This Treatment Improvement Protocol (TIP) is a revision of TIP 19, Detoxification From Alcohol and Other Drugs (Center for Substance Abuse Treatment 1995d). It provides clinicians with updated information and expands on the issues commonly encountered in the delivery of detoxification services. Like its predecessor, this TIP was created by a panel of experts (the consensus panel) with diverse experience in detoxification services—physicians, psychologists, counselors, nurses, and social workers, all with particular expertise to share.

This diverse group agreed to the following principles, which served as a basis for the TIP:

1.

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

2.

The detoxification process consists of three essential components, which should be available to all people seeking treatment:

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Evaluation

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Stabilization

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Fostering patient readiness for and entry into substance abuse treatment

3.

Detoxification can take place in a wide variety of settings and at a number of levels of intensity within these settings. Placement should be appropriate to the patient's needs.

4.

All persons requiring treatment for substance use disorders should receive treatment of the same quality and appropriate thoroughness and should be put into contact with substance abuse treatment providers after detoxification.

5.

Ultimately, insurance coverage for the full range of detoxification services is cost-effective.

6.

Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as unique health needs and life situations. Programs offering detoxification should be equipped to tailor treatment to their client populations.

7.

A successful detoxification process can be measured, in part, by whether an individual who is substance dependent enters and remains in some form of substance abuse treatment/rehabilitation after detoxification.

Among the issues covered in this TIP is the importance of detoxification as one component in the continuum of healthcare services for substance-related disorders. The TIP reinforces the urgent need for nontraditional settings—emergency rooms, medical and surgical wards in hospitals, acute care clinics, and others—to be prepared to participate in the process of getting the patient who is in need of detoxification services into treatment as quickly as possible. Furthermore, it promotes the latest strategies for retaining individuals in detoxification while also encouraging the development of the therapeutic alliance to promote the patient's entrance into substance abuse treatment. The TIP also includes suggestions on addressing psychosocial issues that may impact detoxification treatment, such as providing culturally appropriate services to the patient population.

Matching patients to appropriate care represents a challenge to detoxification programs. Given the wide variety of settings and the unique needs of the individual patient, establishing criteria that take into account all the possible needs of patients receiving detoxification and treatment services is an extraordinarily complex task. Addiction medicine has sought to develop an efficient system of care that matches patients' clinical needs with the appropriate care setting in the least restrictive and most cost-effective manner. Patient placement criteria, such as those published by the American Society of Addiction Medicine (ASAM) in the Patient Placement Criteria, Second Edition, Revised, represent an effort to define how care settings may be matched to patient needs and special characteristics. These criteria—the five “Adult Detoxification” placement levels—define the most broadly accepted standard of care for detoxification services. The five levels of care are

1.

Level ID: Ambulatory Detoxification Without Extended Onsite Monitoring

2.

Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring

3.

Level II.2-D: Clinically Managed Residential Detoxification

4.

Level III.7-D: Medically Monitored Inpatient Detoxification

5.

Level IV-D: Medically Managed Intensive Inpatient Detoxification

ASAM criteria are being adopted extensively on the basis of their face validity, though their outcome validity has yet to be clinically proven. The ASAM guidelines are to be regarded as a work in progress, as their authors readily admit. They are an important set of guidelines that are of great help to clinicians. For administrators, the standards published by such groups as the Joint Commission on Accreditation of Healthcare Organizations and the Commission on Accreditation of Rehabilitation Facilities provide guidance for overall program operations.

Placement will depend in part on the substance of abuse. The consensus panel suggests that for alcohol, sedative-hypnotic, and opioid withdrawal syndromes, hospitalization (or some form of 24-hour medical care) is often the preferred setting for detoxification, based on principles of safety and humanitarian concerns. When hospitalization cannot be provided, then a setting that provides a high level of nursing and medical backup 24 hours a day, 7 days a week is desirable.

A further challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients often leave detoxification without followup to the treatment needed to achieve long-term abstinence. Each year at least 300,000 patients with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals, while additional numbers obtain detoxification in other settings. Only 20 percent of people discharged from acute care hospitals receive substance abuse treatment during that hospitalization. Only 15 percent of people who are admitted to a detoxification program through an emergency room and then discharged go on to receive treatment.

The consensus panel recognizes that medically assisted withdrawal is not always necessary or desirable. A nonmedical approach can be highly cost-effective and provide inexpensive access to treatment for individuals seeking aid. Young individuals in good health, with no history of previous withdrawal reactions, may be well served by management of withdrawal without medication. However, personnel supervising in this setting should be trained to identify life-threatening symptoms and solicit help through the emergency medical system as needed.

The consensus panel also agreed on several guidelines for nonmedical detoxification programs. Such programs should follow local governmental regulations regarding their licensing and inspection. In addition, it is desirable that all such programs have an alcohol and drug-free environment as well as personnel who are familiar with the features of substance use withdrawal syndromes, have training in basic life support, and have access to an emergency medical system that can transport patients to emergency departments and other sites for clinical care.

A major clinical question for detoxification is the appropriateness of the use of medication in the management of an individual in withdrawal. This can be a difficult matter because protocols have not been firmly established through scientific studies or evidence-based methods. Furthermore, the course of withdrawal is unpredictable and currently available techniques of screening and assessment do not predict who will experience life-threatening complications.

Although it is the philosophy of some treatment facilities to discontinue all medications, this course of action is not always in the best interest of the patient. Abrupt cessation of psychotherapeutic medications may cause severe withdrawal symptoms or the re-emergence of a psychiatric disorder. As a general rule, therapeutic doses of medication should be continued through any withdrawal if the patient has been taking the medication as prescribed. Decisions about discontinuing the medication should be deferred until after the individual has completed detoxification. If, however, the patient has been abusing the medication or the psychiatric condition was clearly caused by substance use, then the rationale for discontinuing the medication is strengthened. Finally, practitioners should consider withholding medication that lowers the seizure threshold (e.g., bupropion, conventional antipsychotics) during the acute alcohol withdrawal period or at least prescribing a loading dose or scheduled taper of benzodiazepine.

Further studies are needed to confirm the clinical experience that psychiatric symptoms (including anxiety, depression, and personality disorders) respond to specific treatment of the addiction. For example, cognitive–behavioral techniques employed in the 12-Step treatment approach have been effective in the management of anxiety and depression associated with addiction. Although challenging, treatment of both addiction and co-occurring psychiatric conditions has proven cost-effective in some studies.

This TIP also provides medical information on detoxification protocols for specific substances as well as considerations for individuals with co-occurring medical conditions including mental disorders. While the TIP is not intended to take the place of medical texts, it provides the practitioner with an overview of common medical complications seen in individuals who use substances. Disorders of several systems are discussed in some detail: gastrointestinal (including the gastrointestinal tract, liver, and pancreas), cardiovascular system, hematologic (blood) abnormalities, pulmonary (lung) diseases, diseases of the central and peripheral nervous system, infectious diseases, and special miscellaneous disorders. The TIP presents a cursory overview of special conditions, modifications in protocols, and the use of detoxification medications in patients with co-occurring medical conditions or mental disorders. Overall treatment of specific conditions is not addressed unless modification of such treatment is needed.

The setting in which detoxification occurs is also influenced by the existence of co-occurring medical disorders. It is highly desirable that individuals undergoing detoxification be assessed by primary care practitioners (i.e., physicians, physician assistants, nurse practitioners) with some experience in substance abuse treatment. Such an assessment should determine whether the patient is currently intoxicated and the degree of intoxication; the type and severity of the withdrawal syndrome; information regarding past withdrawals; and the presence of co-occurring psychiatric, medical, and surgical conditions that might require specialized care. Particular attention should be paid to those individuals who have undergone multiple withdrawals in the past and for whom each withdrawal appears worse than previous ones. Subjects with a history of severe withdrawals, multiple withdrawals, delirium tremens (a potentially fatal syndrome associated with alcohol withdrawal), or seizures are not good candidates for detoxification programs in nonmedical settings.

The setting in which detoxification is carried out should be appropriate for the medical and psychological conditions present and should be adequate to provide the degree of monitoring needed to ensure safety (e.g., oximetry [a measurement of the amount of oxygen present in the blood], greater frequency of taking vital signs, etc.). Acute, life-threatening conditions need to be addressed concurrently with the withdrawal process and intensive care unit monitoring may be indicated. Detoxification staff providing support should be familiar with the signs and symptoms of common co-occurring medical disorders. Likewise, personnel at medical facilities (e.g., emergency rooms, physicians' offices) should be aware of the signs of withdrawal and how it affects the treatment of the presenting medical conditions.

This TIP will also bring clinicians and administrators up to date on administrative issues related to detoxification, including how the services themselves can be paid for. It is unusual in a clinical treatment improvement protocol to discuss issues related to how clinical services are reimbursed. In the field of substance abuse and detoxification services, however, reimbursement issues have become so intertwined with the delivery of services that the consensus panel deemed it necessary to address the conflicts and misunderstandings that sometimes arise between the care systems and the reimbursement systems.

Third-party payors sometimes prefer to manage payment for detoxification separately from other phases of substance abuse treatment, thus treating detoxification as if it occurred in isolation from that treatment. This “unbundling” of services can result in the separation of services into scattered segments. In other instances, reimbursement and utilization policies dictate that only detoxification can be authorized. This detoxification often does not cover the nonmedical counseling that is an integral part of substance abuse treatment.

Finally, identifying and maintaining funding sources is a major issue in detoxification. Substance abuse treatment in the United States is financed through a diverse mix of public and private sources, with substantially more being spent by the public sector. The existence of diverse funding streams in substance abuse treatment funding presents both management challenges and opportunities for program independence and stability. However, a program with only one major funding source is financially and clinically vulnerable to changes in its major source's budget and priorities. This situation should be avoided. The TIP suggests ways to diversify funding sources to create a steady stream of resources that can withstand the loss of one particular funding source.

This TIP also makes recommendations for fostering relationships with reimbursement organizations, such as managed care organizations (MCOs). These positive working relationships are vital to successfully link the patient to the needed services. For example, the MCO may use a wide variety of specific criteria and protocols to determine whether or not services may be authorized for substance abuse, typically including the ASAM patient placement criteria and other level of care or diagnosis-based criteria sets. Successfully addressing the needs of the staff at MCOs that are responsible for authorizing the care provided to patients is a critical element in maintaining a relationship with an MCO and the program's clinical and financial viability. To do so, staff should understand what MCO staff do, be well trained in conducting professional relationships over the telephone, be familiar with the criteria and protocols used by the MCOs with which the program has contracts, and have easy access to the abundance of clinical and service information required by an MCO in order to help them complete a review and authorize services. Maintaining thorough, clear, and accurate records is essential to this process. Detoxification staff also should be familiar with each MCO's appeal or exceptions process for those occasions when the outcome of a first-level review is unsatisfactory.

Regardless of their role in providing detoxification services, all personnel should keep in mind that patients undergoing detoxification are in the midst of a personal and medical crisis. For many patients, this crisis represents a window of opportunity to acknowledge their substance abuse problem and become willing to seek treatment. Physicians, nurses, substance abuse counselors, and administrators are in a unique position, not only to ensure a safe and humane withdrawal from substances of dependency, but also to foster the path for the patient's entry into substance abuse treatment. This TIP suggests ways for clinicians and programs to prepare the patient for treatment while addressing the complex psychosocial and medical variables involved in detoxification.