliver this training: one with clinical/ 

medical expertise and one with mental health/counseling expertise. 

In addition to these two core trainers, guest lecturers might be 

appropriate, when possible, to cover more specialized topics. 

This training will be most effective if trainers with prior training experience 

are used to deliver all six of the training modules. 

E . Training Logistics 

This training is best conducted in facilities with movable seating. The 

initial seating arrangement needs to be designed to facilitate largegroup discussions, such as a U-shaped or semicircular layout. Trainers 

should be able to easily move the seating or have ample room so that 

participants can form small groups for the small-group activities. 

If possible, the day before the training, inspect the training room for 

proper setup and required equipment. 

Develop a pre-training checklist to ensure that all required training aids— 

flip charts, markers, tape, LCD projectors, PowerPoint® presentations, 

Overview 5 
TIP 45: Detoxification and Substance Abuse Treatment 

overhead projectors, overheads, etc.—are available well before the 

training date. 

The PowerPoint slides can be downloaded from the KAP Web site, http:// 

www.kap.samhsa.gov/products/trainingcurriculums/index.htm. The slides 

can be saved as presentations or, if necessary, printed to make overhead 

slides. 

Photocopy in advance any handouts and homework assignments and 

make arrangements for the trainers to meet or conduct a conference call 

prior to the training. 

If appropriate, ensure that arrangements for refreshments are completed 

well before the training date. 

F . Cultural Considerations 

Successful detoxification and substance abuse treatment services are 

dependent upon an individual’s successful behavior change. Behavior 

change is a highly complex process, particularly since behavior can be 

deeply rooted in culture. 

Individuals seeking detoxification and substance abuse treatment 

services, as well as the individuals who are providing these services, have 

diverse cultural backgrounds. 

Trainers need to be aware of cultural dynamics that can influence the 

behaviors of the individuals their training participants work with, including 

alcohol and drug-using behavior, how individuals choose to communicate 

about personal issues, and their attitudes toward seeking information 

and assistance. Trainers likewise need to be aware of differing cultural 

dynamics among their training participants. 

The operating definition of culture used here is the shared values, norms, 

traditions, customs, arts, history, folklore, and institutions of a group of 

people. These shared beliefs serve as guides to and determinants of 

behavior within cultural groups. 

While cultural commonalities can be observed among groups of people, 

considerable variation can also be identified within groups based on 

factors of age, education, gender, and exposure to other cultures. Keep in 

mind also that culture is complex and never static; it is always changing 

and adapting to a continuously changing environment. 

The best approach for trainers is to be sensitive and aware of the cultural 

issues that may be influencing the behavior of the individuals training 

participants work with, as well as of the training participants themselves. 

Effective communication with training participants of different cultures 

includes 

■ Actively listening to what a participant is saying. 

■ Responding to what is being said, not how it is said. 

6 Overview 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Allowing individuals to fully express themselves before responding 

to a situation or a concern. 

■		Avoiding reactions like anger, shock, or laughter that may convey 

disapproval of a participant’s viewpoint. 

■		Asking open-ended questions to clarify what a participant is saying. 

■		Acknowledging the person’s point of view. 

■		Not making a value judgment about what a participant is saying. 

■		Knowing that it is acceptable to offer different points of view. 

■		Knowing that it is all right to “agree to disagree.” 

■		Committing to being available to provide support. 

■		Always thanking participants for sharing their points of view and/or 

concerns with the group. 

Keep in mind that some people and cultures focus more on individuality 

while others focus more on being members of a group; this could 

influence interaction and participation in the training. 

G . Evaluation 

It is not uncommon for trainers to overlook evaluation of their efforts, yet 

this type of feedback is critical to help improve future course content and 

delivery. 

Evaluation can be conducted using written forms and/or facilitating an 

oral discussion. 

An effective way to obtain feedback using an oral discussion format is to 

list on newsprint participants’ “pluses” and “wishes” for each module. 

Participants share what they found beneficial or liked about the training 

and describe their wishes for improvements to the training. Oral input, like 

written input, can be used to guide future trainings. 

VI . Training Manual Design 

This manual outlines a training that has been divided into six modules 

that can be adapted to meet the training needs of the participants. The 

manual includes talking points, discussion initiators, slides/overheads, 

large-group facilitated discussions, and small-group exercises. 

Each of the six training modules includes 

■		Learning objectives. 

■		TIP 45 references. 

■		Suggested total time to deliver module. 

■		Training equipment and supplies. 

Overview 7 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Participant materials. 

■		Detailed training plans with suggested times, including 

- Didactic presentations. 

- Facilitated large-group discussions. 

- Directions for small-group exercises and exercise processing. 

■		Summary and closing. 

In the left-hand margin of each module page, there are symbols indicating 

materials required, thumbnails of actual slides/overheads, trainer notes, 

group exercises, a time clock, cultural considerations, TIP 45, and other 

symbols to help guide trainers. 

VII . Trainer’s Role and Responsibilities 

To increase participants’ knowledge of detoxification and substance 

abuse treatment, the trainer will deliver informative lectures, facilitate 

group discussions, and process small-group activities. 

The trainer will ensure that all logistical considerations have been met, 

potentially including CEUs, Certificates of Completion, and refreshments. 

As the group leader, or co-group leader, the trainer also is the official 

timekeeper. The trainer needs to keep the discussion on topic and the 

training on time. 

In providing expertise and guidance to participants, the trainer should 

not prescribe the use of any single model or strategy over another and 

should ensure that participants receive accurate information on effective 

detoxification and substance abuse treatment strategies. 

It is the trainer’s responsibility to ensure that all participants are fully 

engaged in the training process and are treated with respect. 

8 Overview 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 1: Overview, 

Essential Concepts 

and Definitions in 

Detoxification 

Learning Objectives 

Upon completion of Module 1, participants will be able to 

1.		 Define detoxification as distinct from substance abuse 

treatment. 

2.		 Describe the three essential components of detoxification: 

evaluation, stabilization, and fostering the patient’s entry into 

treatment. 

3.		 Distinguish the six different DSM-IV-TR Definitions of Terms 

related to detoxification and substance abuse treatment. 

4.	 Summarize the guiding principles developed by the Consensus 

Panel for TIP 45, Detoxification and Substance Abuse 

Treatment. 

5.	 Identify at least two challenges to providing effective 

detoxification. 

TIP 45 References 

■		What is a TIP?, pp. vii–viii 

■		Executive Summary, pp. xv–xix 

■		Chapter 1: Overview, Essential Concepts, and Definitions in 

Detoxification, pp. 1–10 

Total Time to Deliver Module 

One hour; can be longer depending on participants’ needs 

Module 1 9 
TIP 45: Detoxification and Substance Abuse Treatment 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD projector or overhead transparency projector 

■ PowerPoint ® presentation or overhead transparencies 

■ Nametags 

■ Attendance log 

■ Pens, pencils 

■ Post-it ® notes or stickies 

Participant Materials 

■ TIP 45: Detoxification and Substance Abuse Treatment 

■ Module 1 Slides/Overheads Handout 

I . Welcome and Introductions 

A . Trainer Introductions 

Welcome participants to this professional training program on TIP 45: 

Detoxification and Substance Abuse Treatment. 

Introduce yourself and your co-trainer(s). Provide a brief (i.e., 1-minute) 

introduction to identify your workplace and position, describe any 

experience you have had with detoxification, and share a personal piece 

of information. 

Thank participants for choosing to attend this training and acknowledge 

that it is often hard to get out of the office for activities like this. 

Explain that the Treatment Improvement Protocols (TIPs) are manuals of 

best-practice guidelines for the treatment of substance abuse disorders 

developed by the Center for Substance Abuse Treatment (CSAT), one 

of the Centers of the Substance Abuse and Mental Health Services 

Administration (SAMHSA). 

A Consensus Panel of experts across the country reviewed current 

information on detoxification and substance abuse treatment, 

deliberated, and reached consensus on recommendations that formed 

the basis of the TIP. 

State that there are currently 47 TIPs available in CSAT’s TIP Series, which 

began in 1991. 

Direct participants’ attention to a prepared newsprint listing the National 

Library of Medicine’s (NLM) Web site, http://www.ncbi.nlm.nih.gov/ 

books/bv.fcgi?rid=hstat5; page down the left-hand column and click on 

“SAMHSA/CSAT Treatment Improvement Protocols.” 

Copies of the TIPs can also be obtained by calling SAMHSA’s Health 

Information Network (SHIN) at 877-726-4727 (English and Español). 

Trainer note: Prepare a newsprint in advance listing information on how 

to access the TIP Series; post this in the training room. 

10 Module 1 
TIP 45: Detoxification and Substance Abuse Treatment 

B . Participant Introductions 

Ask the participants to introduce themselves. Allow no more than 2 

minutes per participant. Assure participants that though time is limited 

now, they will have plenty of time to become acquainted with each other 

over the course of the training. Participants should state their 

■		Name. 

■		Workplace. 

■		Position. 

■		Experience with detoxification and substance abuse treatment. 

In addition, each should share something personal with the group. 

Trainer note: Prepare a newsprint in advance listing items for participant 

introductions; post it in the training room and have participants refer to it 

when introducing themselves. 

II . Training Process and Training Goals 

A . Training Process 

Explain to participants that this training will cover all six chapters, or 

modules, of TIP 45. Make sure that all participants have received a copy 

of TIP 45: Detoxification and Substance Abuse Treatment or hand out the 

TIP now. Let the participants know that the training will consist of brief 

lectures and interactive exercises. 

Trainer note: Also tell participants that they will be given reading 

assignments for upcoming modules if you are conducting the training 

over more than a single day. 

B . Training Goals 

Review the goals of this training, saying that upon completion of this 

training, participants will have a basic understanding of the complex 

issues and required resources to develop and/or refine successful 

strategies for detoxification and substance abuse treatment services. 

Specifically, at the training’s end, participants will have an increased 

understanding of the 

■		Essential concepts and definitions in detoxification (Module 1). 

■		Different treatment settings and the role they play in the delivery of 

detoxification and substance abuse treatment services (Module 2). 

■		Psychosocial and biomedical issues during detoxification (Module 3). 

■		Physical detoxification services for withdrawal from specific 

substances (Module 4). 

■		Co-occurring medical and psychiatric conditions (Module 5). 

Module 1 11 
 

 

 

 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Financing and organizational issues, including program development 

and working in a managed care environment (Module 6). 

Trainer note: Prepare a newsprint listing the overall goals of the training; 

post this in the training room and refer to it as you go over the goals. 

III . Housekeeping, Ground Rules, and 

Participant Expectations 

A . Housekeeping 

Discuss housekeeping issues with participants including 

■		Meeting times and breaks and information for lunch, if appropriate. 

■		Bathroom, public telephone locations, and designated smoking areas. 

■		Attendance sign-in sheets. 

■		Parking lot. 

Trainer note: Explain that attendance needs to be taken and make sure 

all participants have signed in on a predeveloped sign-in sheet. If you are 

giving Continuing Education Units (CEUs) or Certificates of Completion, 

explain that signing in is even more important. Prepare a newsprint entitled 

“Parking Lot” with two sections—“Immediate” and “Later”—and post this in 

the training room. Distribute Post-its® or stickies to participants and explain 

that they can write down questions and post them in the Parking Lot, where 

their questions will be addressed at some point during the training or after 

the training has been completed. 

B . Ground Rules 

Review ground rules for the training with participants. 

Trainer note: Prepare a newsprint listing the ground rules; keep it posted 

in the training room throughout the training. 

■		Commit to attend— This training is an interactive experience in 

which the information builds upon itself. Participants need to be 

present for the entire training and not arrive late or leave early. 

■		Manage time and task— The trainer commits to begin activities on 

time and to end on time. Ask participants to share the responsibility 

for staying on task and returning on time after breaks. If the course 

is for more that 1 day, ask participants to be responsible for starting 

on time each day. 

■		Respect all opinions— Explain that it is a diverse group and there 

will not always be agreement on issues. Remind participants that 

everyone has a right to her or his beliefs and ideas. Never ridicule or 

make fun of others. Respecting differences is essential to a positive 

learning process. 

12 Module 1 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Observe confidentiality— Remind participants that it is very 

important to keep confidential any personal information revealed 

during the training. 

■		Assume personal responsibility— Let participants know that if they 

find themselves unsure of a concept or information being shared 

during the training, it is expected that they will let the trainer(s) 

know. Likewise, if any of the issues being discussed are disturbing 

to participants, they need to let the trainer know. 

■		One at a time— Explain that everyone cannot be heard at the same 

time. Allow others to speak without interrupting them. Listen while 

others are speaking and do not participate in side conversations. 

■		No beepers or cell phones— Ask participants to turn these devices 

off or put them on silent/vibrate. They will be able to retrieve 

messages during breaks. 

■ Ask participants if they would like to add any other rules and list 

them on the newsprint. 

C . Participant Expectations 

This is a brief discussion to identify participant expectations for the 

course. Conduct a large-group callout and ask participants to share their 

expectations. Write their responses on a newsprint titled “Participant 

Expectations” and post this in the training room. 

Trainer note: Upon completion of the training, as part of the training 

summary and closing, you can review the Participant Expectations to see 

if they were met. 

IV . Introduction to Module 1 

Tell participants that Module 1 will provide them with an overview of the 

history of detoxification services, essential concepts, and definitions in 

detoxification. This module will also explain the guiding principles used 

in the development of the TIP and explore basic challenges to providing 

detoxification services. 

Explain that the integration of detoxification and substance abuse 

treatment has become an increasingly important part of the continuum of 

care for individuals undergoing supervised withdrawal from substances of 

dependency because: 

■		Individuals undergoing detoxification are in the midst of a personal 

and a medical crisis that can facilitate a real window of opportunity 

for them to acknowledge their substance abuse problem and 

become willing to consider and seek treatment. 

■		Research indicates that detoxification is often followed by reduced 

drug-use and treatment-seeking behavior. 

Module 1 13 
 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Detoxification staffers are in a unique and key position, to not 

only ensure a safe and humane withdrawal from substances of 

dependency, but also facilitate a patient’s entry into treatment. 

While detoxification is a highly valued, key service, it is but one component 

in the continuum of health care services required for substance-related 

disorders. Research has shown that large numbers of people receiving 

detoxification services each year do not receive follow-up treatment. 

Today, due to individuals entering treatment at different points of care, 

there is a special and urgent need for nontraditional settings—such as 

emergency rooms, hospital medical/surgical wards, and acute care 

clinics—to be prepared to help detoxification patients seek treatment 

services as quickly as possible. 

Explain to participants that this training will provide them with valuable 

information for providing detoxification services and ensuring linkages to 

follow-up treatment services. 

V . Module 1 Objectives 

Review Module 1 objectives with the participants. Upon completion of 

Module 1, participants will be able to 

1.		 Define detoxification as distinct from substance abuse 

treatment. 

2.		 Describe the three essential components of detoxification: 

evaluation, stabilization, and fostering the patient’s entry into 

treatment. 

3.		 Distinguish the six different DSM-IV-TR Definitions of Terms 

related to detoxification and substance abuse treatment. 

4.	 Summarize the guiding principles developed by the Consensus 

Panel for TIP 45, Detoxification and Substance Abuse 

Treatment. 

5.	 Identify at least two challenges to providing effective 

detoxification. 

VI . History of Detoxification Services 

This is a didactic presentation that includes facilitated discussion where 

indicated. Begin by stating that attitudes toward and knowledge about 

substance use have changed dramatically since the 1950s. As recently 

as 1971, a person was typically arrested for public intoxication without 

being referred for treatment. Summarize these key events in the history of 

detoxification services: 

■		The American Medical Association declared alcoholism a disease in 

1958, implying need for medical intervention. 

14 Module 1 
TIP 45: Detoxification and Substance Abuse Treatment 

■		The 1971 Uniform Alcoholism and Intoxication Treatment Act 

recommended treatment options over criminal prosecution for 

individuals. 

■		More humanitarian views of people dependent on substances 

emerged that focused on providing treatment and support. 

■		Different “models” for treatment emerged, including the medical 

model and the social model. 

Ask participants what the different models are (medical and social 

models). Make the following points if participants do not: 

■		The medical model uses doctors and nursing staff to administer 

medication to safely assist people through withdrawal. 

■		The social model rejects the use of medication and relies on a 

supportive, non-hospital setting to ease withdrawal. 

■		Today, there is no “pure” model for treatment—for example, medical 

models provide support, and social models sometimes administer 

medication to ease withdrawal. 

■		As views toward addiction and treatment changed, so did drug-use 

patterns and their accompanying detoxification needs. 

Facilitated discussion: Ask participants to point out key changes in druguse patterns they have seen through their work over the years. Record 

their responses on newsprint. 

Trainer note: To increase participant interaction, ask a participant to write 

the responses on newsprint. 

Summarize the discussion with the following points: 

■		The popularity of cocaine and heroin led to the need for different 

types of detoxification services. 

■		With the spread of HIV among injection drug users, particularly after 

1985, demand for detoxification services grew as a way to control 

the spread of HIV. 

■		Polydrug use necessitated changes in detoxification services over time. 

■		Today, the AMA’s position is that dependence on drugs is a disease 

and that all treatment and policy decisions need to be based on this 

fact. Detoxification has come a long way since the 1950s and has 

evolved into a compassionate science. 

Module 1 15 
 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

VII . Definition of Detoxification and 

Other Relevant Terms 

A . Definition of Detoxification 

Begin by stating that detoxification is distinct from substance abuse 

treatment. 

Ask participants how detoxification differs from treatment and write 

their responses on newsprint. Summarize the discussion by making the 

following key points: 

■		Detoxification is a set of interventions aimed at managing acute 

intoxication and withdrawal. 

■		Detoxification is a medical intervention that manages an individual 

safely through the process of acute withdrawal. 

■		A detoxification program is NOT designed to resolve long-standing 

psychological, social, and behavioral problems associated with 

substance abuse.
 

■		Detoxification is NOT substance abuse treatment. 

B . Detoxification as a Process 

This is a brief didactic presentation. State that the Consensus Panel has 

defined detoxification as a broad process with three essential components 

that can occur concurrently or take place as a series of steps. Compassion, 

respect, and understanding for the individual are critical in this process. 

The three components of the detoxification process are 

■		Evaluation—screening and assessment in order to 

- Detect presence and concentration of substances. 

- Identify co-occurring medical and psychological conditions. 

- Determine social situation in order to select appropriate level of 

treatment after detoxification. 

Evaluation serves as the basis for the initial substance abuse treatment 

plan upon completion of detoxification. 

■		Stabilization—includes assisting the individual through acute 

intoxication and withdrawal to a medically stable, fully supported 

drug-free state: 

- Medications may be used. 

- The process introduces individuals to treatment and their role in 

recovery.
 

- Significant others are involved for support as appropriate, 

maintaining confidentiality.
	

16 Module 1 
 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Fostering readiness and entry into treatment—involves preparing 

the individual for entry into treatment: 

- Stresses the importance of follow-through regarding the complete 

substance abuse treatment continuum of care 

- Educates about the treatment process and the disease of addiction 

- Can use written treatment contracts 

C . Substance Abuse Treatment Terms 

Provide a brief review of related substance abuse treatment terms, using 

the “DSM-IV-TR Definition of Terms.” 

■		Substance—a drug of abuse, a medication or a toxin 

■		Substance-related disorders—disorders related to the taking of a 

drug of abuse, side effects of medications and toxin exposure 

■		Substance dependence—also referred to as “substance abuse” in 

TIP 45—a group of cognitive, behavioral, and physiological symptoms 

indicating a continuing use of a substance; results in tolerance to the 

substance, withdrawal, and compulsive drug-taking behavior 

■		Substance abuse—also called “substance dependence” in TIP 45—a 

pattern of substance use that can harm a person’s life, marked by 

significant negative consequences related to substance use 

■		Substance intoxication—a reversible substance-specific syndrome 

resulting from recent ingestion 

■		Substance withdrawal—a substance-specific behavior change 

that results from the stopping of or reduction in heavy, prolonged 

substance use 

Describe substance abuse treatment and maintenance. 

■		Treatment or rehabilitation of individuals has the goal of attaining 

a higher level of social functioning while fostering abstinence and 

includes 

- Ongoing assessment of physical, psychological, and social status. 

- Identification of triggers for relapse and strategies for coping with them. 

- Delivery of primary medical and psychiatric care, if needed. 

■		Maintenance includes 

- Continuation of counseling and support, as outlined in the 

treatment plan. 

- Refinement and strengthening of strategies for relapse prevention. 

Close this discussion by saying that from this point forward for TIP 45, you 

will be using the term patient to describe persons in need of detoxification 

services and substance abuse treatment because these persons are 

coming into contact with various personnel (doctors, nurses, social 

workers) in a medical setting where the patient is often sick from the 

effects of withdrawal. In some settings, however, the term patient might 

not be appropriate. 

Module 1 17 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

VIII . Guiding Principles in Detoxification and 

Substance Abuse Treatment 

Explain to participants that TIP 45’s Consensus Panel agreed to the 

following seven key assumptions, which serve as the basis for the 

development of the TIP and provide guiding principles in detoxification 

and substance abuse treatment. 

■		Detoxification in and of itself does not constitute complete 

substance abuse treatment. 

■		The detoxification process consists of three essential components: 

evaluation, stabilization, and fostering patient readiness for and 

entry into treatment.
 

■		Detoxification can take place in a wide variety of settings and at a 

number of levels of intensity within these settings; placement needs 

to be appropriate to the patient’s needs. 

■		All persons requiring treatment for substance use disorders need 

to receive treatment of the same quality and thoroughness and be 

put into contact with substance abuse treatment providers following 

detoxification. 

■		Insurance coverage for the full range of detoxification services 

is cost-effective; when insurance does not pay for the complete 

detoxification process, patients can be released before the process 

is completed, and complications can result that actually drive up 

health care costs. 

■		Individuals seeking detoxification have diverse cultural/ethnic 

backgrounds, unique health needs, and life situations that 

detoxification programs need to be able to address; training and 

ensuring a culturally competent program staff are essential. 

■		A successful detoxification process can be measured in part 

by whether an individual enters and remains in some form of 

substance abuse treatment after detoxification. 

IX . Challenges to Providing Effective 

Detoxification 

Begin this discussion by repeating that effective detoxification includes 

not only medical stabilization of the patient and safe and humane 

withdrawal from drugs or alcohol, but also entry into treatment. 

Trainer note: After presenting the following points, you will be conducting 

a small-group exercise. 

■		Research has shown that detoxification and its linkage to 

treatment leads to increased recovery and decreased utilization of 

detoxification and treatment services in the future. 

18 Module 1 
 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Recovery leads to reductions in crime, general health care costs, 

and expensive medical and surgical treatments related to untreated 

alcohol and drug addiction. 

■		One of the most important challenges to detoxification providers is 

fostering the patient’s recovery; this includes effective linkage to 

treatment services. 

Small Group Exercise: Providing Linkages to Treatment Services 

Exercise Directions: Divide the participants into two to three small 

groups, depending on the size of the group. Have them count off, and 

then have all of the “ones,” “twos,” etc., assemble into respective groups. 

Tell each group that it will need to assign a recorder, timekeeper, and 

reporter/presenter. Give each group newsprint and markers. 

Ask the participants to brainstorm, based on their knowledge and 

experience, the challenges detoxification providers encounter, particularly 

in providing linkages to treatment. 

Give participants 10 minutes to brainstorm. Have the recorder write down 

their responses on newsprint. 

Processing the Exercise: Reassemble into a large group and have each 

small group present its brainstorming results. 

Summarize this exercise by emphasizing the following challenges to 

providing effective detoxification services. 

■		Detoxification services are often not long enough; one 1997 study 

found the average length of stay to be only 3 days. 

■		The majority of patients discharged from detoxification in acute-care 

hospitals and emergency rooms do not receive any substance abuse 

treatment. 

■		Payment for detoxification services is sometimes treated separately 

from treatment services, which can isolate detoxification from treatment. 

■		Some third-party payors will pay only for detoxification services and 

not cover nonmedical counseling services; this can make it difficult 

or impossible for some providers to hire or use counseling staff. 

■		Payors’ understanding that detoxification is only one component of an 

effective substance abuse treatment strategy is, however, increasing. 

■		More widespread use of patient placement criteria, such as those 

from the American Society of Addiction Medicine (ASAM), is helping 

clinicians and insurers reach agreement on the level of treatment 

required by patients, as well as the appropriate setting in which 

treatment services should be delivered. 

Module 1 19 
TIP 45: Detoxification and Substance Abuse Treatment 

X . Module 1 Summary and Closing 

Tell participants that they have received a basic review of detoxification 

and substance abuse treatment and now have a common language 

to proceed forward to discuss specific aspects of detoxification and 

substance abuse treatment. 

Transition Into Module 2: Settings, Levels of 

Care, and Patient Placement 

Trainer note: If you are delivering this course over more than 1 day, give 

participants a homework assignment to read the modules or sections 

of TIP 45 that you will be covering in the next session. Ask participants 

for feedback on this module in the form of “pluses,” or things they liked 

about the session, and “wishes,” or things that they would like to see 

changed or incorporated into future sessions. Prepare a newsprint with a 

line down the middle and “Pluses” on one side and “Wishes” on the other 

and record participants’ responses. 

20 Module 1 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 2: Settings, 


Levels of Care, and 


Patient Placement
 

Learning Objectives 

Upon completion of Module 2, participants will be able to 

1. Define the types of settings for detoxification and treatment 

services. 

2.	 Describe the role of the settings in the delivery of services. 

3.	 Identify at least two concerns regarding levels of care and 

placement. 

TIP 45 References 

Chapter 2: Settings, Level of Care, and Patient Placement, pp. 11–22 

Total Time to Deliver Module 

One hour; can be longer depending on participants’ needs 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD projector or overhead transparency projector 

■ PowerPoint ® presentation or overhead transparencies 

■ Nametags 

■ Attendance log 

■ Pens, pencils 

■ Post-it ® notes or stickies 

Participant Materials 

■ TIP 45: Detoxification and Substance Abuse Treatment 

■ Module 2 Slides/Overheads Handout 

Module 2 21 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

I . Introduction to Module 2 

Tell participants that Module 2 will cover different detoxification and 

treatment settings and the role they play in the delivery of services. 

■		Patient placement is often a complex process; selecting the 

appropriate treatment setting and required level of care is key to 

ensuring patient success. 

■		The overall goal is to place the patient in the least restrictive setting 

that is also the most cost-effective. 

We all know what cost-effective means. Let’s take a few minutes to 

discuss what we mean by least restrictive: 

■		The term refers to patients’ civil rights and their right to choice of care. 

■		Patients have the ability to disagree with recommendations for care, 

including the right to refuse care. 

■		Patients are informed participants in defining their care plan in 

collaboration with their care providers. 

II . Module 2 Objectives 

Review Module 2 objectives with the participants. Upon completion of 

Module 2, participants will be able to 

1.		 Define the types of settings for detoxification and treatment 

services. 

2.	 Describe the role of the settings in the delivery of services. 

3.		 Identify at least five issues to consider in determining whether 

inpatient or outpatient detoxification is the preferred setting. 

III . Role of Detoxification and Treatment 

Settings in the Delivery of Services 

Begin this didactic presentation by stating that you will now present five 

different settings and describe their roles in the delivery of detoxification 

and treatment services. 

Trainer note: Depending on your audience’s level of experience, you can 

conduct this presentation as a facilitated discussion with participant input. 

The five settings are 

■		Physician’s office. 

■		Freestanding urgent care center or emergency department. 

■		Freestanding substance abuse treatment or mental health facility. 

■		Intensive outpatient and partial hospitalization programs. 

■		Acute care inpatient services. 

22 Module 2 
TIP 45: Detoxification and Substance Abuse Treatment 

Tell participants that before they discuss each of these settings in detail, 

they will review the standard assessment criteria to use in making patient 

detoxification placement decisions. 

These criteria were developed by the American Society of Addiction 

Medicine (ASAM). 

The criteria represent a consensus-based clinical tool for matching 

patients to the appropriate setting and level of care. 

The six ASAM assessment criteria to be used in patient evaluation and 

placement decisions are 

■		Acute intoxication and/or withdrawal potential. 

■		Biomedical conditions and complications. 

■		Emotional, behavioral, or cognitive conditions and complications. 

■		Readiness to change. 

■		Relapse, continued use, or continued problem potential. 

■		Recovery/living environment. 

Trainer note: Tell participants to refer to their TIP 45 manual, pp. 12–13, 

for more information on these guidelines. Participants can also consult 

TIP 13: The Role and Current Status of Patient Placement Criteria in the 

Treatment of Substance Use Disorders. 

Close this section by reminding participants that in Module 1, they 

discussed the fact that effective detoxification includes not only medical 

stabilization of the patient and safe and humane withdrawal from drugs 

or alcohol, but also entry into treatment. Ask them to keep this in mind as 

they proceed through the different settings. 

A . Setting #1: Physician’s Office 

Begin by explaining that this setting is appropriate for patients with mild 

to moderate withdrawal symptoms. 

State that detoxification can be safely implemented on an outpatient 

basis in an office setting. 

Level of Care 

The next step is determining the appropriate level of care for outpatient 

detoxification within this setting. 

There are two levels of care to choose from: ambulatory detoxification 

without extended onsite monitoring and ambulatory detoxification with 

extended onsite monitoring. 

Ambulatory Detoxification Without Extended Onsite 

Monitoring 

■		Services are provided by trained clinicians in compliance with 

established policies and procedures and/or medical protocols. 

Module 2 23 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Services include medically supervised evaluation, detoxification, 

and referrals. 

■		Patients are monitored according to a predetermined schedule. 

■		Patients need to have a positive social support network. 

■		Services can be delivered in an office setting, health care or 

addiction treatment facility, or patient’s home. 

Ambulatory Detoxification With Extended Onsite 

Monitoring 

■		Services are provided by credentialed/licensed nurses: RNs or LPNs. 

■		Services are provided in compliance with established policies and 

procedures and/or medical protocols. 

■		Patients are monitored for several hours each day of treatment. 

■		Services include medically supervised evaluation, detoxification, 

and referrals. 

■		Patients need to have a positive social support network. 

■		Services are provided in settings such as a day hospital. 

B . Setting #2: Freestanding Urgent Care Center 

or Emergency Department 

Begin by explaining that these settings are appropriate for patients with 

mild to moderate withdrawal symptoms. 

Ask participants to explain the difference between a freestanding urgent 

care center and an emergency department. 

Summarize this discussion by reviewing the differences. 

■		Urgent care is most often used by patients who cannot or do not 

want to wait until they see their health care provider. 

■		Emergency departments are most often used by patients who 

perceive themselves to be in a crisis situation. 

Level of Care 

Next, discuss the level of care in freestanding urgent care centers and 

emergency departments. 

■		Care is provided to patients whose withdrawal symptoms are severe 

enough to require primary medical and nursing care services. 

■		Services are delivered using physician-managed procedures or 

protocols. 

24 Module 2 
 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Medically directed assessments and acute care include the 

initiation of detoxification for substance use withdrawal. 

■		Such care is not likely to offer satisfactory biomedical stabilization 

or 24-hour observation. 

■		Triage to inpatient care can be facilitated. 

■		Staffing is typically physicians; credentialed nursing staff can 

provide care and observation. 

C . Setting #3: Freestanding Substance Abuse 

Treatment or Mental Health Facility 

Begin by explaining that these settings are appropriate for patients with 

mild to moderate withdrawal symptoms. 

Freestanding substance abuse treatment facilities can vary in their ability 

to provide assessment and treatment of co-occurring psychiatric conditions. 

Inpatient mental health facilities, however, typically can provide treatment 

for co-occurring psychiatric conditions. 

Having a clear understanding of the specific services in a given setting 

will help identify the best patient placement option. 

Level of Care 

There are two types of programs to choose from in freestanding 

substance abuse treatment or mental health facilities: inpatient and 

residential. 

Inpatient 

■		Provides medically managed intensive patient detoxification 

■		Provides 24-hour supervision, observation, and support for 

intoxicated or withdrawing patients 

■		Emphasizes stabilizing the patient and facilitating linkages to other 

inpatient and outpatient services 

■		Staffing includes an interdisciplinary team of physicians, RNs, LPNs, 

counselors, social workers, and psychologists 

Residential 

■		These facilities vary greatly in the level of care they provide. 

■		Some settings can medically manage detoxification and withdrawal. 

■		Other settings have no medical oversight and use a “social 

detoxification” model in which they link patients to medical care when 

necessary. 

Module 2 25 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		They provide 24-hour supervision, observation, and support for 

intoxicated or withdrawing patients. 

■		Such settings emphasize peer and social support. 

■		They have medical/psychiatric transfer policies and procedures. 

■		Staffing includes appropriately credentialed personnel who 

implement physician-approved protocols for observation, 

monitoring, and supervision. 

■		Medical evaluation and consultation are typically available 24 hours 

a day. 

■		Some programs provide supervision of self-administered medication 

for withdrawal management. 

D . Setting #4: Intensive Outpatient and Partial 

Hospitalization Programs 

Begin by explaining that an intensive outpatient program (IOP) or partial 

hospitalization program (PHP) is appropriate for patients with mild to 

moderate withdrawal symptoms. 

In addition to biomedical assessment and stabilization, psychosocial 

assessment and intervention may be available in these settings. 

These programs provide linkages to hospitals or hospital centers for 

higher levels of care when needed. 

Level of Care 

■		Provides regularly scheduled detoxification sessions 

■		Delivers services using established policies and procedures or 

protocols 

■		Requires several hours a day of onsite patient monitoring 

■		Provides linkages to treatment services 

■		Staffing includes a multidisciplinary team of physicians, RNs, LPNs, 

counselors, social workers, and psychologists 

E . Setting #5: Acute Care Inpatient Settings 

Begin by explaining that acute care inpatient programs provide 

detoxification services to patients in danger of experiencing severe or lifethreatening withdrawal. 

When stabilized, patients can be transitioned to an IOP or PHP; this is 

sometimes called a “step-down” program. 

26 Module 2 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Acute care inpatient settings include acute care general hospitals, acute 

care addiction treatment units in acute care general hospitals, acute care 

psychiatric hospitals, and other licensed chemical dependency specialty 

hospitals. 

Level of Care 

■		Provides medically monitored inpatient detoxification 

■		Provides 24-hour medically supervised evaluation and withdrawal 

management 

■		Services are delivered using established policies and procedures or 

protocols 

■		Staffed by a multidisciplinary team of physicians, nurses, 

counselors, social workers, and psychologists 

■		Counselors available 8 hours a day to provide planned interventions 

IV . Other Concerns Regarding 

Levels of Care and Placement 

Tell participants that when determining levels of care and placement 

for patients, it is important to determine whether inpatient or outpatient 

detoxification is preferred. 

As a response to research results and the need to keep costs down, 

outpatient detoxification is now becoming the standard for treatment of 

alcohol and drug withdrawal symptoms. 

Facilitated discussion: Based on what was reviewed regarding the 

different settings and levels of care within each setting, ask participants 

what they think needs to be considered when evaluating a patient for 

outpatient vs. inpatient detoxification and treatment. Write participants’ 

responses on newsprint. 

Trainer note: To increase interaction, you can enlist the support of a 

participant to write the responses on the newsprint. 

Summarize the discussion, reviewing the following considerations when 

evaluating patients for outpatient vs. inpatient detoxification: 

■		Ability to arrive at outpatient setting on a daily basis—critical for 

outpatient detoxification 

■		History of previous withdrawal seizures or delirium tremens—could 

indicate a contraindication to outpatient detoxification 

■		No capacity for informed consent—indicates a protective (inpatient) 

environment is needed 

■		Suicidal/homicidal/psychotic condition—indicates a protective 

(inpatient) environment is needed 

Module 2 27 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Able/willing to follow treatment—if unable to follow guidelines or 

schedule, indicates need for an inpatient environment 

■		Co-occurring medical conditions, such as diabetes, hypertension, 

and pregnancy—can indicate contraindications to outpatient 

detoxification 

■		Supportive person to assist—not essential, but advisable for 

outpatient detoxification 

V . Module 2 Summary and Closing 

Tell participants that they have received a basic description of the 

settings, levels of care, and patient placement issues involved in delivering 

appropriate and cost-effective detoxification and treatment services. 

Keep in mind that detoxification, whether on an outpatient or inpatient 

basis, is often the first therapeutic encounter between patient and clinician. 

As we’ve already discussed, the detoxification process provides a critical 

opportunity for biomedical (and sometimes psychosocial) assessment, 

referral for appropriate services, and linkage to further treatment 

services. 

Module 3 will provide an overview of the psychosocial issues relevant to 

detoxification and strategies to engage patients and provide linkage to 

follow-up treatment and services. 

Trainer note: If you are delivering this course over more than 1 day, give 

participants a homework assignment to read the modules or sections 

of TIP 45 that you will be covering in the next session. Ask participants 

for feedback on this module in the form of “pluses,” or things they liked 

about the session, and “wishes,” or things they would like to see changed 

or incorporated into future sessions. Prepare a newsprint with a line 

down the middle and “pluses” on one side and “wishes” on the other and 

record the participants’ responses. 

28 Module 2 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 3: An Overview 

of Psychological and 

Biomedical Issues 

During Detoxification 

Learning Objectives 

Upon completion of Module 3, participants will be able to 

1.	 Identify the overarching principles for patient care during 

detoxification. 

2.	 Describe strategies for evaluating and addressing psychosocial 

and medical issues for patients in detoxification. 

3.	 Identify at least two considerations for special populations 

in detoxification in each of the following areas: adolescents, 

parents with dependent children, domestic violence victims, 

and culturally diverse patients. 

4.	 Describe strategies for engaging and retaining patients in 

detoxification. 

5.	 Identify effective referral techniques that promote the initiation 

of substance abuse treatment. 

TIP 45 References 

Chapter 3: An Overview of Psychological and Biomedical Issues During 

Detoxification, pp. 23–46 

Total Time to Deliver Module 

Two hours; can be shorter depending on participants’ needs 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD projector or overhead transparency projector 

Module 3 29 
TIP 45: Detoxification and Substance Abuse Treatment 

■		PowerPoint ® presentation or overhead transparencies 

■		Nametags 

■		Attendance log 

■		Pens, pencils 

■		Post-it ® notes or stickies 

Participant Materials 

■		TIP 45: Detoxification and Substance Abuse Treatment 

■		Module 3 Slides/Overheads Handout 

I . Introduction to Module 3 

Tell participants that Module 3 will address the psychosocial issues that 

can affect detoxification and treatment. 

Trainer note: This module consists of three sections: Evaluating and 

Addressing Psychosocial and Biomedical Issues, Strategies for Engaging 

and Retaining Patients in Detoxification, and Referrals and Linkages. It 

is recommended that you break up Module 3 by presenting each section 

separately, with breaks for participants in between. 

It is vital to address psychosocial issues because research indicates that 

doing so increases the likelihood that the patient will experience a safe 

detoxification and go on to participate in substance abuse treatment. 

As already discussed, detoxification presents a unique opportunity 

to intervene during a period of crisis and motivate a patient to make 

changes in the direction of health and recovery. 

Before discussing psychosocial issues, review the overarching principles 

for care during detoxification services: 

■		Detoxification does not offer a “cure”; however, it is often a first step 

toward recovery. 

■		Substance use disorders are treatable. 

■		Substance use disorders are brain disorders, not evidence of moral 

weakness. 

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

■		Patients are treated in a nonjudgmental and supportive manner. 

■		Services are planned in partnership with patients and their support 

network. 

■		Patient caregivers will provide linkages to treatment after detoxification. 

■		Active involvement of family/support systems is encouraged, while 

respecting patient privacy and confidentiality. 

■		Patients are treated with due consideration for individual 

background, culture, vulnerabilities, and strengths. 

30 Module 3 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

II . Module 3 Objectives 

Review Module 3 objectives with the participants. Upon completion of 

Module 3, participants will be able to 

1.	 Identify the overarching principles of patient care during 

detoxification. 

2.	 Describe strategies for evaluating and addressing psychosocial 

and medical issues for patients in detoxification. 

3.	 Identify at least two considerations for special populations 

in detoxification in each of the following areas: adolescents, 

parents with dependent children, domestic violence victims, 

and culturally diverse patients. 

4.	 Describe strategies for engaging and retaining patients in 

detoxification. 

5.	 Identify effective referral techniques that promote the initiation 

of substance abuse treatment. 

III . Evaluating and Addressing Psychosocial 

and Biomedical Issues 

Begin by stating that patients who enter detoxification are in the process 

of undergoing profound personal and medical crises. 

Withdrawal itself can cause or exacerbate (make worse) emotional or 

psychological conditions. 

Talk about specific evaluation procedures for patients undergoing 

detoxification including 

■		Conducting the initial evaluation 

■		Addressing immediate medical concerns and mental health needs 

■		Addressing nutritional concerns 

■		Addressing special considerations for adolescents, parents with 

dependent children, victims of domestic violence, culturally diverse 

patients, and chronic relapsers 

Trainer note: Throughout Section III, A through I, there will be facilitated 

discussions after presentations. To increase participant involvement, 

ask one or several participants to assist you by recording responses on 

newsprint. 

A . Conducting the Initial Evaluation 

Begin by explaining to participants that initial patient evaluations help 

determine in advance any variables—both biomedical and psychosocial— 

that might complicate a safe and effective withdrawal during detoxification. 

Module 3 31 
TIP 45: Detoxification and Substance Abuse Treatment 

There are established evaluation domains, or areas that need to be 

evaluated, for both biomedical and psychosocial status that can affect the 

stabilization of a patient. 

Biomedical Evaluation Domains 

■		General health history, including surgeries, medical and psychiatric 

conditions, allergies, and history of seizures 

■		Mental status, including oriented, alert, cooperative, psychotic, and 

destructive thoughts 

■		Physical assessment, including neurological exam, vital signs, and 

urine toxicology screen for commonly abused substances 

■		Substances of major use and patterns of abuse 

■		Past substance abuse treatments or detoxification, including any 

complications 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations regarding biomedical 

domains and discuss. Record their responses on newsprint. 

Psychosocial Evaluation Domains 

■		Demographics: gender, age, ethnicity, language, education 

■		Living conditions: homeless, shelter, personal residence; are there 

others in the home who can safely supervise? 

■		Violence, suicide risk: aggressive behavior, depression, violence/ 

abuse history 

■		Transportation availability 

■		Financial situation: resources available, employment 

■		Dependent children: ability to care/provide for children and ensure 

their safety 

■		Legal status: residency status, is treatment court ordered 

■		Physical, sensory, or cognitive disabilities 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations regarding psychosocial 

domains and discuss. Record their responses on newsprint. 

B . Medical Concerns 

Tell participants that it is not unusual for detoxification to be complicated 

by medical concerns because substance abuse affects all body systems 

and is typically associated with lack of self-care. Nor is it unusual for 

detoxification to be complicated by mental health and preexisting 

psychiatric conditions. 

32 Module 3 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Trainer note: Let participants know that in TIP 45, Module 5: Co-Occurring 

Medical and Psychiatric Conditions, there is a detailed clinical overview of 

co-occurring medical and psychiatric conditions geared primarily toward 

medical/clinical personnel. Training will cover highlights of this chapter 

in Module 5. Participants might want to share the detailed information in 

Chapter 5 with appropriate staff at their facilities. Also, tell participants 

about TIP 42: Substance Abuse Treatment for Persons With Co-Occurring 

Disorders. 

In an initial evaluation, any deviation from the expected course of 

withdrawal needs to be determined quickly and observed closely. 

Begin by identifying medical concerns staffers need to be aware of that can 

affect a patient’s health and well-being during the detoxification process. 

All staff members need to be aware of the signs and symptoms that 

indicate co-occurring medical conditions, some of which have the 

potential to be life-threatening. 

The following conditions all require immediate medical attention: 

■		Change in mental status 

■		Increasing anxiety and panic 

■		Hallucinations 

■		Temperature greater than 100.4 degrees Fahrenheit; this could 

indicate an infection 

■		Significant increases or decreases in blood pressure and heart rate 

■		Insomnia 

■		Abdominal pain 

■		Upper and lower gastrointestinal bleeding 

■		Changes in responsiveness of pupils 

Seizures during withdrawal are of special concern, and staffers need to 

be trained on how to prevent injury in the event of a seizure. 

Signs of an impending seizure include 

■		Tremors. 

■		Increased blood pressure. 

■		Overactive reflexes. 

■		High temperature and pulse. 

C . Mental Health Concerns 

Patients can also have immediate mental health concerns that need to 

be identified as soon as possible. 

Module 3 33 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Suicide, anger, and aggression and co-occurring mental disorders can all 

affect the detoxification process. 

Suicide 

■		The risk of suicide increases with alcohol and drug dependence. 

■		Patients undergoing detoxification need to be continually evaluated 

for suicide risk. 

■		Facilities need to provide an environment that minimizes 

opportunities for suicide attempts. 

■		Safety checks need to be increased when signs of depression, 

shame, guilt, and hopelessness are present. 

■		Patients at risk for suicide need to be placed in areas staff can 

easily monitor. 

Anger and Aggression 

■		Alcohol, cocaine, and hallucinogenics are associated with increased 

risk of violence. 

■		Symptoms associated with increased risk for violence include 

hallucinations, paranoia, anxiety, and depression. 

■		As a precaution, all patients who are intoxicated need to be treated 

as potentially violent. 

■		Programs need to have in place well-developed plans to promote 

staff and patient safety, including protocols for involving local law 

enforcement agencies or private security contractors. 

De-Escalating Aggressive Behaviors 

Managing patients who are angry and aggressive can be challenging. Here 

are some strategies staff can use to de-escalate aggressive behaviors: 

■		Speak in a soft voice 

■		Isolate the individual from loud noises or distractions 

■		Provide reassurance while avoiding confrontation, judgments, or 

angry tones 

■		Enlist assistance from family members or others the patient trusts 

■		Offer medication when appropriate 

■		Separate the person from others who many encourage or support 

the aggressive behavior 

■		Enlist other staff as visible backup if the situation continues to escalate 

■		Make sure that both the patient and the staff person have easy 

access to a clear exit path 

34 Module 3 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Know your own comfort level regarding patient interaction and 

respect your personal limits 

Co-Occurring Mental Disorders 

■		During acute intoxication and withdrawal, diagnosis of co-occurring 

mental disorders is very difficult. 

■		When the patient moves from severe to moderate withdrawal 

symptoms, the focus can move from symptom management to 

diagnosis of co-occurring mental disorders. 

■		APA and ASAM both recommend a period of 2 to 4 weeks before 

trying to diagnose a psychiatric or mental disorder. 

■		Obtaining a thorough mental health history—with family involvement 

when appropriate—will help with diagnosis. 

Close this presentation by telling participants that many special issues 

can affect detoxification and stabilization. 

Next, discuss these issues as they relate to common concerns and 

specific populations. 

D . Nutritional Considerations During 

Detoxification 

Trainer note: After this section on nutrition and each of the following 

sections, which discuss special populations, it is recommended that you 

conduct an interactive summary discussion, or “facilitated discussion,” 

with participants in which they can contribute their own experiences 

working with these issues and populations. 

Explain to participants that nutrition can have a big impact on a patient’s 

experience with detoxification and stabilization. 

■		Persons with substance use disorders often have irregular eating 

habits and poor nutritional intake. 

■		The abuse of drugs can interfere with a person’s nutrient utilization 

and storage. 

■		Malnutrition is a big concern because nutrient deficiencies can 

interfere with or even prolong the detoxification process. 

■		The detoxification process is stressful to the body and can result in 

the need for greater amounts of nutrients. 

■		Proper nutrition can help ease the detoxification process. 

■		All persons undergoing detoxification need to have a nutritional 

evaluation that consists of an assessment of their nutritional status, 

a detailed nutritional history, and nutrition counseling. 

Module 3 35 
 

TIP 45: Detoxification and Substance Abuse Treatment 

There are many strategies for addressing nutritional deficits; these include 

■		Switching the paradigm from ingesting substances harmful to the 

body to taking in foods that heal the body. 

■		Developing regular mealtimes with meals that focus on taste and 

presentation. 

■		Avoiding substitution of one addiction for another—for example, 

consuming excessive amounts of caffeine or sugar. 

■		Managing gastrointestinal symptoms (nausea, vomiting, diarrhea) 

that often accompany the first phase of detoxification; dehydration 

and blood chemistry changes can lead to mental status changes, 

neurological or heart problems, and other conditions. 

■		Any special dietary requirements due to conditions or dietary 

preference (diabetes, vegetarian, food allergies, ulcers) that may 

require additional nutrition therapy. 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other nutritional considerations and discuss. 

Record their responses on newsprint. 

Tell participants that you will now switch gears and talk about 

detoxification considerations for special populations. 

The first special population we will discuss is adolescents. 

E . Detoxification Considerations for Adolescents 

Adults and adolescents have a similar experience with detoxification. 

There are, however, important differences and special issues to consider 

for adolescents undergoing detoxification. 

Adolescents are more likely than adults to 

■		Engage in binge drinking (drinking large amounts of alcohol over a 

short period). 

■		Use drugs they cannot identify. 

■		Combine multiple substances with alcohol. 

■ Be unwilling to disclose drug use.
 

Because of these differences, when working with adolescents, 

detoxification providers need to 

■		Be particularly alert to rising blood alcohol levels; binge drinking can 

cause escalating blood alcohol levels following admission. 

■		Routinely screen for illicit drugs. 

■		Screen for suicide potential. 

36 Module 3 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Obtain an as-accurate-as-possible substance abuse history, 

asking open-ended questions and referring to drugs using street 

terminology and teen slang that will help establish rapport. 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations for adolescents and 

discuss. Record their responses on newsprint. 

Trainer note: Tell participants they can access more information on 

working with adolescents in TIP 31: Screening and Assessing Adolescents 

for Substance Use Disorders, developed by CSAT. 

F . Detoxification Considerations for Parents 

With Dependent Children 

Parents with dependent children face unique challenges during 

detoxification. 

■		Parents, especially mothers, are often concerned for the safety of 

their children while they are receiving services, presenting a big 

barrier to treatment and retention. 

■		Some children experience severe distress while a parent is 

receiving services, prompting the parent’s unauthorized leave from 

treatment. 

■		Ensuring that children have a safe place to stay while their parent 

is receiving services is critical; supportive family and friends are a 

good place to start. 

■		Social services may need to intervene to secure appropriate 

childcare. 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations for parents and discuss. 

Record their responses on newsprint. 

G . Detoxification Considerations for Domestic 

Violence Victims 

Domestic violence adds another dimension to providing detoxification 

services. 

Staffers need to know the signs of domestic violence and follow 

established procedures to ensure patient safety. 

■		Both men and women may be victims. 

■		Women’s drug use is associated with increased risk of domestic 

violence. 

■		When violence is disclosed, it is important to develop a safety plan 

and provide information and referrals. 

Module 3 37 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		It may be important that the abused person not communicate with 

the abuser while in detoxification. 

■		Parents who are domestic violence victims may need help with 

parenting skills. 

■		Staff need to be familiar with local childcare resources. 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations for domestic violence 

victims and discuss. Record their responses on newsprint. 

Trainer note: For more information on this topic, refer participants to TIP 25: 

Substance Abuse Treatment and Domestic Violence, developed by CSAT. 

H . Detoxification Considerations for Culturally 

Diverse Patients 

When working with culturally diverse patients, cultural sensitivity is very 

important. 

■		Patients’ expectations of detoxification can vary. 

■		Patients’ feelings and experiences with the health care system can 

differ. 

■		Never define patients by their culture/ethnicity. 

■		Always use open-ended questions to obtain a better understanding 

of the patient. 

■		Detoxification providers need to have staff fluent in other languages 

or obtain access to interpreters. 

Facilitated discussion: Ask participants what types of experiences they 

have had and challenges they have faced when working with culturally 

diverse patients and discuss. Record their responses on newsprint. 

I . Detoxification Considerations for Chronic 

Relapsers 

■		A patient who recently relapsed, especially after a period of 

extended abstinence, may feel hopeless and vulnerable. 

■		It is important to acknowledge the progress the individual has made 

prior to relapse. 

■		Reassure the patient that personal gains from past recovery work 

have not been lost. 

■		Reinforce how important recovery is to the patient. 

Facilitated discussion: Ask participants if, based on their experience, 

they would like to add any other considerations for chronic relapsers and 

discuss. Record their responses on newsprint. 

38 Module 3 
 

TIP 45: Detoxification and Substance Abuse Treatment 

IV . Strategies for Engaging and Retaining 

Patients in Detoxification 

A . Overview 

Begin this section by stating that engaging and retaining patients in 

detoxification can be challenging for many reasons. 

In this section, talk about strategies that can be used to successfully 

engage and retain patients in the detoxification process. 

Highlight the following key concepts that will guide the discussion: 

■		It is critical to keep patients who enter detoxification from “falling 

through the cracks.” 

■		Detoxification programs need to continually offer hope and the 

expectation of recovery to patients. 

■		The detoxification atmosphere needs to convey comfort, relaxation, 

cleanliness, and security to patients at all times. 

■		Program staff need to provide a unified message that detoxification 

is only the beginning of the substance abuse treatment process 

and that rehabilitation and maintenance activities are critical to 

sustained recovery. 

Key steps to take in the process of engaging and retaining patients in 

detoxification include 

■		Educating the patient on the withdrawal process—providing 

information about common withdrawal symptoms for specific drugs 

of abuse may reduce discomfort and the likelihood of leaving 

treatment early. 

Trainer note: TIP 45, Chapter 4 has a list of withdrawal symptoms for 

specific drugs. 

■		Utilizing support systems—engaging patient advocates and family 

members to help patients complete detoxification and not leave 

early as well as having patient attend onsite 12-Step or other 

support group meetings when appropriate 

■		Maintaining a drug-free environment—explaining to patients 

and visitors why substances are not allowed in the facility and 

monitoring visiting areas 

■		Considering alternative approaches—including acupuncture and 

other forms of complementary (non-Western) medicine therapies 

■		Enhancing patient motivation—promoting initiation in rehabilitation 

and maintenance activities 

Module 3 39 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Fostering a therapeutic alliance—promoting this relationship among 

patients, their care providers, and their personal support network 

can predict the success of a patient’s recovery 

Trainer note: A separate section on enhancing patient motivation follows 

this discussion. A separate section on fostering a therapeutic alliance 

follows the Enhancing Patient Motivation discussion. 

B . Enhancing Patient Motivation 

Using motivational enhancement techniques in detoxification increases 

the likelihood that patients will seek treatment by helping them 

understand the adverse consequences of continued substance abuse. 

Trainer note: Tell participants that TIP 35: Enhancing Motivation for 

Change in Substance Abuse Treatment, developed by CSAT, covers 

specific interventions in detail. 

Here we will review the basic principles common to motivational 

enhancement techniques, also called motivational interventions: 

■		Focus on the patient’s strengths. 

■		Show respect for a patient’s decisions and autonomy; respect 

needs to be maintained at all times, even when the patient is 

intoxicated. 

■		Avoid confrontation. 

■		Individualize treatment. 

■		Do not use depersonalizing labels, such as “addict” or “alcoholic.” 

■		Empathize with patients; try to understand their perspective and 

accept their feelings. 

■		Recognize that achieving treatment goals involves small steps. 

■		Help patients become aware of any discrepancies between their 

goals or values and their current behavior. 

■		Listen reflectively to the patient’s concerns and ask open-ended 

questions. 

Facilitated discussion: Ask participants what they have done to enhance 

patient motivation. Record their responses on newsprint. 

C . Tailoring Motivational Interventions to 

Stages of Change 

When developing motivational interventions, it is useful to employ 

the Stages of Change model that has been validated in the research 

literature. This model was developed by DiClemente and Prochaska, and 

the interventions in TIP 35 are based on this model. 

40 Module 3 
TIP 45: Detoxification and Substance Abuse Treatment 

Some participants may already be familiar with this model, but review it 

for everyone. 

This model consists of five stages of readiness to change behavior. The 

model is progressive, and successful completion of each stage moves the 

individual closer to change—or in this case, recovery. 

Here is a graphic representation of the Stages of Change model. 

The five stages are 

1. Precontemplation. 

2. Contemplation. 

3. Preparation. 

4. Action. 

5. Maintenance. 

The model assumes that individuals may move back and forth between 

stages over time. While individual progress can be challenged by 

obstacles and unanticipated events, continuous encouragement and 

support helps patients stay motivated and move through the stages. 

Discuss each of the stages. 

Stage 1: Precontemplation 

■		In this stage, no change is being considered for the near future. 

■		A person can be unaware that substance use is a problem or be 

unwilling or too discouraged to make a change. 

■		A person often has not experienced serious consequences of 

substance use. 

■		The goal is to get the patient to begin to consider changing. 

Module 3 41 
TIP 45: Detoxification and Substance Abuse Treatment 

Stage 2: Contemplation 

■		In this stage, there is some awareness by the individual that 

substance use presents a problem. 

■		The patient may express a desire or willingness to change but has 

not formulated definite plans to do so. 

■		Most individuals in this stage are ambivalent about changing. 

■		The goal is to get the patient to move toward considering adoption 

of a new behavior. 

Stage 3: Preparation 

■		In this stage, the patient is aware that substance use is a problem 

and desires change. 

■		Individuals make a conscious decision to commit themselves to a 

behavior change. 

■		Goals are set and decisions made regarding treatment. 

■		The goal is to help the patient develop a plan of action or a 

behavioral contract. 

Stage 4: Action, and Stage 5: Maintenance 

■		In the Action stage, the patient takes active steps to change 

substance use behavior; the goal is to help the patient successfully 

change. 

■		In the Maintenance stage, the patient works to maintain the 

changes initiated in the Action stage; the goal is to help the patient 

maintain change. 

Close this presentation by asking participants if they have any questions 

on this model and discuss. 

Trainer note: Refer participants again to TIP 35, which discusses 

interventions to increase patient motivation for substance abuse 

treatment, using the Stages of Change model. 

D . Fostering a Therapeutic Alliance 

A therapeutic alliance is made up of positive relationships among 

patients and their care providers and personal/social support networks. 

Given that detoxification is often the entry point for patients into 

substance abuse treatment, work on establishing a therapeutic alliance 

begins with admission. 

The role of the clinician or provider cannot be overemphasized in this 

process. 

42 Module 3 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Clinician/provider characteristics considered most important to the 

therapeutic alliance include being 

■		Supportive, empathetic, and nonjudgmental. 

■		Aware when patients can be engaged and when they need to be 

referred to another provider. 

■		Able to establish rapport with all patients. 

■		Mindful of the need to discuss confidentiality issues. 

■		Cognizant of challenges on the road to recovery. 

■		Consistent, trustworthy, and reliable. 

■		Calm and cool, even when a patient is upset. 

■		Confident but humble. 

■		Able to set limits without engaging in a power struggle. 

■		Cognizant of the client’s progress toward a goal. 

■		Encouraging of clients’ self-expression. 

Facilitated discussion: Ask participants if they would like to add other 

characteristics to this list and record their responses on newsprint. 

E . Optional: Create an Exercise to Illustrate 

Engaging and Retaining Patients in 

Detoxification 

Trainer note: The following exercise is designed to provide participants 

with a greater “hands on” understanding of the challenges regarding 

engaging and retaining patients in detoxification. It may not be 

appropriate for all audiences. 

Small-Group Exercise: Engaging and Retaining 

Patients in Detoxification 

Exercise creation directions: You will need to develop two different 

patient descriptions. Use as much detail as possible, including 

demographics (gender, age, race, education level, economic status), life 

situation, substance abuse history, current substance use, family and 

social supports, and reason for seeking detoxification services. 

1. Describe a patient who is having a successful detoxification 

experience. 

2. Describe a patient who is having problems with detoxification 

and is threatening to leave early. 

Module 3 43 
TIP 45: Detoxification and Substance Abuse Treatment 

Draw on your own experience to develop these descriptions, or prior to 

the training, ask selected program staff where you will be training to help 

you develop descriptions based on real-life patients. 

Exercise directions: Divide the participants into two or four small groups, 

depending on the size of the large group. Have them count off and then 

have all of the “ones,” “twos,” etc., assemble in their respective groups. 

Tell each group that it will need to assign a recorder, timekeeper, and 

reporter/presenter. Give each group newsprint and markers. 

Distribute the two patient descriptions evenly among the small groups. 

Ask participants to read their patient description and address the 

following questions: 

Trainer note: Put these questions on the handouts that have the patient 

descriptions. 

■		What strategies would you use to ensure that this patient is 

successfully engaged in detoxification? 

■		What would you do to enhance the patient’s motivation? 

■		What Stage of Change do you think this patient is in? 

■		What would you do as a staff person in a detoxification program to 

foster a therapeutic alliance with this patient? 

Give participants 15 minutes to brainstorm and develop their responses; 

the recorder will write their responses on the newsprint. 

Processing the exercise: Reassemble the large group and have each 

small group present its brainstorming results. Facilitate discussion and 

address any participant questions or concerns. 

V . Referrals and Linkages 

Begin this section by explaining that once a person has gotten past the 

most severe withdrawal symptoms and is safe and medically stable, the 

focus shifts towards actively preparing the person for substance abuse 

treatment and maintenance activities. 

There can, however, be many barriers to ensuring a patient’s entry into 

substance abuse treatment. 

Facilitated discussion: Ask participants to identify barriers that might 

affect a patient’s entry into substance abuse treatment, based on their 

experience. Write their responses on newsprint. 

Close this discussion by mentioning the following common barriers: 

■		Patients believe that once they have eliminated the substance(s) of 

abuse from their bodies, they are “cured” and no longer need any help. 

44 Module 3 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Some insurers provide only partial coverage for needed services— 

or no coverage for certain types of treatment; the amount of 

paperwork/documentation can be overwhelming; and patients 

often have difficulty navigating the insurance system to determine 

the treatment coverage available to them. 

A . Evaluating the Patient’s Rehabilitation Needs 

Let participants know that the first step in providing referrals and linkages 

to treatment is evaluating the patient’s rehabilitation needs. 

To review what was covered in Module 2, criteria for determining the most 

appropriate level of rehabilitation are based on six dimensions: 

■		Acute intoxication and/or withdrawal potential 

■		Biomedical conditions and complications 

■		Emotional, behavioral, or cognitive conditions or complications 

■		Readiness to change 

■		Relapse, continued use, or problem potential 

■		Recovery/living environment 

It is often challenging for detoxification programs to complete an in-depth 

assessment of rehabilitation needs because of the short amount of time 

a patient spends in detoxification. 

Because of this short duration of stay, programs need to consider many 

factors in evaluating a patient’s rehabilitation needs, including 

■		Psychosocial needs assessment may need to be conducted by the 

substance abuse treatment program the patient is being referred to. 

■		Special needs, like co-occurring psychiatric and medical conditions, 

may limit access to available rehabilitation services. 

■		Pregnancy, physical limitations, and cognitive impairments will limit 

suitable treatment settings. 

■		Support systems issues—like family support, domestic violence, and 

isolation—will influence decisions about residential vs. outpatient 

settings. 

■		Dependent children needs may affect patient needs. 

■		There may be a need for gender-specific treatment. 

TIP 45 recommends 14 specific areas for assessment to determine the 

most appropriate rehabilitation plan for a patient. 

Trainer note: Direct participants to the chart on page 40 of TIP 45 or 

make this page into a handout to distribute to participants. Elaborate on 

each of the assessment areas using the information in the chart as well 

as your own experience to provide real-life examples. You can also ask 

participants to provide examples based on their experience to make the 

discussion more interactive. 

Module 3 45 
TIP 45: Detoxification and Substance Abuse Treatment 

1. Medical conditions and complications 

2. Motivation/readiness to change 

3. Physical, sensory, or mobility limitations 

4. Relapse history and potential 

5. Substance abuse/dependence 

6. Developmental and cognitive issues 

7. Family and social support 

8. Co-occurring psychiatric disorders 

9. Dependent children 

10. Trauma and violence 

11. Treatment history 

12. Cultural background 

13. Strengths and resources 

14. Language 

Tell participants that they will find in TIP 45’s Appendix C useful 

instruments to use in evaluating patient rehabilitation needs. Another 

resource is TIP 13: The Role and Current Status of Patient Placement 

Criteria in the Treatment of Substance Use Disorders, developed by CSAT. 

B . Treatment Settings 

Talk about the different types of treatment settings participants might 

be referring patients to after detoxification. Just like the detoxification 

services discussed in Module 2, substance abuse treatment and 

maintenance activities are offered in a variety of settings that include 

■		Inpatient programs—generally delivered in hospitals and 

freestanding clinics, providing intensive treatment and 24-hour 

nursing care for substance-related medical problems; length of stay 

varies depending on program and client needs. 

■		Residential treatment programs—deliver intensive counseling and 

24 hour supervision by nonmedical staff; length of stay is typically 

between 7 and 30 days. 

■		Therapeutic communities (TCs)—based on a self-help concept, 

provide intensive counseling that relies on peer support and 

confrontation; length of stay is generally between 30 and 90 days 

but can be longer. 

■		Transitional residential and halfway houses—patients often work 

during daytime hours and participate in counseling and peer 

support in the evenings; have 24-hour supervision by nonmedical 

staff; length of stay varies depending on program and client needs. 

■		Partial hospitalization and day-treatment programs—high-intensity 

counseling services are provided to patients during daytime 

hours; patients return home in the evenings; length of stay varies 

depending on program and client needs. 

46 Module 3 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Intensive outpatient programs—patients receive 6 to 9 hours of 

counseling services per week in two or three contacts; services 

are delivered by nonmedical staff in a clinic location; length of 

treatment varies depending on client needs. 

■		Traditional outpatient services—counseling services delivered by 

counselors in a clinic or office location; length of treatment varies 

depending on client needs. 

■		Recovery maintenance activities—include 12-Step and other 

support groups aimed at maintaining gains accomplished in any of 

the above treatment settings. 

C . Providing Linkage to Treatment and 

Maintenance Activities 

It is important to understand how difficult recovery can be for patients. 

About half of those making their first appointment for treatment do not 

show up. 

Research indicates that patients are more likely to initiate treatment if they 

■		Believe the services will help them with their life problems. 

■		Are employed. 

■		Are motivated beyond the precontemplation stage. 

■		Have family and social support. 

■		Have co-occurring psychiatric conditions. 

Strategies that detoxification programs can use to promote the initiation 

of treatment and maintenance activities include 

■		Performing assessment of urgency for treatment. 

■		Reducing time between initial call and appointment. 

■		Calling to reschedule missed appointments. 

■		Providing information about what to expect at the first session. 

■		Providing information about confidentiality. 

■		Offering tangible incentives. 

■		Engaging the support of family members. 

■		Introducing the client to the counselor who will deliver rehabilitation 

services. 

■		Offering services to address basic needs like housing, employment, 

and childcare. 

Other strategies and considerations for ensuring a patient’s initiation and 

engagement in substance abuse treatment include 

Module 3 47 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Providing referrals to other needed services besides substance 

abuse treatment and utilizing case management to reduce service 

access issues and ensure services are being received. 

■		Minimizing as much as possible access barriers like transportation, 

childcare, language, and safety issues. 

■		If a patient is placed on a waiting list, maintaining motivation for 

treatment. 

■		If a patient has a co-occurring psychiatric disorder, facilitating 

coordination between the mental health provider and substance 

abuse treatment program. 

■		If a patient has a chronic medical condition or needs follow-up 

medical care, ensuring appointments are made before the patient 

leaves detoxification. 

■		Considering that individuals who detoxify regularly and have 

limited periods of abstinence may require something other than a 

traditional treatment approach. 

Trainer note: TIP 27: Comprehensive Case Management for Substance 

Abuse Treatment developed by CSAT has information on dealing with 

individuals who detox regularly. 

VI . Module 3 Summary and Closing 

Tell participants that they have received a basic description of the 

psychosocial and biomedical issues in detoxification and strategies for 

engaging and retaining patients in detoxification and providing referrals 

and linkages to treatment. 

Keep in mind that detoxification, whether done on an outpatient or 

inpatient basis, is often the first therapeutic encounter between patient 

and clinician. 

As already discussed, the detoxification process provides a critical 

opportunity for biomedical (and sometimes psychosocial) assessment, 

referral for appropriate services, and linkage to further treatment services. 

Module 4 will highlight treatment for specific substances and provide 

guidance on the medical, nursing, and social service aspects of treatment 

for specific substances. 

Trainer note: If you are delivering this course over more than one day, 

give participants a homework assignment to read the modules or sections 

of TIP 45 you will be covering in the next session. Ask participants for 

feedback on this module in the form of “pluses,” or things that they liked 

about the session, and “wishes,” or things that they would like to see 

changed or incorporated into future sessions. Prepare a newsprint with a 

line down the middle with “pluses” on one side and “wishes” on the other 

and record participants’ responses. 

48 Module 3 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 4: Physical 

Detoxification Services 

for Withdrawal From 

Specific Substances 

Learning Objectives 

Upon completion of Module 4, participants will be able to 

1.	 Identify biochemical markers and their use in patient screening 

and assessment. 

2.		 Describe key concepts for treatment regimens for detoxification 

from specific substances. 

3.	 Explain why the management of polydrug abuse and the use of 

alternative approaches in detoxification are important. 

4.	 Identify special considerations for special populations in the 

detoxification process. 

TIP 45 References 

Chapter 4: Physical Detoxification Services for Withdrawal From Specific 

Substances, pp. 47–120 

Total Time to Deliver Module 

One to 2 hours; can be adjusted to be shorter or longer depending on 

participants’ needs 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD or overhead transparency projector 

■ PowerPoint ® presentation or overhead transparencies 

■ Nametags 

■ Attendance log 

■ Pens, pencils 

■ Post-it ® notes or stickies 

Module 4 49 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Participant Materials 

■		TIP 45: Detoxification and Substance Abuse Treatment 

■		Dyad Exercise: Patient Descriptions and Patient “Snapshots” for 

Optional Attitudes Toward Substance Users 

I . Introduction to Module 4 

Tell participants that Module 4 will highlight treatment for specific 

substances and provide guidance on the medical, nursing, and social 

service aspects for treatment for specific substances. 

In TIP 45, Chapter 4 provides detailed medical information primarily 

for health care professionals. In this training, we will provide a broad 

overview of the information presented in Chapter 4. We encourage you to 

share this information with medical personnel in your organization. 

Trainer note: The information in this module is highly technical and is 

therefore presented in a didactic format. To facilitate interaction, you can 

have participants ask questions as you proceed through the material and 

have them share their experiences, if appropriate and time permits. There 

is an optional exercise toward the end of the module that deals with 

attitudes toward substance users and special populations that you can 

conduct if appropriate for your audience and if time permits. 

II . Module 4 Objectives 

Review Module 4 objectives with participants. 

1.	 Identify biochemical markers and their use in patient screening 

and assessment. 

2.		 Describe key concepts for treatment regimens for detoxification 

from specific substances. 

3.	 Explain why the management of polydrug abuse and the use of 

alternative approaches in detoxification are important. 

4.	 Identify special considerations for special populations in the 

detoxification process. 

III . Psychosocial and Biomedical Screening 

and Assessment 

Module 2 talked about screening and assessment for patients. Point out 

here that there are several assessment instruments in TIP 45’s Appendix 

C that can be used for specific substances—for example, alcohol, cocaine, 

and opioids. 

In the screening and assessment process, biochemical markers are often 

used. These will be briefly discussed next. 

50	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

A . Biochemical Markers and Their Use 

Begin this didactic presentation by explaining to participants what 

biochemical markers are. 

Biochemical markers: 

■		Are laboratory tests that detect the presence of alcohol or other 

substances of abuse 

■		Are used to support a diagnosis of substance use; they are never 

used alone, without thorough psychosocial and medical assessment 

■		Can often serve as a motivational enhancement for patients 

■		Can help a patient move from contemplating treatment to actually 

beginning treatment 

Common uses of biochemical markers are: 

■		In initial screening, to support or refute other information that helps 

with proper diagnosis, assessment, and management 

■		For forensic purposes, such as evaluating a driver after a car accident 

■		In detecting occult (secretive or hidden) use of alcohol or other 

substances in therapeutic settings where abstinence, rehabilitation, 

and treatment are being promoted 

Six of the most common biochemical markers are: 

■		Blood alcohol levels—combined with clinical information, can be 

used to make predictions regarding the acuteness of withdrawal. 

■		Breath alcohol levels—less invasive; can be monitored during the 

course of assessment and detoxification. 

■		Urine drug screens—vary widely in methods of detection, sensitivity/ 

specificity, expense, and availability and test for cocaine, opioids, 

amphetamines, and other substances. Different types of assays 

(test measurements) are used, including enzyme multipleassay techniques, thin-layer chromatography, and urine alcohol 

concentration. 

■		Gamma-glutamyltransferase (GGT)—can provide a measure of 

cumulative alcohol use, but is an expensive test that has relatively 

low accuracy, particularly in women. 

■		Carbohydrate-deficient transferrin (CDT)—also provides a measure 

of cumulative alcohol use that is generally more accurate than GGT; 

has only recently become widely available as a clinical tool. 

■		Mean corpuscular volume (MCV)—measures red-blood-cell size 

and often is part of a complete blood count; most often used to 

complement GGT and CDT. 

Module 4 51 
 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

Trainer note: Tell participants that they will now review nine different 

substances, including alcohol. Let participants know that TIP 45’s 

Chapter 4 contains detailed information on each of these substances that 

can be shared with clinical and medical personnel in their organizations. 

IV . Alcohol Intoxication and Withdrawal 

A . Alcohol Intoxication 

The clinical presentation of alcohol intoxication varies widely, depending in 

part on blood alcohol level and level of previously developed tolerance. Look 

at different blood alcohol levels and their corresponding clinical pictures. 

Blood Alcohol Level Clinical Picture 

20–100 mg percent ■ Mood and behavioral changes 

■ Reduced coordination 

■ Impaired ability to drive a car or operate 

machinery 

101–200 mg percent ■ Reduced coordination for most activities 

■ Speech impairment 

■ Trouble walking 

■ General impairment of thinking and 

judgment 

201–300 mg percent ■ Marked impairment of thinking, 

memory, and coordination 

■ Marked reduction in level of alertness 

■ Memory blackouts 

■ Nausea, vomiting, and blackouts 

301–400 mg percent ■ Worsening of above symptoms with 

reduction of body temperature and 

blood pressure 

■ Excessive sleepiness 

■ Amnesia 

■ Nausea and vomiting 

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

■ Serious decreases in pulse, 

temperature, blood pressure, and rate 

of breathing 

■ Urinary and bowel incontinence 

■ Death 

B . Alcohol Withdrawal 

Talk with participants about alcohol withdrawal, a condition that is often 

unrecognized and undertreated. 

The signs and symptoms of acute alcohol withdrawal usually start 6 to 24 

hours after the patient takes his or her last drink. 

Alcohol withdrawal, however, can begin when the patient still has 

significant blood alcohol levels. 

52 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

Alcohol withdrawal signs and symptoms include 

■		Restlessness, irritability, anxiety, and agitation. 

■		Anorexia (lack of appetite), nausea, and vomiting. 

■		Tremor (shakiness), elevated heart rate, and increased blood 

pressure. 

■		Insomnia, intense dreaming, and nightmares. 

■		Poor concentration and impaired memory and judgment. 

■		Increased sensitivity to sound, light, and tactile sensations. 

■		Hallucinations—auditory, visual, or tactile. 

■		Delusions, usually of paranoid or persecutory varieties. 

■		Grand mal seizures. 

■		Hyperthermia (high fever). 

■		Delirium, with disorientation regarding time, place, person, and 

situation and fluctuation in levels of consciousness. 

C . Medical Management 

Tell participants that TIP 45’s Chapter 4, pp. 56–68, discusses medical 

management of alcohol intoxication and withdrawal in detail and that they 

can use it for guidance in their programs. 

During detoxification, support, hygienic care, and adequate nutrition need 

to be provided to patients. Attention must also be given to the treatment 

of scabies, body lice, and other skin conditions, and patients need to be 

screened for physical trauma. 

Trainer note: Seizures can be common for some patients during 

detoxification, and it is important to briefly review what to do in the event 

of a seizure. Personnel in participants’ organizations need to be familiar 

with how to manage patients experiencing seizures. 

■		At the first sign of what appears to be a seizure, notify trained 

medical personnel; depending on the setting, this may mean calling 

911 or calling the duty nurse or doctor for the clinic or hospital unit. 

■		While waiting for medical help, prevent injury to the person by 

protecting the head and body from hard or sharp objects; place a 

soft object under the head and neck if jerking is extreme. 

■		Do not place anything in the mouth, like spoons or pens; these can 

damage the teeth and tongue or be partially swallowed, obstructing 

the airway. 

■		If the person begins to vomit, place him or her on his or her side so 

the vomit is not swallowed. 

Module 4 53 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Even if a person appears to become fully awake, alert, and oriented 

after a seizure, without apparent harm, he or she should be referred 

for medical evaluation. 

■		Individuals who wake up confused and/or disoriented after a 

seizure should be given brief, reassuring messages to reorient them 

as to what happened and where they are. 

V . Opioids 

Opioids are highly addicting, and their chronic use leads to withdrawal 

symptoms that can be extremely unpleasant and produce a high degree 

of discomfort. 

A . Opioid Intoxication and Withdrawal Signs 

and Symptoms 

First, review the signs and symptoms of opioid intoxication. 

Opioid Intoxication Signs Opioid Intoxication Symptoms 

■ Slow pulse (bradycardia) 

■ Low blood pressure (hypotension) 

■ Low body temperature 

(hypothermia) 

■ Sedation 

■ Pinpoint pupils (meiosis) 

■ Slowed movement (hypokinesis) 

■ Slurred speech 

■ Head nodding 

■ Euphoria

■ Imperviousness to pain 

■ Calmness

Now discuss with participants opioid withdrawal signs and symptoms. 

Opioid Withdrawal Signs Opioid Withdrawal Symptoms 

■ Fast pulse (tachycardia) 

■ High blood pressure 

(hypertension) 

■ High body temperature 

(hyperthermia) 

■ Insomnia 

■ Enlarged pupils (mydriasis) 

■ Abnormally heightened reflexes 

(hyperreflexia) 

■ Sweating (diaphoresis) 

■ Gooseflesh (piloerection) 

■ Increased respiratory rate 

■ Tearing (lacrimation), yawning 

■ Runny nose (rhinorrhea) 

■ Muscle spasms 

■ Abdominal cramps, 

nausea, vomiting, 

diarrhea 

■ Bone and muscle pain

■ Anxiety 

54	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

B . Medical Management 

Begin by explaining to participants that managing opioid withdrawal with 

medications is very common; it is not recommended that withdrawal be 

managed without medications. Refer participants to TIP 45’s Chapter 

4, pp. 66–74, for more detailed information on medical management of 

opioid withdrawal. 

Opioid detoxification can usually be conducted without significant patient 

discomfort when medications are used. 

In general, patients are ambulatory and able to participate in 

rehabilitative activities during detoxification. During the first 24 hours, 

however, patients may require bed rest or reduction in activity. 

Common agents used to manage opioid withdrawal include 

■		Methadone/methadone maintenance—FDA-approved treatment; 

can be dispensed only at designated treatment centers; need to 

avoid overmedicating because it can lead to overdosing. 

■		Clonidine (Catapres)—not FDA-approved for opioid withdrawal, but is 

used because the research substantiates its effectiveness for this 

condition; sometimes used in place of methadone because it has 

less potential for abuse. 

■		Buprenorphine—received recent FDA-approval for opioid withdrawal 

and is another alternative to methadone; is safer than methadone 

in regard to overdose potential and can be dispensed at a doctor’s 

office. 

■		Rapid and ultrarapid detoxification—provides a rapid, painless 

process to patients using narcotics; remains unproven regarding 

effectiveness and long-term abstinence rates and is very 

controversial. 

Trainer note: Let participants know about TIP 43: Medication-Assisted 

Treatment for Opioid Addiction in Opioid Treatment Programs. 

Opioid dependence, particularly intravenous heroin dependence, is 

typically associated with a number of medical conditions, and patients 

need to have a complete medical evaluation including 

■		Screening for tuberculosis, HIV/AIDS, hepatitis, sexually transmitted 

diseases, and opportunistic infections. 

■		Examining injection sites for infection or abscess. 

■		Asking patients about night sweats, chills, nutritional intake, 

diarrhea and gastrointestinal distress, fever, and cough. 

■		Determining history or evidence of trauma. 

Module 4 55 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

VI . Benzodiazepines and Other Sedative 

Hypnotics 

A . Intoxication and Withdrawal Symptoms 

■		Intoxication symptoms with benzodiazepines and other sedative 

hypnotics are similar to alcohol. 

■		When used alone, benzodiazepines rarely lead to death. 

■		Most individuals who use benzodiazepines use them in combination 

with other drugs of abuse, which can be fatal if not managed 

appropriately. 

B . Medical Management 

The management of withdrawal from benzodiazepine and other sedative 

hypnotics is not recommended without medical supervision. 

Medical complications of withdrawal include problems similar to those in 

alcohol withdrawal, including seizures and delirium. 

Patient assessment needs to include 

■		Name of medication, amount taken (dose), and length of taking/using. 

■		Alcohol use, particularly in combination with benzodiazepine. 

■		Use of other sedative hypnotics, such as sleep aids. 

■		Presence or history of co-occurring psychiatric disorders, like 

panic disorder. 

■		Physical assessment, mental status, and neurological exams. 

Trainer note: Explain to participants that there are different ways to 

manage withdrawal from these substances with medications. These are 

described in detail in TIP 45’s Chapter 4, pp. 75–76. 

When preparing for and undergoing detoxification from benzodiazepines 

and other sedative hypnotics, the following factors can help achieve 

patient success: 

■		Starting detoxification during a period of low external stressors 

■		Patient commitment to tapering off substance 

■		A plan for managing underlying anxiety disorders (if present) 

■		Frequent patient contact 

VII . Stimulants: Cocaine, Crack Cocaine, 

Amphetamines 

Cocaine and amphetamines are the most frequently abused central 

nervous system stimulants. People who are dependent on stimulants 

experience profound loss of control over stimulant intake. 

56	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

A . Withdrawal Symptoms 

Withdrawal symptoms from stimulants differ markedly from those seen 

with alcohol, opioid, and sedative dependence, and include 

■		Depression. 

■		Hypersomnia or insomnia. 

■		Fatigue. 

■		Anxiety. 

■		Irritability. 

■		Poor concentration. 

■		Psychomotor retardation. 

■		Increased appetite. 

■		Paranoia. 

■		Drug craving. 

B . Medical Management 

Stimulant withdrawal is not usually associated with medical complications 

or severe physical symptoms. Patients with recent cocaine use, however, 

can experience persistent cardiac complications. In addition, seizures can 

occur during withdrawal. 

Withdrawal is typically managed without medications, although some 

medications are being researched for cocaine detoxification. 

Effective stimulant withdrawal 

■		Establishes a period of abstinence from stimulants being abused. 

■		Uses intensive outpatient treatment to assist the patient to cease 

use long enough for withdrawal symptoms to abate. 

■		Helps patients develop strategies for avoiding cue-induced craving. 

■		Helps patients abstain from other addictive drugs. 

When planning stimulant withdrawal, important variables to keep in 

mind include 

■		Patients are often sleep-deprived and may be unable to participate 

in therapeutic activities in the first 24 to 36 hours of abstinence. 

■		Patients are often hungry and may initially need large meal portions 

because their food intake might have been inadequate during active 

addiction. 

■		Stimulant users can be irritable and should avoid needless 

confrontation during the initial withdrawal phase. 

■		Headaches are frequent and can be treated symptomatically. 

■		As withdrawal symptoms wane, patients can be referred to ongoing 

treatment. 

Module 4 57 
TIP 45: Detoxification and Substance Abuse Treatment 

VIII . Inhalants/Solvents 

The term inhalants is used to describe a large and varied group of 

substances found in household, industrial, and medical products that are 

inhaled for their effects. 

There are many types of commonly abused inhalants; some examples follow. 

Trainer note: Tell participants that a detailed listing of types of inhalants 

and the chemicals they contain is in TIP 45’s Chapter 4, pp. 83–84. 

Type Example Chemical(s) in Inhalant 

Adhesives Airplane glue Ethyl acetate 

Aerosols Spray paint Butane, propane, fluorocarbons 

Cleaning agents Spot remover Xylene 

Solvents and gases Paint thinner Toluene, methylene chloride 

Food products Whipped cream Nitrous oxide 

A . Withdrawal Symptoms 

Dependence on inhalants and subsequent withdrawal symptoms are 

relatively uncommon events. 

That said, there is no specific or characteristic withdrawal syndrome 

that would include all drugs in the inhalant class. Examples of some 

withdrawal symptoms than can occur follow. 

■		Intoxication from solvents, aerosols, and gases produces symptoms 

like those of alcohol, but which last only 15 to 45 minutes. 

■		Some chemicals in inhalants can induce delirium and tremors. 

■		Long-time users may exhibit weakness, weight loss, inattentive 

behavior, and depression. 

■		When withdrawal is present, it usually lasts 2 to 5 days. 

B . Medical Management 

Most patients presenting for treatment for inhalant dependence are 

adolescents. 

While there may be no withdrawal associated with inhalants, a large 

number of medical complications can result from usage, including 

■		Impaired cognitive, motor, and sensory functioning. 

■ Internal organ damage, including the heart, lungs, kidneys, and liver. 

When withdrawal symptoms are present, medical management focuses on 

■		Providing patients with a safe environment that removes them from 

access to inhalants. 

58	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Providing supportive care, including helping patients get enough 

sleep and eat a well-balanced diet. 

■		Quickly determining whether the patient has been abusing other 

substances and treating accordingly. 

■		Assessing mental status and providing appropriate therapy and 

intervention. 

IX . Nicotine 

Explain to participants that it has traditionally been thought that nicotine 

detoxification concurrent with detoxification from other substances is too 

difficult for most patients to manage. 

Therefore, nicotine detoxification has not been a big focus of substance 

abuse providers. Several factors are involved, including 

■		Patient ambivalence or lack of interest in quitting. 

■		Treatment program ambivalence about the importance of smoking 

cessation early in treatment. 

■		Staff use of nicotine. 

■		Easy availability of cigarettes from peers, friends, family, and at 

12-Step meetings. 

■		Lack of training among program staff in managing nicotine withdrawal. 

■		Staff resistance to patient smoking cessation because withdrawal 

symptoms might make patients more difficult to manage. 

A . Withdrawal Symptoms 

Using nicotine daily for at least several weeks and stopping abruptly or 

reducing the amount of nicotine consumed is usually followed within 24 

hours by four or more of these symptoms: 

■		Depressed mood (dysphoria). 

■		Insomnia. 

■		Irritability, frustration, or anger. 

■		Anxiety. 

■		Difficulty concentrating. 

■		Restlessness. 

■		Decreased heart rate. 

■		Increased appetite or weight gain. 

Programs and staff need to be aware that symptoms of withdrawal from 

nicotine can masquerade as other psychiatric conditions, especially 

anxiety and depression. 

Trainer note: Tell participants that in TIP 45’s Chapter 4, pp. 86–89, 

assessment instruments are referenced to assess severity of nicotine 

dependence. 

Module 4 59 
 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

B . Medical Management 

While many persons opt for quitting on their own, nonmedical and 

medical interventions are available to assist them and enhance their 

success. 

■		Self-help interventions—pamphlets, manuals, video/audiotapes, 

support groups, telephone helplines 

■		Behavioral interventions—problem solving, coping skills, plan for 

quitting 

■		Nicotine replacement therapy (NRT)—nicotine chewing gum, patch 

■		Bupropion SR/Sustained Release (Zyban)—an antidepressant 

■		Combination therapy—joint use of the nicotine gum and patch 

The U.S. Public Health Service has developed a 5-step intervention, 

known as the “5 As”: 

■		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 the quit attempt. For the patient willing to make a quit 

attempt, use counseling and pharmacotherapy to help him or her quit. 

■		Arrange follow-up. Schedule follow-up contact, preferably with the 

first week after the quit date. 

If a patient in detoxification or substance abuse treatment requests help 

with smoking cessation, it is important to 

■		Present a supportive and nonjudgmental attitude. 

■		Develop a therapeutic alliance with the patient. 

■		Emphasize that it is very common to relapse after quitting and that 

most people make more than one attempt to quit before succeeding. 

■		Discuss withdrawal symptoms and what to expect. 

■		Provide strategies to avoid weight gain. 

■		Stress the importance of smoke-free living and work environments. 

■		Refer patient to a smoking cessation program, if appropriate. 

60	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

X . Other Drugs 

Trainer note: Tell participants that you will next cover several other drugs 

briefly and that they can obtain more detailed information in TIP 45’s 

Chapter 4, pp. 95–101. 

A . Marijuana and Other Drugs Containing THC 

Marijuana and hashish are the two substances containing THC that are 

commonly used today. 

While controversial in the past, most experts now agree that a withdrawal 

syndrome occurs in some patients who are heavy users. 

■		THC abstinence syndrome starts within 24 hours of cessation. 

■		The amount of THC that needs to have been ingested in order to 

experience withdrawal is unknown. 

■		Common withdrawal symptoms include anxiety, restlessness, 

irritability, sleep disturbance, and change in appetite—usually anorexia. 

■		There are no medical complications of withdrawal from THC, and 

medication is generally not used. 

B . Anabolic Steroids 

■		Subject to abuse as a means of increasing muscle mass 

■		Can produce aggressive, manic-like behavior that may include 

delusions 

■		Men involved in professional sports, weightlifting, and body building 

are more prone to anabolic steroid use than are women 

■		Withdrawal symptoms include craving for more steroids, fatigue, 

depression, restlessness, anorexia, insomnia, reduced sex drive, 

headaches, and nausea 

■		Due to long duration of action, side effects cannot be quickly 

reversed when steroids are discontinued and may require medical 

management 

■		Side effects of withdrawal include urinary tract infections, skin 

blistering and redness, swelling (edema) of hands and feet, and 

behavioral disturbances 

■		There is no recommended detoxification protocol for steroids, but 

interventions directed toward cessation should include patient 

education, support, and referral to psychotherapy
 

Module 4 61 
 

TIP 45: Detoxification and Substance Abuse Treatment 

C . Club Drugs 

■		Represent diverse classes of drugs that include sedative hypnotics 

and stimulant/hallucinogens 

■		Include GHB (gamma-hydroxybutyrate), Ecstasy, and Rohypnol (the 

“date rape” drug) 

■		Are used in nightclubs, dance clubs, and at parties and “raves” 

(overnight dance parties, usually with several hundred people in 

attendance) 

■		Most frequent withdrawal symptoms reported with some of these 

drugs: intoxication and severe intoxication with overdose 

■		Appear to have destructive effects on the nervous system and 

mental health 

XI . Management of Polydrug Abuse: 

An Integrated Approach 

■		One of the most significant changes in detoxification has been the 

increase in patients requiring detoxification from more than one 

substance. 

■		Programs must be aware that even if patients admit using one 

substance, they may not admit the use of others or feel that the 

information isn’t important. 

Programs should carefully screen to determine all substances being 

used; this might involve a drug screen. 

While substances of abuse may have complex interactions, it is 

not always possible to determine how those interactions will affect 

withdrawal. Best practice includes 

■		Prioritizing the substances on which the patient has been 

dependent. 

■		Treating sequentially according to the severity of the withdrawal 

produced by each substance. 

■		Being aware that the substances with the most serious withdrawal 

symptoms (resulting in fatality) are alcohol and sedative-hypnotics. 

■		After sedative-hypnotics, making management of opioid 

detoxification the next priority. 

■		In general, recognizing that other substances—like stimulants, 

marijuana, hallucinogens, and inhalants—will not require specific 

treatment in patients who are being detoxified from sedativehypnotics and/or opioids. 

62	 Module 4 
 

TIP 45: Detoxification and Substance Abuse Treatment 

XII . Alternative Approaches 

Alternative methods that have been scientifically studied do not claim to 

be standalone withdrawal methods or treatment modalities. 

In terms of alternative approaches 

■		They are designed to be used in an integrated substance abuse 

treatment system to promote health and well-being, provide 

symptom relief, and improve patient retention. 

■		Studies have shown that acupuncture—typically in the ear— reduces 

cravings and enhances the patient’s sense of engagement in the 

treatment process. 

■		Herbal remedies are used in many cultures worldwide but have not 

been proven effective scientifically; there currently is much research 

in this area. 

XIII . Considerations for Special 

Populations 

Trainer note: You have the option of having participants engage in an 

exercise to explore attitudes toward substance users, particularly as 

they relate to special populations. The exercise will be followed by a 

brief overview of several special populations. Participants can get more 

information on these populations in TIP 45’s Chapter 4, pp. 105–120. 

If you do not have time or feel this exercise is not appropriate for your 

participants, just present the didactic information on special populations. 

A . Optional Exercise: Attitudes Toward 

Substance Users 

Trainer note: The following exercise is designed to provide participants 

with a greater understanding of how attitudes can affect patient 

interaction and success, particularly in special populations, regarding 

engaging in and completing detoxification as well as seeking ongoing 

substance abuse treatment. It is designed to “set the stage” for the more 

didactic presentation that follows on special considerations for different 

population groups. It may not be appropriate for all audiences. 

Dyads Exercise: Attitudes Toward Substance Users 

Exercise creation directions: You will need to develop two different 

detailed patient descriptions representing two different special population 

groups. It is best to use populations the participants work or are more 

experienced with. You can select different racial/ethnic minorities, 

adolescents, older adults, pregnant women, gay or lesbian individuals, 

or incarcerated persons. Use as much detail as possible to include 

demographics (gender, age, education level, socioeconomic status), 

language, life situation, substance abuse history, current substance use, 

family and social supports, and reason for seeking detoxification services. 

Module 4 63 
TIP 45: Detoxification and Substance Abuse Treatment 

Draw on your own experience to develop the patient descriptions, or prior 

to the training, ask selected program staff where you will be training to 

help you develop patient descriptions based on real-life patients. 

After you have put together the two different, detailed patient 

descriptions, you will next need to develop a short (three or four 

sentences) “snapshot” for each of the two detailed patient descriptions. 

For example, “This is a 24-year-old African-American woman who is 

pregnant and seeking detoxification services.” 

Exercise directions: Divide the participants into dyads (groups of two). 

Have them select a partner and encourage them to work with someone 

they do not know well. 

Have each person take a turn at being the intake counselor and a turn at 

being the patient. 

In each of the dyads, distribute the detailed patient descriptions to 

the patients and the corresponding patient “snapshots” to the intake 

counselors. Be sure to distribute the detailed patient descriptions and 

corresponding patient “snapshots” evenly among the dyads. 

Give the intake counselors 5 to 10 minutes to begin interviewing the 

patients about their reasons for requesting detoxification services or why 

they are here today. Tell the intake counselors that they are free to ask 

as many questions as they like to get an initial “read” on client readiness 

and appropriateness for detoxification services. 

At the end of 5 or 10 minutes, have the groups stop, switch roles, and 

repeat the exercise, maintaining the same dyads. 

Give the dyads 5 minutes to process how they felt going through this 

exercise, focusing on any attitudes or behaviors the intake counselor 

exhibited that caused them discomfort or mistrust. Have them also talk 

about how the intake counselor’s behavior might impact their decision to 

receive detoxification services. 

Processing the exercise: Reassemble the dyads into a large group and 

ask participants to share lessons learned and experiences with the whole 

group. Facilitate the discussion and address any questions or concerns 

from participants. 

Thank participants for participating in the exercise, noting how difficult 

it can be to recognize attitudes that might present barriers to patients 

seeking and/or undergoing detoxification. 

Tell participants that they will now be talking about selected populations 

and special considerations for them regarding detoxification and 

substance abuse treatment, starting with pregnant women. 

64 Module 4 
 

TIP 45: Detoxification and Substance Abuse Treatment 

B . Considerations for Pregnant Women 

While in detoxification, pregnant women need to receive comprehensive 

medical care, particularly since this may be the first time they are seeking 

any type of care or treatment. 

Programs ideally need to offer the following services or have strong 

linkages to agencies that provide services for pregnant women: 

■		Detoxification on demand 

■		Woman-centered medical services 

■		Transportation 

■		Childcare 

■		Counseling and case management 

■		Access to drug-free, safe, and affordable housing 

■		Help with legal, nutritional, and other social service needs 

Pregnant women have special issues and needs during detoxification. 

■		Health and safety of both the mother and the fetus must be 

ensured. 

■		Before giving any medications, the woman needs to understand the 

risks and benefits of taking them and give informed consent. 

■		Protocols for withdrawal from specific substances may vary with 

pregnancy and stage of pregnancy. 

Trainer note: TIP 45’s Chapter 4, pp. 105–109, contains information on 

withdrawal from specific substances for pregnant women. 

C . Considerations for Older Adults 

Older adults undergoing detoxification have unique needs. 

Here are some recommendations programs can follow when treating 

older adults. 

■		Utilize age-specific group treatment that is supportive and 

nonconfrontational. 

■		Screen for depression, grief, and loss-related issues; older adults in 

particular may be dealing with loneliness or loss of career or a loved one. 

■		Provide linkages to medical and specialized services for the aging. 

■		Be aware that alcohol and drug-related disorders are often more 

severe in the elderly. 

■		Know that the elderly are at increased risk for co-occurring medical 

disorders and may have more medical complications when 

undergoing detoxification. 

■		Conduct assessments and provide ongoing monitoring for heart 

disease, respiratory disease, diabetes, and dementia. 

Module 4 65 
 

TIP 45: Detoxification and Substance Abuse Treatment 

Trainer note: Refer participants to CSAT’s TIP 26: Substance Abuse 

Among Older Adults, for more information on this population. 

D . Special Considerations for People With 

Disabilities or Co-Occurring Conditions 

Explain to participants that substance abuse treatment programs must 

be in compliance with two Federal laws: the 1992 Amendments to the 

Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) 

of 1990. 

Trainer note: More information on these Federal laws, as well as this 

population, is provided in CSAT’s TIP 29: Substance Use Disorder 

Treatment for People with Physical and Cognitive Disabilities. 

Programs need to eliminate four fundamental groups of barriers to 

treatment for people with disabilities and/or co-occurring disorders: 

■		Attitudinal barriers 

■		Discriminatory policies, practices, and procedures 

■		Communications barriers 

■		Architectural barriers 

Take some time to review with participants 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 on or lack of ability to perform an activity in 

the manner or within the range considered normal for a human being 

■		Functional capacities—The degree of ability an individual has 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 because of a disability 

The field of disability services has its own terminology to discuss physical, 

sensory, and cognitive disabilities, which has been grouped into four main 

categories of impairments: 

■		Physical—Caused by congenital or acquired diseases/disorders or 

by injury or trauma, like spina bifida and diabetes 

■		Sensory—Includes blindness and deafness, which may be caused by 

congenital disorders or disease or injury 

■		Cognitive—Disruptions of thinking and communication skills, spatial 

disorientation, problems with sequencing, and misperception of 

time, like learning disabilities, mental retardation, and ADD 

66	 Module 4 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Affective—Disruptions in the way emotions are processed and 

expressed, like depression, bipolar disorder, PTSD, anxiety, and 

eating disorders 

When working with this special population, detoxification programs need to 

■		Routinely screen for disabilities and co-occurring medical and/or 

psychiatric conditions. 

■		Be in compliance with all Federal laws. 

■		Provide access to needed services. 

■		Coordinate treatment and care in cases where all services are not 

being provided in the same place. 

■		Be knowledgeable about local disability resources, as well as 

national disability organizations that can serve as resources, like 

United Cerebral Palsy, National Association of the Deaf, and the 

Association for Retarded Citizens. 

E . Special Considerations for Racial/Ethnic 

Minority Populations 

Trainer note: Explain to participants that there are special considerations 

for racial/ethnic minority populations that are discussed in detail in TIP 

45’s Chapter 4, pp. 113–119. Let participants know that there is a CSAT 

TIP—Improving Cultural Competence in Substance Abuse Treatment— 

under development. 

Highlight some of these considerations for detoxification, starting with 

African Americans. 

■		African Americans are at greater risk for diabetes and high blood 

pressure, which can predispose them to risk of stroke. 

■		When working with other cultures, African Americans may display 

mistrust and a reluctance to show any weakness, making it critical 

for staff to respect patients and facilitate their participation in 

treatment as equal partners. 

■		African Americans may be at greater risk of developing toxic side 

effects when prescribed antidepressants. 

Next, discuss some special considerations for Asians and Pacific 

Islanders. 

■		This is a diverse group with widely differing languages, beliefs, 

practices, and values. 

■		Members of this group are concerned about the clinician’s 

credibility and trustworthiness; education, level of experience, and 

cultural sensitivity are important. 

■		A concrete, logical approach is valued. 

Module 4 67 
TIP 45: Detoxification and Substance Abuse Treatment 

Here are some issues for programs to consider in terms of detoxification 

for Asians and Pacific Islanders. 

■		Incorporate traditional healing methods, if possible and appropriate. 

■		When discussing detoxification medications, be sure to talk about 

how patients might feel toward Western medicine. 

■		Asians tend to have greater sensitivity to alcohol than do whites. 

■		Smoking rates among males, especially immigrant males, tend to 

be exceptionally high. 

■		Some detoxification medications are metabolized more slowly and 

might require lower dosages. 

American Indians are another population that has special considerations 

for detoxification. 

■		There are more than 500 federally recognized American Indian 

tribes. 

■		This population has great diversity in practices, language, traditions, 

religious beliefs, and values. 

■		Among all racial/ethnic groups, American Indians have the highest 

rates of alcohol and illicit drug use, but there is variability among 

tribes. 

Regarding detoxification, the following issues need to be considered by 

programs when working with this population. 

■		Greater trust in the detoxification process is established when 

the process is not rushed and the patient is treated in a 

nonconfrontational manner.
 

■		Using fables, illustrative stories, and “Talking Circles” can assist the 

process. 

■		Avoidance of eye contact is traditional in this population. 

■		Fetal Alcohol Syndrome (FAS) is 33 times higher in this population 

than the national average. 

■		When 12-Step programs are introduced, framing the steps in terms 

of a circle rather than a ladder may be better received (relates to 

Talking Circles). 

■		American Indians are more likely to seek treatment later and have 

more medical complications and poorer nutrition. 

Hispanics/Latinos are the last racial/ethnic minority group to be 

discussed. 

■		Hispanics are the largest racial/ethnic minority group in the United 

States. 

68	 Module 4 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Assessment of the patient’s level of acculturation can be helpful in 

understanding drug and alcohol patterns. 

■		Language competency in both Spanish and English can be a 

significant aid in treatment entry and success. 

■		Family is very important and needs to be involved in the 

detoxification and treatment process. 

■		Alcohol and drug dependence are often viewed as a moral failing or 

personal weakness. 

F . Special Considerations for Other Populations— 

Gays and Lesbians, Adolescents, and 

Incarcerated/Detained Persons 

There are a number of principles of care for treating gay and lesbian 

individuals, which are outlined in CSAT’s TIP, A Provider’s Introduction to 

Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender 

Individuals, which we will outline here: 

■		Monitor individual feelings among counselors and clinicians about 

working with this population in order to provide professional, ethical, 

and competent care; since many misconceptions and stereotypes 

exist, it is important for individuals to assess their beliefs and not 

impose them on patients. 

■		Help patients heal from the negative experiences of homophobia 

and heterosexism. 

■		Help patients understand their reactions to discrimination and 

prejudice. 

■		Help patients accept personal power over their own lives to improve 

their self-images and build support networks. 

We talked earlier in this module about protocols for adolescents. Here 

are several additional considerations for adolescents undergoing 

detoxification that programs need to be aware of: 

■		Physical dependence is generally not as severe, and response to 

detoxification is more rapid than in adults. 

■		Retention is a major problem. 

■		Peer relationships play a large role in treatment. 

■		It is estimated that 75 percent of those reporting steroid use are 

high school students, and most of them are male. 

■		The use of club drugs is higher in adolescents compared with other 

populations. 

Module 4 69 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

Another population that has special needs is incarcerated and/or 

detained persons. 

■		Substance use disorders are common in this population. 

■		An estimated 70 to 80 percent of all inmates in local jails and 

Federal and State prisons had experienced regular drug use or had 

committed a drug offense. 

■		Although women make up a small proportion of the incarcerated 

population, females have a greater prevalence of drug use than do 

males. 

■		Abrupt withdrawal from alcohol can be life-threatening. 

■		Abrupt withdrawal from opioids or benzodiazepines, while not lifethreatening, can cause great distress. 

■		Many correctional facilities have restrictions on the use of 

methadone, and special provisions may need to be made. 

■		Substance abuse continues to be a problem while persons are 

incarcerated. 

■		Access to appropriate detoxification and continuing care is 

problematic in many facilities. 

Trainer note: CSAT has three TIPs for this population—TIP 30: Continuity 

of Offender Treatment for Substance Use Disorders From Institution to 

Community; TIP 21: Combining Alcohol and Other Drug Abuse Treatment 

With Diversion for Juveniles in the Justice System; and TIP 44: Substance 

Abuse Treatment for Adults in the Criminal Justice System. 

XIV . Module 4 Summary and Closing 

Tell participants that they have received a more detailed description 

of specific treatment regimens for specific substances, information on 

managing polydrug abuse, and alternative approaches, as well as special 

considerations for special populations, in the detoxification process. 

Module 5 will provide you with more detailed information on co-occurring 

medical and psychiatric conditions and how they affect the detoxification 

process. 

Trainer note: If you are delivering this course over more than 1 day, give 

participants a homework assignment to read the modules or sections 

of TIP 45 you will be covering in the next session. Ask participants for 

feedback on this module in the form of “pluses,” or things that they liked 

about the session, and “wishes,” or things that they would like to see 

changed or incorporated into future sessions. Prepare a newsprint with a 

line down the middle with “pluses” on one side and “wishes” on the other 

and record participants’ responses. 

70	 Module 4 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 5: Co-Occurring 

Medical and Psychiatric 

Conditions 

Learning Objectives 

Upon completion of Module 5, participants will be able to 

1. Explain special considerations for detoxification programs 

regarding treating patients with co-occurring medical and 

psychiatric conditions.
 

2. List five common co-occurring medical conditions. 

3. Describe four co-occurring psychiatric disorders. 

TIP 45 References 

Chapter 5: Co-Occurring Medical and Psychiatric Conditions, pp. 121–144 

Total Time to Deliver Module 

30 minutes 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD or overhead transparency projector 

■ PowerPoint ® presentation or overhead transparencies 

■ Nametags 

■ Attendance log 

■ Pens, pencils 

■ Post-it ® notes or stickies 

Participant Materials 

■ TIP 45: Detoxification and Substance Abuse Treatment 

■ Module 5 Slides/Overheads Handout 

Module 5 71 
TIP 45: Detoxification and Substance Abuse Treatment 

I . Introduction to Module 5 

Tell participants that you are going to give a brief overview of the 

co-occurring medical and psychiatric conditions described in detail in 

TIP 45’s Chapter 5. 

Trainer note: The material in this module will be presented didactically. 

Let participants know that while the information in Chapter 5 is highly 

technical and geared toward medical professionals, nonmedical 

personnel may find it helpful in developing a greater understanding 

of how co-occurring medical and psychiatric conditions can affect 

withdrawal from specific substances. 

Trainer note: For more information on treating patients with co-occurring 

medical and psychiatric disorders, refer participants to CSAT’s TIP 42: 

Substance Abuse Treatment for Persons With Co-Occurring Disorders. 

Begin by sharing some basic information on patients undergoing 

detoxification. 

■		Medical and psychological conditions can greatly affect both patient 

well-being and the detoxification process. 

■		Medical conditions can be preexisting and not related to substance 

use nor a direct outcome of the substance abuse. 

■		Detoxification can negatively impact the co-occurring disorder, or 

vice versa. 

■		Individuals who abuse substances often present with medical 

conditions in advanced stages or because they are undergoing a 

medical crisis. 

■		Psychological disorders are likely to be exacerbated (made worse) 

by substance abuse. 

II . Module 5 Objectives 

Review Module 5 objectives with the participants. Upon completion of 

Module 5, participants will be able to 

1. Explain special considerations for detoxification programs 

regarding treating patients with co-occurring medical and 

psychiatric conditions. 

2. List five common co-occurring medical conditions. 

3. Describe four co-occurring psychiatric disorders. 

72 Module 5 
 

TIP 45: Detoxification and Substance Abuse Treatment 

III . General Principles of Care of Patients With 

a Co-Occurring Medical Condition 

■		Patients who use substances can present with a single condition or 

any combination of conditions that occur in the general population. 

■		In most cases, medical management of the condition(s) does not 

differ from that of any other patient. 

■		Detoxification medicine and protocols may, however, need to be 

modified to minimize potentially harmful effects on the co-occurring 

condition. 

Talk about what programs can do to provide the best possible 

detoxification experience for individuals with co-occurring medical 

conditions. 

■		Staff need to be familiar with the signs and symptoms of common 

co-occurring medical disorders. 

■		Detoxification settings need to be appropriate for the medical 

conditions present and able to provide any required patient 

monitoring. 

■		Consultations with specialists may need to be arranged, depending 

on the condition. 

■		Co-occurring medical conditions can present an opportunity to 

engage the patient in substance abuse treatment. By focusing on 

the adverse effects of substance abuse on patients’ health, staff 

can help patients see the importance of engaging in treatment. 

■		Before discharge from detoxification, patients need to have 

appointments made for follow-up care for medical conditions, 

conditions requiring further evaluation, and substance abuse 

treatment. 

Common co-occurring medical conditions for patients undergoing 

detoxification include 

■		Gastrointestinal disorders, like reflux esophagitis (acid reflux), 

gastritis, and pancreatitis. 

■		Liver disorders, like cirrhosis. 

■		Cardiovascular disorders, like hypertension (high blood pressure) 

and arrhythmia (irregular heartbeat). 

■		Hematological (blood) disorders, like anemia. 

■		Pulmonary disorders, like asthma. 

■		Neurological disorders/conditions, like alcohol and sedative 

withdrawal seizures and stroke. 

Module 5 73 
 

 

 

 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Infectious diseases, like endocarditis, tuberculosis, sexually 

transmitted diseases, and HIV/AIDS. 

■		Other conditions, like diabetes. 

Trainer note: Reinforce with participants that TIP 45’s Chapter 5 

discusses the management of these medical conditions in detail. 

Participants who are not clinicians might find this information helpful and 

can review this chapter and discuss the information with the appropriate 

medical/clinical personnel in their organization. 

IV . Treatment of Co-Occurring Psychiatric 

Conditions 

Start with some basic information about detoxification and the treatment 

of co-occurring psychiatric conditions. 

■		In detoxification, patient care can be complicated by medications 

taken for co-occurring psychiatric conditions. 

■		Patients can exhibit symptoms from detoxification medications that 

mimic psychiatric conditions. 

■		It is not always advisable to discontinue all medications during 

detoxification; abrupt termination of psychiatric medication may 

cause withdrawal symptoms or the reemergence of the psychiatric 

disorder. 

■		Treatment of an addictive disorder can be difficult without adequate 

treatment of a psychiatric condition—for example, a patient with 

mania who is euphoric and delusional will have difficulty cooperating 

with the addiction treatment if the mania is not addressed. 

■		When psychiatric disorders are left untreated, they can result in 

mood, anxiety, or thought disorders that can prevent or retard 

recovery from substance abuse. 

■		Patients with co-occurring psychiatric conditions need a longterm plan for rehabilitation, including psychotherapy and illness 

management. 

A . Standard of Care for Co-Occurring Psychiatric 

Conditions 

Because alcohol and drugs can induce almost any psychiatric symptom 

or sign or mimic any psychiatric disorder, their effects should always be 

considered before a co-occurring condition diagnosis is established or 

treated. 

Standards of care have been developed for different psychiatric 

conditions or disorders. TIP 45’s Chapter 5 lists general approaches and 

pharmacologic therapies for anxiety, depressive, bipolar, and psychotic 

disorders. 

74 Module 5 
TIP 45: Detoxification and Substance Abuse Treatment 

Anxiety Disorders 

■		Studies indicate that prevalence rates for the co-occurrence of 

anxiety and addiction disorders range from 5 to 20 percent. 

■		Antianxiety agents can oversedate and dull a patient’s reaction to 

internal and external influences. 

■		Anxiety in recovery can be important and help move a patient 

toward change. 

■		Withdrawal produces varying levels of anxiety in patients; the longer 

and more chronic the substance abuse has been, the more severe 

the anxiety can be. 

■		Treatment is indicated when anxiety persists after substance abuse 

treatment or it is suspected that anxiety is preventing the patient 

from participating in treatment. 

■		Medication can be started at any time if the condition is persistent 

and waiting is not possible. 

■		Commonly used agents include benzodiazepines and 

antidepressants. 

Depressive Disorders 

■		Studies indicate that prevalence rates for the co-occurrence of 

depressive and addictive disorders range from 5 to 25 percent. 

■		Depressive disorders can occur independently of addictive 

disorders or can be induced by alcohol and drug use. 

■		Depression can result during recovery and can be part of a patient’s 

healing process due to the losses suffered by a patient, including 

the loss of alcohol, drugs, and relationships based on drug use. 

■		Depressant drugs (alcohol) can produce depression during 

intoxication. 

■		Stimulant drugs (cocaine) can produce depression during 

withdrawal. 

■		Depression can be prolonged with certain drugs, like marijuana and 

benzodiazepines, that linger in the body. 

■		Depression is more common in older adults and women. 

■		Medication can be started at any time if the condition is persistent 

and waiting is not possible. 

■		Treatment is usually with antidepressants once it is established that 

the depression is not drug-induced. 

Module 5 75 
TIP 45: Detoxification and Substance Abuse Treatment 

Bipolar Disorders 

■		Studies indicate that prevalence rates for the co-occurrence of 

bipolar and addictive disorders range from 30 to 60 percent. 

■		Bipolar disorder may be complicated by alcohol or drugs—for 

example, mania can be produced by stimulants (cocaine) and 

depression by depressants (alcohol). 

■		Medication can be started at any time, if the condition is persistent 

and waiting is not possible. 

■		Mood-stabilizing drugs used include lithium and anticonvulsives. 

Psychotic Disorders 

■		Studies indicate that prevalence rates for co-occurrence of 

schizophrenic and addictive disorders range from 40 to 80 percent. 

■		Psychoses can be caused by stimulant drug use during intoxication 

and depressant drug/alcohol use during withdrawal. 

■		Medication can be started at any time if the condition is persistent 

and waiting is not possible. 

■		Medications used include antianxiety agents like benzodiazepines, 

antipsychotic agents, and antidepressants. 

V . Module 5 Summary 

Tell participants that they should now have a basic understanding of 

co-occurring medical and psychiatric conditions and how they can affect 

the detoxification process. Remind participants that they can get more 

comprehensive information in TIP 45’s Chapter 5. 

Module 6 will provide you with an overview of the financing and 

organizational issues involved with preparing and developing a 

detoxification program. 

Trainer note: If you are delivering this course over more than 1 day, give 

participants a homework assignment to read the modules or sections 

of TIP 45 that you will be covering in the next session. Ask participants 

for feedback on this module in the form of “pluses,” or things they liked 

about the session, and “wishes,” or things they would like to see changed 

or incorporated into future sessions. Prepare a newsprint with a line down 

the middle, with “pluses” on one side and “wishes” on the other, and 

record participants’ responses. 

76 Module 5 
TIP 45: Detoxification and Substance Abuse Treatment 

Module 6: Financing 

and Organizational 

Issues 

Learning Objectives 

Upon completion of Module 6, participants will be able to 

1.		 Describe the changing patterns of detoxification service 

utilization. 

2.	 Identify at least four major funding streams available to 

detoxification and substance abuse treatment programs. 

3.		 Explain the different types of financial arrangements involved in 

managed care contracts and their risks. 

4.	 Describe other aspects of working in a managed care 

environment, including accreditation, credentialing, 

performance measurement and utilization, and case 

management. 

5.		 State two strategies for strengthening the financial base and 

market position of a detoxification program. 

TIP 45 References 

Chapter 6: Financing and Organizational Issues, pp. 145–168 

Total Time to Deliver Module 

One hour; can be longer depending on participants’ needs 

Training Equipment and Supplies 

■ Easel and newsprint pads, markers, masking tape 

■ LCD or overhead transparency projector 

■ PowerPoint ® presentation or overhead transparencies 

■ Nametags 

■ Attendance log 

■ Pens, pencils 

■ Post-it ® notes or stickies 

Module 6 77 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

Participant Materials 

■ TIP 45: Detoxification and Substance Abuse Treatment 

■ Module 6 Slides/Overheads Handout 

I . Introduction to Module 6 

Tell participants that you are going to switch gears now to talk about 

financing and organizational issues involved in developing a detoxification 

program. 

Explain that the program development process will require careful 

planning, particularly regarding financial support. 

Trainer note: This module involves didactic presentation. Whenever 

possible, use the facilitated discussion technique to involve participants 

and draw on their experience. This type of interaction will help make the 

material more relevant to participants. 

II . Module 6 Objectives 

Review Module 6 objectives with the participants. Upon completion of 

Module 6, participants will be able to 

1.		 Describe the changing patterns of detoxification service 

utilization. 

2.	 Identify at least four major funding streams available to 

detoxification and substance abuse treatment programs. 

3.		 Explain the different types of financial arrangements involved in 

managed care contracts and their risks. 

4.	 Describe other aspects of working in a managed care 

environment, including accreditation, credentialing, 

performance measurement and utilization, and case 

management. 

5.		 State two strategies for strengthening the financial base and 

market position of a detoxification program. 

III . Preparing and Developing a Program 

A . Understanding the Changing Utilization 

Patterns of Detoxification Services 

Begin by stating that both the setting and primary substance abuse 

problem for admission to detoxification services have changed over the 

last 10 years. 

Program planners need to understand these changes as they determine 

what type of program will best meet their target populations’ needs: 

78 Module 6 
 

TIP 45: Detoxification and Substance Abuse Treatment 

■		The setting for services has shifted from largely inpatient to 

outpatient programs. 

■		The primary substance abuse problem has also shifted from alcohol 

and cocaine/crack to heroin and other opioids. 

■		There are more opportunities today to provide community-based 

and private detoxification services. 

■		The number of hospital-owned freestanding detoxification facilities 

has increased. 

Prospective programs need to research their own local markets to 

determine services currently available and identify service gaps. 

They also need to obtain current data on utilization and demand for 

detoxification services in their area. 

B . Funding Streams and Other Resources for 

Program Development 

Once a program has been defined, the next step is determining how 

funding will be secured. 

Tell participants about money and resources available for program 

development. 

Tell participants that substance abuse treatment in the United States 

is financed by both public and private funding sources, with more funds 

coming from the public sector. 

In order for a program to be successful, it must develop a diverse funding 

stream and not rely on a single, large funding source for its operation. 

Explain to participants that there are many nuances to securing funding 

and that once funding is secured, each funding stream will have different 

reporting and accounting requirements. 

State that you will not be going into depth on these issues now; TIP 45’s 

Chapter 6 will give participants more detailed information on issues 

regarding securing funding and developing a diverse funding stream. 

Prospective programs might also want to secure the services of a 

professional fundraiser to assist them with this process. 

Today’s goal is to provide participants with an overview of the key funding 

streams that are available for programs providing substance abuse 

treatment. 

Participants can find more detailed information on each of these funding 

streams, as well as additional funding opportunities, in Chapter 6. 

Specific Web sites with additional information on funding resources are 

also included throughout Chapter 6. 

Module 6 79 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

Trainer note: You can prepare a handout of the Web sites for the different 

funding streams beforehand or write them on a newsprint and post it in 

the training room. 

Substance Abuse Prevention and Treatment 

(SAPT) Block Grant Program 

■		Federal funding is available from SAMHSA for substance abuse 

programs. 

■		Block grant funds are sent from the Federal Government to 

each State’s Single State Agency (SSA) for substance abuse for 

distribution throughout the State. 

■		Funds can be subject to set-asides for special populations. 

■		Each State maintains its own funding eligibility criteria. 

■		Providers who provide services in more than one State need to 

check for opportunities in each State in which they operate. 

■		SAMHSA has other funding (non-block grants) for grants and 

contracts. 

Medicaid 

■		This is a Federal Government program administered by the Centers 

for Medicare and Medicaid Services (CMS); each State pays for 

medical care for specifically defined eligible persons. 

■		Medicaid expands medical coverage, including substance abuse 

services, to the uninsured, including low-income children, pregnant 

women, the elderly, and persons who are blind or otherwise disabled. 

■		It is up to each State to determine whether it will include benefits for 

substance abuse treatment in its Medicaid program (most States do). 

■		States also select the precise services and levels of care in 

substance abuse treatment that will be reimbursed. 

■		Rates of payment/reimbursement are independently determined by 

each State and may vary within the State among different coverage 

arrangements. Medicaid may pay for substance abuse treatment 

directly through fee-for-service arrangements or through a managed 

behavioral health care or other managed care organization with 

which it contracts; more than one type of arrangement may exist 

within the same State. 

■		While most States offer some coverage for detoxification services 

under their Medicaid programs, not all settings or types of 

detoxification programs may be covered. 

When available, Medicaid coverage offers advantages to substance 

abuse treatment programs: 

80 Module 6 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Medicaid can provide significant funding for high-risk groups, like 

low-income mothers and adolescents. 

■		Treatment may not require a client copay, depending on the State; 

this allows the program to receive the entire fee without having to 

collect funds from clients. 

■		Medicaid can help in negotiating rates with commercial payors by 

not allowing acceptance of contract terms with any other purchaser 

at rates lower than those established for Medicaid. 

■		Certification as a Medicaid provider can position a program to 

receive patients from other public-sector referral sources, like social 

services and criminal/juvenile justice. 

Medicare 

■		Federal Government program administered by the Centers for 

Medicare and Medicaid Services (CMS) 

■		Provides coverage to individuals over age 65 and people under the 

age of 65 with certified disabilities, as well as to people with endstage renal disease 

■		Provides coverage to patients in hospital-based detoxification 

programs that are certified by Medicare 

■		Does not cover detoxification programs that provide a structured 

environment, socialization, or vocational rehabilitation 

The State Children’s Health Insurance Program 

(SCHIP) 

■		Provides low-cost health insurance for children in low-income 

families who are not eligible for Medicaid 

■		Provides funds for substance abuse treatment of children and 

adolescents, but varies from State to State 

■		Can provide funds under a State’s Medicaid program or through a 

separate children’s health insurance program 

■		State alcohol and drug abuse agencies may be able to provide 

resource treatment information for youth over the maximum age for 

SCHIP 

Social Services 

■		The Temporary Assistance for Needy Families (TANF) block grant 

program administered by States will fund—depending on the State— 

substance abuse treatment services that are considered medical, 

but there is broad interpretation as to what constitutes “medical” 

services. 

Module 6 81 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Initiatives through the U.S. Department of Labor fund nonmedical 

substance abuse treatment services through the Welfare-to-Work 

program. 

■		HUD funds treatment of public housing residents under the Public 

Housing Drug Elimination Program. 

■		Federal vocational rehabilitation education funds—channeled 

through State agencies responsible for vocational rehabilitation— 

support services that help persons with disabilities participate in 

the workforce, including treating them for substance use disorders. 

■		Children’s protective services: Title IV of the Social Security Act 

funds court-ordered substance abuse treatment for parents who 

are at risk of losing custody of their children. 

■		Ryan White Title I provides funds for substance abuse treatment 

in eligible metropolitan areas most severely affected by the HIV 

epidemic. 

Criminal Justice/Juvenile Justice (CJ/JJ) Systems 

■		State corrections systems may provide funds for treatment of 

offenders who are returning to the community via parole offices, 

halfway houses, or residential correctional facilities. 

■		Community drug courts can contract with substance abuse 

treatment programs and send nonviolent offenders to treatment in 

lieu of incarceration. 

■		Substance abuse treatment programs with expertise in treating 

adolescents can obtain contracts from the juvenile court system to 

provide treatment in a juvenile correctional facility or to juveniles in 

the justice system. 

Other Funding Streams/Resources 

■		TRICARE: the managed care program for the military; will 

sometimes pay for substance abuse treatment services subject to 

preauthorization requirements 

■		Local funding through county and local governments 

■		Private payors, including managed care organizations, managed 

behavioral health care organizations, local employers, and 

employee assistance programs 

■		Contributions and grants to support program costs from 

foundations, local charities, businesses, and individual donors 

■		Research grants from public and private sources 

■		Self-pay patients 

82 Module 6 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

IV . Working in a Managed Care 

Environment 

Begin this section by stating that all health care providers, including 

substance abuse treatment providers, operate in a managed care 

environment whether they are public or private entities. 

It is important for program developers to become knowledgeable about 

managed care and how the industry works. 

There are four fundamental aspects of managed care arrangements: 

■		Managed care contracts must specify the obligations of each party 

completely and clearly. 

■		After signing a managed care contract, a detoxification program 

or its parent agency becomes a member of the managed care 

organization’s network. 

■		All managed care contracts include performance measurement 

and reporting and may have financial or referral incentives or 

disincentives associated with measured performance. 

■		All managed care contracts include utilization management to 

determine what services are “medically necessary” and eligible for 

reimbursement and case management or utilization that requires 

initial and continuing approvals for treatment and referrals. 

In order to assess and negotiate a managed care contract and monitor 

your program’s performance under that contract, you need to know the 

cost of the detoxification services you are going to provide. 

The cost of services can be challenging to determine; there is guidance 

in TIP 45 on page 163 for different methodologies of determining service 

cost. 

Cost of services generally includes 

■		Staff time spent with patients. 

■		Administrative time spend on meetings and paperwork. 

■		Capital and operating expenses. 

Only when the cost of delivering a unit of a particular service is known 

can a program negotiate a reasonable rate for specific services. 

A . Financial Arrangements and Risks in 

Managed Care Contracts 

Talk with participants about financial arrangements under managed care. 

There are three major categories of financial arrangements or methods of 

payment in managed care contracts that program administrators need to 

understand. 

Module 6 83 
TIP 45: Detoxification and Substance Abuse Treatment 

While all financial arrangement have risks, each major category has 

specific associated risks that program developers and managers need to 

be aware of. 

Fee-for-Service 

■		Fee-for-service generally requires precertification and utilization 

management for some or all procedures and services. 

■		Approved services are documented in patients’ benefit plans. 

■		A rate is received for the services provided: typically a standard 

program session with specific services bundled in. 

■		This is the least risky arrangement for providers. 

■		When negotiating a fee-for-service contract, it is necessary to 

ensure that the rate is sufficient to cover the actual costs. 

■		All services must be costed out prior to contract negotiation so 

actual costs of treatment components are known and can be 

compared with what is offered. The managed care organization has 

the option of refusing to pay for some of the bundled services a 

program may be offering. 

Capitation Agreement 

■		This is used when a managed care organization establishes a 

stipulated dollar amount to cover treatment costs for a group of 

people using one-per-person rate for everyone. 

■		The provider agrees to provide all or some treatment services for 

an expected number of managed care “covered lives”—for example, 

100,000 subscribers. 

■		Usually, only large service providers have the assets and volume of 

services to enter into capitated agreements. 

■		If many more people than are predicted require treatment, the 

provider may not be able to cover service delivery costs. 

■		Programs need to track actual dollars against the budget in real 

time to avoid unexpected deficits. 

Case Rate Agreement 

■		For a fixed per-patient fee, the provider covers all the services a 

client requires for a specific period. 

■		The “set” of services is determined by the managed care organization. 

■		Case rate removes some of the utilization risk from the service 

provider compared with capitation agreements. 

■		There is, however, a risk that clients will need services more 

frequently or at higher levels than the case rate covers. 

84 Module 6 
TIP 45: Detoxification and Substance Abuse Treatment 

■		Programs need to track actual average dollars per case against the 

contracted care rate in real time to avoid unexpected deficits. 

B . Accreditation and Credentialing 

When you join a managed care organization’s network of providers, 

you must meet that organization’s standards for staff credentials and 

program accreditation. These standards are rarely negotiable. 

■		Managed care organizations credential individual providers, not 

organizations. 

■		Staff credentialing requirements can vary by managed care organization. 

■		Staff credentialing most often includes providers who are licensed 

in psychology, nursing, medicine, and social work. 

■		Substance abuse treatment staff can vary from the traditional 

types of providers, and programs will need to educate managed 

care organizations about the types of staff needed and the kinds of 

services provided. 

■		Detoxification programs need to participate in both medical and 

behavioral networks of managed care organizations. 

■		Some managed care organizations require that the program itself 

be accredited by one of the major national health care accrediting 

organizations. The Commission on Accreditation of Rehabilitation 

Facilities (CARF) is the one most substance abuse providers use, 

but if offering inpatient detoxification services, you will need 

accreditation from the Joint Commission on Accreditation of 

Healthcare Organizations (JCAHO). 

Trainer note: Tell participants that more information on credentialing and 

associated Web site addresses are on page 161, Chapter 6, of TIP 45. 

C . Organizational Performance Measurement 

Begin this discussion by telling participants that performance 

measurement is an important component of managed care. Some 

organizations even use financial incentives and/or disincentives tied to 

performance. 

Managed care organizations have their own measures and procedures 

for performance measurement, some of which are prescribed by the 

organizations that accredit them. 

Performance measurement results required by a managed care 

organization can affect a program’s financial success and ability to 

continue as a network provider. 

Regardless of what managed care organizations require, well-managed 

programs develop and use their own internal performance measures, 

striving always to improve their performance. 

Module 6 85 
TIP 45: Detoxification and Substance Abuse Treatment 

Key process and outcome measures that all programs can use include 

the percentage of clients who 

■		Complete a defined treatment regimen that meets their individual 

needs. 

■		Drop out within the first 7 days following treatment initiation. 

■		Remain in documented but less intensive treatment 30 days after 

discharge from the program. 

■		Are employed or attending school 6 months after discharge from 

the program. 

The National Committee for Quality Assurance (NCQA) has developed four 

major “domains” for programs to develop substance abuse performance 

measures around: 

■		Prevention/education 

■		Recognition or identification of substance abuse 

■		Treatment, including initiation of alcohol and other plan services; 

linkage of detoxification and alcohol and other drug plan services; 

treatment engagement; and use of interventions for family 

members and significant others 

■		Maintenance of treatment effects 

D . Utilization and Case Management 

Open up discussion about utilization and case management in managed 

care organizations and how they can affect a detoxification program. 

■		Utilization management focuses on a single type of service. 

■		Case management focuses on the coordination of the appropriate 

array of services needed by a specific individual. 

■		In practice, both utilization and case management staff at a 

managed care organization authorize specific services for payment. 

■		A wide variety of criteria and protocols may be used by managed 

care organizations to determine whether services may be 

authorized for substance abuse, typically including American 

Society of Addiction Medicine (ASAM) criteria. 

Successfully addressing the needs of managed care organizations’ 

utilization and case management staff is critical to maintaining a 

program’s viability. 

To do so, detoxification program staff need to 

■		Understand what utilization and case management staff at 

managed care organizations do. 

86 Module 6 
 

 

TIP 45: Detoxification and Substance Abuse Treatment 

■		Be well trained in conducting professional relationships over the 

telephone. 

■		Be familiar with the criteria and protocols employed by the managed 

care organization with which the program contracts. 

■		Have easy access to clinical and service information required 

by a managed care organization to help it complete reviews and 

authorize services. 

■		Maintain complete records of all interactions and requests. 

E . Strengthening the Financial Base and Market 

Position of Detoxification Programs 

Begin discussion about strategies detoxification programs can use to 

facilitate larger numbers of patients and generate greater revenues per 

patient. 

■		Achieve recognition for quality and effectiveness of services. If a 

program has a reputation for providing effective care, managed care 

enrollees and other potential clients will want to use it. 

■		Serve special populations. Providing services to a population no 

other program serves is a potential marketing advantage. 

■		Develop economies of scale. Adding clinic or program sites may 

allow you to spread some of the fixed program costs among a larger 

number of patients, driving down per capita costs. 

■		Gain community visibility and support. Expanding a program’s 

board of directors to include governmental and community agency 

executives or politicians can raise a program’s profile. 

■		Form alliances with other treatment providers. Setting up coalitions 

to compete or work with managed care organizations and other 

purchasers, like Medicaid, may help strengthen a program. 

V . Module 6 Summary and Closing of 

Detoxification and Substance Abuse 

Training 

Tell participants that they have now received a basic understanding of 

funding streams and other resources they can use, as well as a greater 

understanding of working in a managed care environment. 

Let participants know that you have covered a great deal of information 

on detoxification and substance abuse treatment in a short period. 

It was the intention of this training to provide participants with a broad 

overview of detoxification and substance abuse treatment. 

Module 6 87 
TIP 45: Detoxification and Substance Abuse Treatment 

Remind participants that they can get more comprehensive information 

on all of the topics discussed in this training in TIP 45. 

Trainer note: If you have conducted this training over the course of 

several days, skip the “Pluses and Wishes” exercise specifically for 

Module 6 and evaluate the training as a whole, as follows: 

Closing discussion: Take some time to discuss and evaluate this training. 

Ask participants for feedback on the training in the form of “pluses,” or 

things they liked about the training, and “wishes,” or things they would 

like to see changed or incorporated into future trainings. Prepare a 

newsprint with a line down the middle with “pluses” on one side and 

“wishes” on the other, and record participants’ responses. 

Next, review participants’ expectations generated at the beginning of the 

training to determine whether/how well expectations were met and what 

follow-up is required. 

After this discussion, distribute Participant Feedback Forms on the 

training and ask participants to complete them before leaving the training 

room. 

88 Module 6 
HHS Publication No. (SMA) 09-4331
 

Printed 2008
 

Reprinted 2009