Medical Model Programs

Medical model programs are directed by a physician and staffed by other health care personnel. They range from hospital-based inpatient programs to free-standing medically based residential programs in hospitals or in community facilities that can draw on various medical resources.

Social Model Programs

Social model AOD abuse treatment programs concentrate on providing psychosocial services. Social workers and other clinicians provide services such as individual and family counseling and coordination of care. Patients who need a physician's care may be referred to a nearby emergency department, which is not a cost-effective source of detoxification services. Some programs that provide detoxification services have a physician on call who can prescribe detoxification medications.

Social model programs use a variety of approaches to detoxification, but the emphasis is most often on nonpharmacological management of withdrawal. Usually, counselors do not have prescribing privileges and cannot legally administer medications from stock bottles to patients. In some programs, counselors can assist patients in taking detoxification medications. The patient's medication supply must be in a container that is labeled with the patient's name and that includes instructions for taking the medication. Counselors observe the patient take the medication, and they maintain a log. Counselors can also monitor patients' symptoms and call physicians or nurse practitioners if patients become ill.

Social model programs should not provide detoxification for people who have severe dependence on alcohol or other sedative-hypnotics, as withdrawal can be life threatening in these cases. Patients must be properly medically evaluated when they enter a social model program.

Inpatient Detoxification

Inpatient detoxification is offered in medical hospitals, psychiatric hospitals, and medically managed residential treatment programs.

Outpatient Detoxification

Again, outpatient detoxification has three major advantages: It is less expensive; it is less disruptive; and it allows the patient to remain in the same setting where he or she will function when drug free. Outpatient detoxification usually is offered in community mental health centers, AOD abuse treatment clinics, and private clinics.

Emergency Departments. The emergency department (ED) often serves as a gateway to AOD detoxification services. AOD detoxification programs may rely on emergency department staff to assess and initiate treatment for patients with medical conditions or medical complications that occur during detoxification. For social model programs, EDs are often a safety net for patients who need medical treatment. For the AOD abuser who has overdosed or who is experiencing a medical complication of AOD abuse, the ED may be the initial point of contact with the health services system. It serves as a source of case identification and referral to AOD detoxification programs. Certain illnesses treated in emergency departments may mimic, mask, or resemble symptoms of withdrawal from AODs. Urine and blood toxicology testing may assist ED staff in making the correct diagnosis.

ED staff should refer patients who enter for detoxification to a more appropriate treatment site as soon as they have been assessed and stabilized. The ED of an acute care hospital is neither an appropriate setting for detoxification, nor is it a cost-effective one. However, because of the key role of the ED in the initial management and identification of persons in need of detoxification, ED staff should have both clinical expertise and familiarity with local AOD abuse treatment resources.

Intensive Outpatient Programs. Intensive outpatient programs offer a minimum of 9 hours a week of professionally directed evaluation and treatment in a structured environment. Examples include day or evening programs in which patients attend a full spectrum of treatment programming but live at home or in special residences. Some programs provide medical detoxification. Many programs have established linkages through which they may refer patients to behavioral and psychosocial treatment. One strength of these programs is the daily contact between patients and staff. Another TIP in this series, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse, describes these programs in detail.

Nonintensive Outpatient Programs. In nonintensive outpatient programs, patients attend regularly scheduled sessions that usually total no more than 9 hours of professionally directed evaluation and treatment per week. These programs may provide detoxification services. Treatment approaches and philosophies in staffing of outpatient programs vary considerably. Some offer only assessments; in others, counseling may continue for a year or longer. A majority of programs provide one or two weekly patient visits and may deliver psychiatric or psychological counseling and other services, such as resource referral and management. Many combine counseling with 12-step recovery.

Methadone Maintenance (Maintenance Pharmacotherapy) Clinics. These clinics may provide medically supervised withdrawal for persons abusing heroin who do not want to enter a methadone maintenance program but instead want to use methadone for withdrawal only, as well as for people who want to withdraw from methadone maintenance. The clinics, which must be licensed by the Food and Drug Administration, the Drug Enforcement Administration, and State regulatory agencies, are the only programs in which methadone maintenance may be conducted for opiate addicts. They may be publicly funded and/or on a fee-for-service basis, but the distinction between public and private clinics is not clearcut; for example, many private clinics have contracts with the State or county to provide detoxification services.

Program Administration

The "modified medical model" detoxification program is headed by a medical director who has knowledge of and skills in the treatment of addiction and who holds ultimate responsibility for patient care. The clinical responsibilities of the medical director include seeing patients when necessary and remaining on call for consultations. The director's primary administrative duties are supervising detoxification staff and establishing clinical protocols.

Triage

Triage and ongoing patient evaluation are essential components of the proposed "modified medical model." Staff regularly monitor each patient's vital signs, and the decision to medicate or not to medicate is made by a physician. Such a routine stands in sharp contrast to that of traditional social model programs. Frequently, in these settings, no one is available to monitor patients' vital signs. When crises occur, patients must be transported to a local emergency department. This practice is not cost-effective and does not ensure optimal patient care.

Staffing

A nurse practitioner or a physician's assistant manages day-to-day program operations. If the staff of the modified medical detoxification unit does not include a nurse practitioner or physician's assistant, the medical director's time in the program is expanded.

The nurse's chief responsibilities are to monitor patients' vital signs and to perform other nursing services. When an individual needs medical attention, the nurses call on a member of the medical team, if one is available to the unit, rather than referring the patient to an emergency department. However, if a member of the medical team is not available, the patient should be seen in an emergency department. A registered nurse should remain on call, and nurse's aides (such as rehabilitation technicians or detoxification aides) should be on duty at all times. Appropriate support for the nurse's aides includes, at a minimum, a nurse and a backup physician.

Staff Training, Certification, and Licensure

Ideally, all staff working in the program, including nurses, nurse practitioners, nurse's aides, and physician's assistants, are trained in detoxification and in the treatment of chemical dependency. Taking and interpreting vital signs constitute a minimal standard of care, and some staff members, such as nurse's aides, might be trained to interpret signs relevant to AOD abuse issues, since such training is not provided in many standard curricula. Nurse's aides undoubtedly would also require additional training in AOD abuse issues in order to serve as effective members of the care team in a detoxification unit. Program administrators should establish minimum standards for licensure and accreditation of modified medical programs and staff.

Patient Placement Criteria

For those who seek additional guidance in this area, a number of criteria sets have been developed to guide the process of matching patients to treatment settings. The Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (Hoffman, 1991), developed by the American Society of Addiction Medicine (ASAM) in 1991, are used by many programs. The ASAM criteria, which are intended for use as a clinical tool for matching patients to appropriate levels of care, reflect a clinical consensus of adult and adolescent treatment specialists and incorporate the results of a field review.

According to the ASAM Patient Placement Criteria, the three goals for management of detoxification are (1) avoidance of potential hazardous consequences of discontinuation of the drug of dependence; (2) facilitation of the patient's completion of detoxification and timely entry into continued treatment; and (3) promotion of patient dignity and easing of discomfort during the withdrawal process.

The ASAM criteria describe levels of treatment that are differentiated by the following three characteristics:

• Degree of direct medical management provided
• Degree of structure, safety, and security provided
• Degree of treatment intensity provided.

The ASAM levels of care range from outpatient treatment to medically managed intensive inpatient care. (The ASAM criteria do not provide for detoxification in social model programs.)

The ASAM criteria offer a variety of options, on the premise that each patient should be placed in a level of care that has the appropriate resources (staff, facilities, and services) to assess and treat the substance use disorder. While the criteria describe four levels of care, variations in staffing and support services may give some programs the capacity for more or less intense monitoring of detoxification than other programs at the same level of care.

The levels of care addressed by the ASAM Patient Placement Criteria are matched with the corresponding recommended detoxification settings described in Exhibit 2-1. The TIP titled The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (TIP 13; Center for Substance Abuse Treatment, 1995) provides a framework to help providers understand the issues surrounding patient placement criteria and offers potential strategies that can be useful in developing criteria. This TIP represents an initial effort to develop criteria that are more consistent with the overall needs of the treatment field.

Table

ASAM Patient Placement Criteria Applied to Detoxification Settings.

It provides an analysis of several sets of public and private criteria, including the ASAM criteria and those used by the States of Minnesota, Massachusetts, and Iowa. The TIP provides recommendations for filling in the gaps in existing criteria sets, so uniform criteria can be developed that are acceptable to both treatment providers and payers.

A managed care bibliography that includes information on patient placement criteria is available from CSAT. This bibliography, titled Annotated Bibliography: Substance Abuse Treatment Services and Health Care Reform, can be obtained by contacting CSAT's Division of State and Community Assistance at (301) 443-8391.

Advantages and Disadvantages of Placement Criteria

In recent years, some States have begun to develop standards of care on the basis of models such as the ASAM Patient Placement Criteria. The move toward the development of standards of care and their subsequent application across a broad range of detoxification settings has advantages and disadvantages.

Properly developed and executed, such standards have the potential to ensure increased uniformity of treatment and improved appropriateness and cost-effective allocation of resources. A basic consideration is meeting these expectations while at the same time maintaining the focus on the patient's clinical needs as the primary concern. Patient placement criteria can provide a safety net that protects patients from falling to the lowest level of care as a consequence of economic considerations or a lack of treatment alternatives. A major risk in the use of placement standards, however, is that they may be taken too literally by those not directly involved in patient care. This could result in a patient's receiving an inappropriate level of care that does not meet his or her clinical needs.

Clinicians must exercise judgment in all cases. If a single approach to care is widely adopted and strictly adhered to as the "correct" approach, treatment innovation may be stifled. The chief value of any criteria set is the added power that it gives providers to identify specific patient needs by means of a consistent and detailed assessment process and to choose a level of care that will specifically address those needs.