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Detoxification and Substance Abuse Treatment [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 45.)
In This Chapter….
Establishing criteria that take into account all the possible needs of patients receiving detoxification and treatment services is an extraordinarily complex task. This chapter discusses the criteria for placing patients in the appropriate treatment settings and offering the required intensity of services (i.e., level of care).
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. (For an explanation of least restrictive care, see the text box, p. 12.) Challenges to effective placement matching for clients arise from a number of factors:
Deficits in the full range of care settings and levels of care
Limitations imposed by third-party payors (e.g., strict adherence to standardized admission criteria)
Clinicians' lack of authority (and sometimes sufficient knowledge) to determine the most appropriate care setting and level of care
Insurance that does not have a substance use disorder benefit available as part of its patient coverage
Absence of any health insurance at all (Gastfriend et al. 2000)
No clear solution or formula to meet these challenges has emerged.
Least Restrictive Care.
In spite of the impediments, some progress has been made in developing comprehensive patient placement criteria. Because the choice of a treatment setting and intensity of treatment (level of care) are so important, the American Society of Addiction Medicine (ASAM) created the Patient Placement Criteria, Second Edition, Revised (PPC-2R) a consensus-based clinical tool for matching patients to the appropriate setting and level of care. The ASAM PPC-2R represents an effort to define how care settings may be matched to patient needs and special characteristics. These criteria currently define the most broadly accepted standard of care for the treatment of substance use disorders. ASAM criteria are intended to provide flexible clinical guidelines; these criteria may not be appropriate for particular patients or specific care settings.
The PPC-2R identifies six “assessment dimensions to be evaluated in making placement decisions” (ASAM 2001, p. 4). They are as follows:
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
The ASAM PPC-2R describes both the settings in which services may take place and the intensity of services (i.e., level of care) that patients may receive in particular settings. It is important to reiterate, however, that the ASAM PPC-2R criteria do not characterize all the details that may be essential to the success of treatment (Gastfriend et al. 2000). Moreover, traditional assumptions that certain treatment can be delivered only in a particular setting may not be applicable or valuable to patients. Clinical judgment and consideration of the patient's particular situation are required for appropriate detoxification and treatment.
In addition to the general placement criteria for treatment for substance-related disorders, ASAM also has developed a second set of placement criteria, which are more important for the purposes of this TIP—the five “Adult Detoxification” placement levels of care within Dimension 1 (ASAM 2001). These “Adult Detoxification” levels of care are
Level ID: Ambulatory Detoxification Without Extended Onsite Monitoring (e.g., physician's office, home health care agency). This level of care is an organized outpatient service monitored at predetermined intervals.
Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring (e.g., day hospital service). This level of care is monitored by appropriately credentialed and licensed nurses.
Level III.2-D: Clinically Managed Residential Detoxification (e.g., nonmedical or social detoxification setting). This level emphasizes peer and social support and is intended for patients whose intoxication and/or withdrawal is sufficient to warrant 24-hour support.
Level III.7-D: Medically Monitored Inpatient Detoxification (e.g., freestanding detoxification center). Unlike Level III.2.D, this level provides 24-hour medically supervised detoxification services.
Level IV-D: Medically Managed Intensive Inpatient Detoxification (e.g., psychiatric hospital inpatient center). This level provides 24-hour care in an acute care inpatient settings.
As described by the ASAM PPC-2R, the domain of detoxification refers not only to the reduction of the physiological and psychological features of withdrawal syndromes, but also to the process of interrupting the momentum of compulsive use in persons diagnosed with substance dependence (ASAM 2001). Because of the force of this momentum and the inherent difficulties in overcoming it even when there is no clear withdrawal syndrome, this phase of treatment frequently requires a greater intensity of services initially to establish participation in treatment activities and patient role induction. That is, this phase should increase the patient's readiness for and commitment to substance abuse treatment and foster a solid therapeutic alliance between the patient and care provider.
It is important to note that ASAM PPC-2R criteria are only guidelines, and that there are no uniform protocols for determining which patients are placed in which level of care. For further information on patient placement, readers are advised to consult TIP 13, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (Center for Substance Abuse Treatment [CSAT] 1995h).
Because this TIP is geared to audiences that may or may not be familiar with the ASAM PPC-2R levels of care, this section discusses the services and staffing specific to the care settings that are familiar to a broad audience.
It has been estimated that nearly one half of the patients who visit a primary care provider have some type of problem related to substance use (Miller and Gold 1998). Indeed, because the physician may be the first point of contact for these people, initiation of treatment often begins in the family physician's office (Prater et al. 1999). Physicians should use prudence in determining which patients may undergo detoxification safely on an outpatient basis. As a general rule, outpatient treatment is just as effective as inpatient treatment for patients with mild to moderate withdrawal symptoms (Hayashida 1998).
For physicians treating patients with substance use disorders, preparing the patient to enter treatment and developing a therapeutic alliance between patient and clinician should begin as soon as possible. This includes providing the patient and his family with information on the detoxification process and subsequent substance abuse treatment, in addition to providing medical care or referrals if necessary. Staffing should include certified interpreters for the deaf and other language interpreters if the program is serving patients in need of those services. Physicians should be able to accommodate frequent followup visits during the management of acute withdrawal. Medications should be dispensed in limited amounts.
This level of detoxification (ASAM's Level ID) is an organized outpatient service, which may be delivered in an office setting, healthcare or addiction treatment facility, or in a patient's home by trained clinicians who provide medically supervised evaluation, detoxification, and referral services according to a predetermined schedule. Such services are provided in regularly scheduled sessions. These services should be delivered under a defined set of policies and procedures or medical protocols (ASAM 2001). Ambulatory detoxification is considered appropriate only when a positive and helpful social support network is available to the patient. In this level of care, outpatient detoxification services should be designed to treat the patient's level of clinical severity, to achieve safe and comfortable withdrawal from mood-altering drugs, and to effectively facilitate the patient's transition into treatment and recovery.
Essential to this level of care—and distinguishing it from Ambulatory Detoxification Without Extended Onsite Monitoring—is the availability of appropriately credentialed and licensed nurses (such as registered nurses [RNs] or licensed practical nurses [LPNs]) who monitor patients over a period of several hours each day of service (ASAM 2001). Otherwise, this level of detoxification (ASAM's Level II-D) also is an organized outpatient service. Like Level I-D, in this level of care detoxification services are provided in regularly scheduled sessions and delivered under a defined set of policies and procedures or medical protocols. Outpatient services are designed to treat the patient's level of clinical severity and to achieve safe and comfortable withdrawal from mood-altering drugs, including alcohol, and to effectively facilitate the patient's entry into ongoing treatment and recovery (ASAM 2001).
Although they need not be present in the treatment setting at all times, physicians and nurses are essential to office-based detoxification. In States where physician assistants, nurse practitioners, or advance practice clinical nurse specialists are licensed as physician extenders, they may perform the duties ordinarily carried out by a physician (ASAM 2001).
Because detoxification is conducted on an outpatient basis in these settings, it is important for medical and nursing personnel to be readily available to evaluate and confirm that detoxification in the less supervised setting is safe. All clinicians who assess and treat patients should be able to obtain and interpret information regarding the needs of these persons, and all should be knowledgeable about the biomedical and psychosocial dimensions of alcohol and illicit drug dependence. Requisite skills and knowledge base include the following:
Understanding how to interpret the signs and symptoms of alcohol and other drug intoxication and withdrawal
Understanding the appropriate treatment and monitoring of these conditions
The ability to facilitate the individual's entry into treatment
It is essential that medical consultation is readily available in emergencies. It is desirable that medical staff link patients to treatment services, although this may be an unreasonable expectation that cannot be met in a busy office setting. Linkage to treatment services may be provided by the physician or by designated counselors, psychologists, social workers, and acupuncturists who are available either onsite or through the healthcare system (ASAM 2001).
There are several distinctions between urgent care facilities and emergency rooms (ERs). Urgent care often is used by patients who cannot or do not want to wait until they see their doctor in his or her office, whereas emergency rooms are utilized more often by patients who perceive themselves to be in a crisis situation. Unlike emergency departments, which are required to operate 24 hours a day, freestanding urgent care centers usually have specific hours of operation. Staffing for urgent care centers generally is more limited than for an ER. Standard staffing includes only a physician, an RN, a technician, and a secretary. Despite these distinctions, in actual practice there is considerable overlap between the two—the ER will see medical problems that could be handled by visits to offices, and urgent care facilities will handle some cases of emergency medicine.
A freestanding urgent care center or emergency department reasonably can be expected to provide assessment and acute biomedical (including psychiatric) care. However, these settings often are unable to provide satisfactory psychosocial stabilization or complete biomedical stabilization (which includes both the initiation and taper of medications used in the treatment of substance withdrawal syndromes). Appropriate triage and successful linkage to ongoing detoxification services is essential. The ongoing detoxification services may be provided in an inpatient, residential, or outpatient setting. Patients with more than moderate biomedical or psychosocial complications are more likely to require treatment in an inpatient setting. Care in these settings can be quite costly and should be accessed only when there are serious concerns about a patient's safety.
Although they need not be present in the treatment setting at all times, physicians and nurses are essential to office-based detoxification.
A timely and accurate assessment in an emergency department is of the highest importance. This will permit the rapid transfer of the patient to a setting where complete care can be provided. Ideally, personnel in the emergency department will have at least a small amount of experience and expertise in identifying critically ill substance-using patients who may be about to experience or are already experiencing withdrawal symptoms. Three essential rules apply to emergency departments and their handling of intoxicated patients and patients who have begun to experience withdrawal:
Emergency departments and their clinicians should never simply administer medications to intoxicated persons and then send them home.
No intoxicated patient should ever be allowed to leave a hospital setting. All such persons should be referred to the appropriate detoxification setting if possible, although there are legal restrictions that forbid holding persons against their will under certain conditions (Armenian et al. 1999).
A clear distinction must be made between acute intoxication on the one hand and withdrawal on the other. Acute intoxication, it must be remembered, creates special issues and challenges that need to be addressed. The risk of suicidality in patients who present in a state of intoxication needs to be carefully assessed. Because of their volatility and often risky behavior, patients who are intoxicated, as well as those patients who have begun to experience withdrawal, merit special attention. For more on treating intoxicated patients, see Chapter 3.
Care is provided to patients whose withdrawal signs and symptoms are sufficiently severe to require primary medical and nursing care services. The services are delivered under a defined set of physician-managed procedures or medical protocols. Both settings provide medically directed assessment and acute care that includes the initiation of detoxification for substance use withdrawal. Neither setting is likely to offer satisfactory biomedical stabilization or 24-hour observation. Generally speaking, triage to inpatient care can easily be facilitated from either setting.
Inpatient detoxification provides 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal.
Freestanding urgent care centers and emergency departments are outpatient settings that are uniquely designed to address the needs of patients in biomedical crisis. For patients with substance use disorders, care in these settings is not complete until successful linkage is made to treatment that is focused specifically on the substance use disorder. To accomplish this, a comprehensive assessment, taking into account psychosocial as well as biomedical issues, is recommended wherever possible.
Appreciation of the value of multidimensional patient assessment is central to the clinician's ability to decide which triage (linkage) options are least restrictive and most cost-effective for a given patient.
Both emergency departments and freestanding urgent care units are staffed by physicians. The same rules regarding who may provide care apply here as they did in the discussion of staffing of office-based detoxification (ASAM 2001). An RN or other licensed and credentialed nurse is available for primary nursing care and observation. Psychologists, social workers, addiction counselors, and acupuncturists usually are not available in these settings. The physician or attending nurse usually facilitates linkage to substance abuse treatment.
Freestanding substance abuse treatment facilities may or may not be equipped to provide adequate assessment and treatment of co-occurring psychiatric conditions and biopsychosocial problems, as the range of services varies considerably from one facility to another. Inpatient mental health facilities, on the other hand, are able generally to provide treatment for substance use disorders and co-occurring psychiatric conditions. Nonetheless, like substance abuse treatment facilities, the range of available services varies from one mental health facility to another.
General guidelines for considering patient placement in either of these settings are provided below; however, it should be emphasized that a clear understanding of the specific services that a given setting provides is indispensable to identifying the least restrictive and most cost-effective treatment option that may be available. Concern for safety is of primary importance, and the final decision regarding placement always rests with the treating physician.
Inpatient detoxification provides 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. Since this level of care is relatively more restrictive and more costly than a residential treatment option, the treatment mission in this setting should be clearly focused and limited in scope. Primary emphasis should be placed on ensuring that the patient is medically stable (including the initiation and tapering of medications used for the treatment of substance use withdrawal); assessing for adequate biopsychosocial stability, quickly intervening to establish this adequately; and facilitating effective linkage to and engagement in other appropriate inpatient and outpatient services.
Inpatient settings provide medically managed intensive inpatient detoxification. At this level of care, physicians are available 24 hours per day by telephone. A physician should be available to assess the patient within 24 hours of admission (or sooner, if medically necessary) and should be available to provide onsite monitoring of care and further evaluation on a daily basis. An RN or other qualified nursing specialist should be present to administer an initial assessment. A nurse will be responsible for overseeing the monitoring of the patient's progress and medication administration on an hourly basis, if needed. Appropriately licensed and credentialed staff should be available to administer medications in accordance with physician orders.
Residential settings vary greatly in the level of care that they provide. Those with intensive medical supervision involving physicians, nurse practitioners, physician assistants, and nurses can handle all but the most demanding complications of intoxication and withdrawal. On the other hand, some residential settings have minimally intensive medical oversight. Residential detoxification in settings with limited medical oversight often is referred to as “social detoxification.” (Though the “social detoxification” model is not limited to residential facilities.) Facilities with lower levels of care should have clear procedures in place for implementing and pursuing appropriate medical referral and linkage, especially in the case of emergencies. For example, a patient who is in danger of seizures or delirium tremens needs to be referred to the appropriate medical facility for acute care of presenting symptoms, possibly medicated, and then returned to a social detoxification setting for continuing monitoring and observation. The establishment of this kind of collaborative relationship between institutions provides a good example of a cost-effective way to provide adequate care to patients.
Residential detoxification programs provide 24-hour supervision, observation, and support for patients who are intoxicated or experiencing withdrawal. They are characterized by an emphasis on peer and social support (ASAM 2001). Standards published by such groups as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF) provide further information on quality measures for residential detoxification.
Inpatient detoxification programs employ licensed, certified, or registered clinicians who provide a planned regimen of 24-hour, professionally directed evaluation, care, and treatment services for patients and their families. An interdisciplinary team of appropriately trained clinicians (such as physicians, RNs and LPNs, counselors, social workers, and psychologists) should be available to assess and treat the patient and to obtain and interpret information regarding the patient's needs. The number and disciplines of team members should be appropriate to the range and severity of the patient's problems (ASAM 2001).
Residential detoxification programs are staffed by appropriately credentialed personnel who are trained and competent to implement physician-approved protocols for patient observation and supervision. These persons also are responsible for determining the appropriate level of care and facilitating the patient's transition to ongoing care. Medical evaluation and consultation should be available 24 hours a day, in accordance with treatment/transfer practice guidelines. All clinicians who assess and treat patients should be able to obtain and interpret information regarding the needs of these persons and should be knowledgeable about the biomedical and psychosocial dimensions of alcohol and other drug dependence. Such knowledge includes awareness of the signs and symptoms of alcohol and other drug intoxication and withdrawal, as well as the appropriate treatment and monitoring of those conditions and how to facilitate the individual's entry into ongoing care. Staff should ensure that patients are taking medications according to their physician's orders and legal requirements (ASAM 2001).
Some residential detoxification programs are staffed to supervise self-administered medications for the management of withdrawal. All such programs should rely on established clinical protocols to identify patients who have biomedical needs that exceed the capacity of the facility and to identify which programs will likely have a need for transferring such patients to more appropriate treatment settings.
An intensive outpatient program (IOP) or partial hospitalization program (PHP) is appropriate for patients with mild to moderate withdrawal symptoms. Thorough psychosocial assessment and intervention should be available in addition to biomedical assessment and stabilization. Many of these programs have close clinical and/or administrative ties to hospital centers. When needed, triage to a higher level of care should be easy to accomplish. Outpatient treatment should be delivered in conjunction with all components of detoxification.
This level of detoxification is an organized outpatient service that requires patients to be present onsite for several hours a day. It is thus similar to a physician's office in that ambulatory detoxification with extended onsite monitoring is provided. Unlike the physician's office, in the IOP and PHP it is standard practice to have a multidisciplinary team available to provide or facilitate linkage to a range of medically supervised evaluation, detoxification, and referral services.
Detoxification services also are provided in regularly scheduled sessions and delivered under a defined set of policies and procedures or medical protocols. These outpatient services are designed to treat the patient's level of clinical severity, to achieve safe and comfortable withdrawal from mood-altering drugs (including alcohol), and to effectively facilitate the patient's engagement in ongoing treatment and recovery (ASAM 2001).
A partial hospitalization program may occupy the same setting (i.e., physical space) as an acute care inpatient treatment program. Although occupying the same space, the levels of care provided by these two programs are distinct yet complementary. Acute care inpatient programs provide detoxification services to patients in danger of severe withdrawal and who therefore need the highest level of medically managed intensive care, including access to life support equipment and 24-hour medical support. In contrast, partial hospitalization programs provide services to patients with mild to moderate symptoms of withdrawal that are not likely to be severe or life-threatening and that do not require 24-hour medical support. The transition from an acute care inpatient program to either a partial hospitalization or intensive outpatient program sometimes is referred to as a “step-down.” Typically, whether these programs share space and staff with an acute care inpatient program or are physically distinct from a hospital structure, they have close clinical and/or administrative ties to hospital centers. Collaborative working relationships are indispensable in pursuing the goal of providing patients with the most appropriate level of care in the most cost-effective setting.
IOPs and PHPs should be staffed by physicians who are available daily as active members of an interdisciplinary team of appropriately trained professionals and who medically manage the care of the patient. An RN or other licensed and credentialed nurse should be available for primary nursing care and observation during the treatment day. Addiction counselors or licensed or registered addiction clinicians should be available to administer planned interventions according to the assessed needs of the patient. The multidisciplinary professionals (such as physicians, nurses, counselors, social workers, psychologists, and acupuncturists) should be available as an interdisciplinary team to assess and care for the patient with a substance-related disorder, as well as patients with both a substance use disorder and a co-occurring biomedical, emotional, or behavioral condition. Successful linkage to treatment for the substance use disorder (in addition to biomedical stabilization) is central to the mission of an intensive outpatient or partial hospitalization program (ASAM 2001). For more information, see the TIP Substance Abuse: Clinical Issues in Intensive Outpatient Treatment [SAMHSA in development d].
There are several types of acute care inpatient settings. They include
Acute care general hospitals
Acute care addiction treatment units in acute care general hospitals
Acute care psychiatric hospitals
Other appropriately licensed chemical dependency specialty hospitals
Successful linkage to treatment for the substance use disorder (in addition to biomedical stabilization) is central to the mission of an intensive outpatient or partial hospitalization program.
These settings share the ready availability of acute care medical and nursing staff, life support equipment, and ready access to the full resources of an acute care general hospital or its psychiatric unit. This level of care provides medically managed intensive inpatient detoxification (ASAM 2001).
Acute inpatient care is an organized service that provides medically monitored inpatient detoxification that is delivered by medical and nursing professionals. Medically supervised evaluation and withdrawal management in a permanent facility with inpatient beds is provided for patients whose withdrawal signs and symptoms are sufficiently severe to require 24hour inpatient care. Services should be delivered under a set of policies and procedures or clinical protocols designated and approved by a qualified physician (ASAM 2001).
Acute care inpatient detoxification programs typically are staffed by physicians who are available 24 hours a day as active members of an interdisciplinary team of appropriately trained professionals and who medically manage the care of the patient. In some States, these duties may be performed by an RN or physician assistant. An RN or LPN, as usual, is available for primary nursing care and observation 24 hours a day. Facility-approved addiction counselors or licensed or registered addiction clinicians should be available 8 hours a day to administer planned interventions according to the assessed needs of the patient. An interdisciplinary team of appropriately trained clinicians (such as physicians, nurses, counselors, social workers, and psychologists) should be available to assess and treat the patient with a substance-related disorder, or a patient with co-occurring substance use, biomedical, psychological, or behavioral conditions (ASAM 2001).
In part because of the need to keep costs to a minimum and in part as the result of research in the field, outpatient detoxification is becoming the standard for treatment of symptoms of withdrawal from substance dependence in many locales. Most alcohol treatment programs have found that more than 90 percent of patients with withdrawal symptoms can be treated as outpatients (Abbott et al. 1995). Careful screening of these patients is essential to reserve for inpatient treatment those clients with possibly complicated withdrawal; for example, patients with subacute medical or psychiatric conditions (that in and of themselves would not require hospitalization) and those in danger of seizures or delirium tremens should receive inpatient care. Inpatient addiction treatment programs will vary in the level of acute medical or psychiatric care that can be provided. Figure 2-1 presents an overview of issues to consider in deciding between inpatient and outpatient detoxification.
Issues To Consider in Determining Whether Inpatient or Outpatient Detoxification Is Preferred.
ASAM criteria are being adopted extensively on the basis of their “face validity,” though their outcome validity has yet to be clinically proven. Early studies of more versus less restrictive and intensive treatment settings on randomized samples generally have failed to show group differences, and studies continue to show this pattern (Gastfriend et al. 2000). Whether patients undergoing detoxification will have better results as outpatients rather than as inpatients remains to be established (Hayashida 1998).
Another consideration is that ASAM placement guidelines are not always the best guide to placing a patient in the proper setting at the proper level. For example, what is the clinician to do with the patient who qualifies for outpatient treatment according to the ASAM guidelines but is homeless in sub-zero temperatures? No provision is made for such cases. The ASAM guidelines are to be regarded as a “work in progress,” as their authors readily admit (ASAM 2001, p. 19). Nevertheless, they are an important set of guidelines that are of great help to clinicians. For administrators, the standards published by such groups as JCAHO and CARF offer guidance for overall program operations.
It has become clear that detoxification involves much more than simply medically withdrawing a patient from alcohol or other drugs. Detoxification, whether done on an inpatient, residential, or outpatient basis, frequently is the initial therapeutic encounter between patient and clinician. Irrespective of the substance involved, a detoxification episode should provide an opportunity for biomedical (including psychiatric) assessment, referral for appropriate services, and linkage to treatment services. Chapter 3 provides an overview of the psychosocial and biomedical issues relevant to detoxification, strategies to engage the patient, and an overview of providing adequate linkage to follow up treatment and services.
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