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Detoxification from Alcohol and Other Drugs: Treatment Improvement Protocol (TIP) Series 19

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Detoxification from Alcohol and Other Drugs: Treatment Improvement Protocol (TIP) Series 19 TIP 19: Detoxification From Alcohol and Other Drugs: Treatment Improvement Protocol (TIP) Series 19 A39784 Donald R. Wesson, M.D. Consensus Panel Chair U.S. Department of Health and Human Services Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 95-3046 Printed 1995. Disclaimer This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Sandra Clunies, M.S., served as the CSAT Government project officer. Dorynne Czechowicz, M.D., served as the Government content advisor. Carolyn Davis, Betsy Earp, Jo Lane Gregory-Thomas, Linda Harteker, Lise Markl, and Gail Martin served as writers. The opinions expressed herein are the views of the consensus panel members and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions. What Is a TIP? CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources. The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice. Once a topic has been selected, CSAT creates a Federal resource panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic. This group, known as a non-Federal consensus panel, meets in Washington for 5 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus. The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the chair approves the document for publication. The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment. This TIP, Detoxification From Alcohol and Other Drugs, describes detoxification care in a number of settings. Detoxification and patient matching are discussed. The TIP provides clinical guidelines for detoxification from specific classes of drugs such as sedative-hypnotics, stimulants, and opiates. Detoxification needs of special populations are addressed. The TIP also includes information helpful to planners and policymakers about costs, quality improvement, outcome criteria, health care reform, and linking detoxification -- often the gateway to ongoing treatment -- to the larger continuum of care in the substance abuse treatment system. Legal and ethical issues of concern to detoxification programs are also examined. This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment. Other TIPs may be ordered by contacting the National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889). Contents Consensus Panel Foreword Chapter 1—Introduction Chapter 2—Detoxification Settings and Patient Matching Chapter 3—Clinical Detoxification Protocols Chapter 4—Special Populations Chapter 5—Improving Quality and Measuring Outcomes of AOD Detoxification Services Chapter 6—Costs and Current Payment Mechanisms for AOD Detoxification Appendix A -- Bibliography Appendix B—Glossary Appendix C—Resource List Appendix D—Acronyms Appendix E - Legal and Ethical Issues for Detoxification Programs Appendix F—Federal Resource Panel Appendix G—Field Reviewers TIP 19: Consensus Panel Chair Donald R. Wesson, M.D. Scientific Director MPI Treatment Services Summit Medical Center Oakland, California Facilitators Mary R. Haack, R.N., Ph.D. Senior Research Scientist Center for Health Policy Research The George Washington University Washington, D.C. Karen Larson, R.N., B.S.N. Assistant Director Division of Alcohol and Drug Abuse North Dakota Department of Human Services Bismarck, North Dakota Dorothy B. North, N.C.A.C. II, C.E.A.P. Chief Executive Officer Vitality Center Elko, Nevada Bonnie Baird Wilford, M.S. Director Pharmaceutical Policy Research Center Intergovernmental Health Policy Project The George Washington University Washington, D.C. Workgroup Members Margaret Kent Brooks, J.D. Consultant Montclair, New Jersey Margaret A. Compton, R.N., Ph.D. Post-Doctoral Fellow UCLA Drug Abuse Research Center Neuropsychiatric Institute Los Angeles, California Archie S. Golden, M.D., M.P.H. Director Adolescent Substance Abuse Program and Chairman Department of Pediatrics Johns Hopkins Bayview Medical Center Baltimore, Maryland Richard Harris, R.C.S.W. Director of Housing and Chemical Dependency Services Central City Concern Portland, Oregon Albert E. Jones, L.C.S.W. Program Director New Directions, Inc. Memphis, Tennessee Walter Ling, M.D. Director Los Angeles Addiction Treatment Research Center and Associate Chief of Psychiatry for Substance Abuse West Los Angeles Veterans Administration Medical Center and Professor Chief of Substance Abuse Program University of California, Los Angeles (UCLA) Los Angeles, California Carole A. Madden, R.N., B.S.N., C.D. Coordinator of Intervention Services North Arundel Hospital Glen Burnie, Maryland John Melbourne, M.D. Medical Director Chemical Dependency Services Danbury Hospital Danbury, Connecticut David E. Smith, M.D. Medical Director Haight Ashbury Free Clinics Training and Education Project San Francisco, California Lovetta L. Smith, R.N., D.N.Sc., F.A.A.N. 1 Associate Chief of Nursing Service Surgical and Special Care Service Gainesville Veterans Administration Medical Center Gainesville, Florida Footnotes 1. Lovetta Smith, R.N., D.N.Sc., F.A.A.N., was originally cochair for this TIP but had to withdraw. Her contributions as cochair are appreciated. Dr. Smith also served as a field reviewer for the document. Foreword The Treatment Improvement Protocol (TIP) series fulfills CSAT's mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel's work is reviewed and critiqued by field reviewers as it evolves. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advance our substance abuse treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration David J. Mactas Director Center for Substance Abuse Treatment TIP 19: Chapter 1—Introduction The subject of this Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocol (TIP) is alcohol and other drug (AOD) detoxification -- the process through which a person who is physically dependent on alcohol, illegal drugs, prescription medications, or a combination of these drugs is withdrawn from the drug or drugs of dependence. Since most persons who have a substance use disorder are addicted to a combination of alcohol and/or other drugs (polydrug abuse), detoxification often involves more than one substance. This TIP was written by a panel composed of AOD specialists in detoxification -- physicians specializing in addiction medicine, nurses, counselors, social workers,
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