Detoxification and Substance Abuse Treatment

A Treatment Improvement Protocol TIP 45 Detoxification and Substance Abuse Treatment

A Treatment Improvement Protocol TIP 45

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Electronic Access and Copies This publication was produced under the of Publication Knowledge Application Program (KAP) con- This publication may be ordered from or down- tract numbers 270-99-7072 and 270-04-7049 loaded from SAMHSA’s Publications Ordering with the Substance Abuse and Mental Health Web page at http://store.samhsa.gov. Or, please Services Administration (SAMHSA), U.S. call SAMHSA at 1-877-SAMHSA-7 (1-877-726- Department of Health and Human Services 4727) (English and Español). (HHS). Andrea Kopstein, Ph.D., M.P.H, Karl D. White, Ed.D, and Christina Currier served as Government Project Officers. Recommended Citation Center for Substance Abuse Treatment. Disclaimer Detoxification and Substance Abuse The views, opinions, and content expressed Treatment. Treatment Improvement Protocol herein are those of the consensus panel and do (TIP) Series, No. 45. HHS Publication No. not necessarily reflect the views, opinions, or (SMA) 15-4131. Rockville, MD: Center for policies of SAMHSA or HHS. No official sup- Substance Abuse Treatment, 2006. port of or endorsement by SAMHSA or HHS for these opinions or for particular instru- ments, software, or resources is intended or Originating Office should be inferred. Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Public Domain Notice Treatment, Substance Abuse and Mental All material appearing in this report is in the Health Services Administration, 1 Choke public domain and may be reproduced or Cherry Road, Rockville, MD 20857. copied without permission from SAMHSA. Citation of the source is appreciated. However, HHS Publication No. (SMA) 15-4131 this publication may not be reproduced or dis- Printed 2006 tributed for a fee without the specific, written Revised 2008, 2012, 2013, and 2015 authorization of the Office of Communications, SAMHSA, HHS.

ii Acknowledgments Contents

What Is a TIP?...... vii Consensus Panel ...... ix KAP Expert Panel and Federal Government Participants ...... xi Foreword ...... xiii Executive Summary ...... xv Chapter 1—Overview, Essential Concepts, and Definitions in Detoxification...... 1 Purpose of the TIP...... 1 Audience...... 2 Scope ...... 2 History of Detoxification Services...... 2 Definitions...... 3 Guiding Principles in Detoxification and Substance Abuse Treatment ...... 7 Challenges to Providing Effective Detoxification ...... 8 Chapter 2—Settings, Levels of Care, and Patient Placement...... 11 Role of Various Settings in the Delivery of Services ...... 11 Other Concerns Regarding Levels of Care and Placement...... 20 Chapter 3—An Overview of Psychosocial and Biomedical Issues During Detoxification ...... 23 Evaluating and Addressing Psychosocial and Biomedical Issues ...... 24 Strategies for Engaging and Retaining Patients in Detoxification ...... 33 Referrals and Linkages ...... 38 Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances ...... 47 Psychosocial and Biomedical Screening and Assessment ...... 47 Alcohol Intoxication and Withdrawal...... 52 Opioids ...... 66 Benzodiazepines and Other Sedative­Hypnotics ...... 74 Stimulants...... 76 Inhalants/Solvents...... 82 Nicotine...... 84 Marijuana and Other Drugs Containing THC ...... 95 Anabolic Steroids...... 96 Club Drugs...... 97 Management of Polydrug Abuse: An Integrated Approach...... 101 Alternative Approaches ...... 103 Considerations for Specific Populations...... 105

iii Chapter 5—Co­Occurring Medical and Psychiatric Conditions...... 121 General Principles of Care for Patients With Co­Occurring Medical Conditions ...... 122 Treatment of Co­Occurring Psychiatric Conditions...... 136 Standard of Care for Co­Occurring Psychiatric Conditions ...... 138 Chapter 6—Financing and Organizational Issues ...... 145 Preparing and Developing a Program...... 145 Working in Today’s Managed Care Environment...... 157 Preparing for the Future...... 168 Appendix A—Bibliography...... 169 Appendix B—Common Drug Intoxication Signs and Withdrawal Symptoms ...... 223 Appendix C—Screening and Assessment Instruments ...... 225 Section I: Screening and Assessment for Alcohol Abuse ...... 225 Section II: Screening and Assessment for Alcohol and Other Drug Abuse...... 228 Appendix D—Resource Panel...... 231 Appendix E—Field Reviewers...... 233 Index ...... 237 SAMHSA TIPs and Publications ...... 243 Figures Figure 1­1 DSM­IV­TR Definitions of Terms ...... 6 Figure 1­2 Guiding Principles Recognized by the Consensus Panel ...... 7 Figure 2­1 Issues To Consider in Determining Whether Inpatient or Outpatient Detoxification Is Preferred ...... 21 Figure 3­1 Initial Biomedical and Psychosocial Evaluation Domains...... 25 Figure 3­2 Symptoms and Signs of Conditions That Require Immediate Medical Attention...... 26 Figure 3­3 Strategies for De­escalating Aggressive Behaviors ...... 28 Figure 3­4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural Framework ...... 32 Figure 3­5 The Transtheoretical Model (Stages of Change) ...... 36 Figure 3­6 Clinician’s Characteristics Most Important to the Therapeutic Alliance...... 38 Figure 3­7 Recommended Areas for Assessment To Determine Appropriate Rehabilitation Plans...... 40 Figure 3­8 Strategies To Promote Initiation of Treatment and Maintenance Activities ...... 42 Figure 4­1 Assessment Instruments for Dependence and Withdrawal From Alcohol and Specific Illicit Drugs...... 49 Figure 4­2 Symptoms of Alcohol Intoxication...... 53 Figure 4­3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61 Figure 4­4 Signs and Symptoms of Opioid Intoxication and Withdrawal ...... 67 Figure 4­5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ...... 77

iv Contents Figure 4­6 Other Sedative­Hypnotics and Their Phenobarbital Withdrawal Equivalents ...... 78 Figure 4­7 Stimulant Withdrawal Symptoms...... 79 Figure 4­8 Commonly Abused Inhalants/Solvents...... 83 Figure 4­9 DSM­IV­TR on Nicotine Withdrawal ...... 86 Figure 4­10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ...... 87 Figure 4­11 The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ) ...... 88 Figure 4­12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With Other Psychiatric Conditions ...... 89 Figure 4­13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ...... 90 Figure 4­14 The “5 A’s” for Brief Intervention ...... 91 Figure 4­15 Some Definitions Regarding Disabilities ...... 111 Figure 4­16 Impairment and Disability Chart...... 112 Figure 4­17 Locating Expert Assistance...... 114 Figure 6­1 Financial Arrangements for Providers...... 162

Contents v What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS). Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical, research, and administrative experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed via the Internet at http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. If research supports a particular approach, citations are provided. When no citation is provided, the infor- mation is based on the collective clinical knowledge and experience of the consensus panel.

vii Consensus Panel

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Chair Anthony Radcliffe, M.D., FASAM Norman S. Miller, M.D., FASAM Chief of Addiction Medicine Kaiser Permanente Professor and Director of Addiction Medicine Southern California Permanente Medical Department of Psychiatry Group Michigan State University Fontana, California East Lansing, Michigan Co-Chair Carl Rollynn Sullivan, III, M.D. Professor Steven S. Kipnis, M.D., FACP Director of Addiction Program Medical Director Department of Behavioral Medicine and Russell E. Blaisdell Addiction Treatment Psychiatry Center School of Medicine New York State Office of Alcoholism and West Virginia University Substance Abuse Services Morgantown, West Virginia Orangeburg, New York Nancy R. VanDeMark, M.S.W. Workgroup Managers and Director of Colorado Social Research Co-Managers Associates Anne M. Herron, M.S. Arapahoe House, Inc. Thornton, Colorado Director Division of State and Community Assistance Panelists Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Louis E. Baxter, Sr., M.D., FASAM Administration Executive Director Rockville, Maryland Physicians Health Program Medical Society of New Jersey Ronald J. Hunsicker, D.Min., FACATA Lawrenceville, New Jersey President/Chief Executive Officer National Association of Addiction Treatment Kenneth O. Carter, M.D., M.P.H., Dipl.Ac. Providers Psychiatrist Lancaster, Pennsylvania Acupuncture Detoxification Specialist Carolinas Medical Center Robert J. Malcolm, Jr., M.D. Charlotte, North Carolina Professor of Psychiatry, Family Medicine, and Pediatrics Jean Lau Chin, M.A., Ed.D., ABPP Associate Dean for Continuing Medical President Education CEO Services Center for Drug and Alcohol Programs Alameda, California Institute of Psychiatry Medical University of South Carolina Charleston, South Carolina

ix Charles A. Dackis, M.D. Hendree E. Jones, M.A., Ph.D. Assistant Professor Assistant Professor Department of Psychiatry CAP Research Director University of Pennsylvania School of Medicine Department of Psychiatry and Behavioral Philadelphia, Pennsylvania Sciences Johns Hopkins University Center Sylvia J. Dennison, M.D. Baltimore, Maryland Chief/Medical Director Division of Addiction Services Frances J. Joy, R.N., CD, CASAC Department of Psychiatry Manager University of Illinois Alcohol and Drug Abuse Unit Chicago, Illinois State of Missouri Department of Mental Health Fulton State Hospital Patricia L. Mabry, Ph.D. Fulton, Missouri Health Scientist Administrator/Behavioral Scientist Office of Behavioral and Social Sciences Research Office of the Director National Institutes of Health Bethesda, Maryland

x Consensus Panel KAP Expert Panel and Federal Government Participants

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the individual's current affiliation.

Barry S. Brown, Ph.D. Michael Galer, D.B.A., M.B.A., M.F.A. Adjunct Professor Independent Consultant University of North Carolina at Wilmington Westminster, Massachusetts Carolina Beach, North Carolina Renata J. Henry, M.Ed. Jacqueline Butler, M.S.W., LISW, LPCC, Director CCDC III, CJS Division of Substance Abuse and Professor of Clinical Psychiatry Mental Health College of Medicine Delaware Health and Social Services University of Cincinnati New Castle, Delaware Cincinnati, Ohio Joel Hochberg, M.A. Deion Cash President Executive Director Asher & Partners Community Treatment & Correction Los Angeles, California Center, Inc. Canton, Ohio Jack Hollis, Ph.D. Associate Director Debra A. Claymore, M.Ed.Adm. Center for Health Research Owner/Chief Executive Officer Kaiser Permanente WC Consulting, LLC Portland, Oregon Loveland, Colorado Mary Beth Johnson, M.S.W. Carlo C. DiClemente, Ph.D. Director Chair Addiction Technology Transfer Center Department of Psychology National Office University of Maryland Baltimore County University of Missouri—Kansas City Baltimore, Maryland Kansas City, Missouri

Catherine E. Dube, Ed.D. Eduardo Lopez, B.S. Independent Consultant Executive Producer Brown University EVS Communications Providence, Rhode Island Washington, DC

Jerry P. Flanzer, D.S.W., LCSW, CAC Holly A. Massett, Ph.D. Chief Academy for Educational Development Services Research Branch Washington, DC National Institute on Drug Abuse Bethesda, Maryland

xi Diane Miller Nedra Klein Weinreich, M.S. Chief President Scientific Communications Branch Weinreich Communications National Institute on Alcohol Abuse Canoga Park, California and Alcoholism Kensington, Maryland Clarissa Wittenberg Director Harry B. Montoya, M.A. Office of Communications and Public Liaison President/Chief Executive Officer National Institute of Mental Health Hands Across Cultures Kensington, Maryland Espanola, New Mexico

Richard K. Ries, M.D. Consulting Members Director/Professor Paul Purnell, M.A. Outpatient Mental Health Services Social Solutions, L.L.C. Dual Disorder Programs Potomac, Maryland Harborview Medical Center Seattle, Washington Scott Ratzan, M.D., M.P.A., M.A. Academy for Educational Development Gloria M. Rodriguez, D.S.W. Washington, DC Research Scientist Division of Addiction Services Thomas W. Valente, Ph.D. New Jersey Department of Health Director, Master of Public Health Program and Senior Services Department of Preventive Medicine Trenton, New Jersey School of Medicine University of Southern California Everett Rogers, Ph.D. Alhambra, California Center for Communications Programs Johns Hopkins University Patricia A. Wright, Ed.D. Baltimore, Maryland Independent Consultant Baltimore, Maryland Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland

xii Expert Panel Foreword

The Substance Abuse and Mental Health Services Administration (SAMH- SA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mis- sion to reduce the impact of substance abuse and mental illness on America's communities by providing evidence-based and best practice guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation require- ments. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particu- lar area of expertise until they reach a consensus on best practices. Field reviewers then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field. Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Services Administration Daryl W. Kade Acting Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

xiii Executive Summary

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 informa­ tion 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 detoxi­ fication 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 sub­ stance abuse treatment. 2. The detoxification process consists of three essential components, which should be available to all people seeking treatment: •Evaluation •Stabilization •Fostering patient readiness for and entry into substance abuse treatment 3. Detoxification can take place in a wide variety of settings and at a num­ ber 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 ser­ vices is cost­effective. 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 sub­ stance­related disorders. The TIP reinforces the urgent need for non­

xv traditional settings—emergency rooms, medi­ 5. Level IV­D: Medically Managed Intensive cal and surgical wards in hospitals, acute care Inpatient Detoxification clinics, and others—to be prepared to partici­ pate in the process of getting the patient who ASAM criteria are being adopted extensively is in need of detoxification services into treat­ on the basis of their face validity, though ment as quickly as possible. Furthermore, it their outcome validity has yet to be clinically promotes the latest strategies for retaining proven. The ASAM guidelines are to be individuals in detoxification while also regarded as a work in progress, as their encouraging the development of the therapeu­ authors readily admit. They are an important tic alliance to promote the patient’s entrance set of guidelines that are of great help to clini­ into substance abuse treatment. The TIP also cians. For administrators, the standards pub­ includes suggestions on addressing psychoso­ lished by such groups as the Joint cial issues that may impact detoxification Commission on Accreditation of Healthcare treatment, such as providing culturally Organizations and the Commission on appropriate services to the patient popula­ Accreditation of Rehabilitation Facilities pro­ tion. vide guidance for overall program operations. Matching patients to appropriate care repre­ Placement will depend in part on the sub­ sents a challenge to detoxification programs. stance of abuse. The consensus panel suggests Given the wide variety of settings and the that for alcohol, sedative­hypnotic, and opi­ unique needs of the individual patient, estab­ oid withdrawal syndromes, hospitalization (or lishing criteria that take into account all the some form of 24­hour medical care) is often possible needs of patients receiving detoxifica­ the preferred setting for detoxification, based tion and treatment services is an extraordi­ on principles of safety and humanitarian con­ narily complex task. Addiction medicine has cerns. When hospitalization cannot be pro­ sought to develop an efficient system of care vided, then a setting that provides a high level that matches patients’ clinical needs with the of nursing and medical backup 24 hours a appropriate care setting in the least restric­ day, 7 days a week is desirable. tive and most cost­effective manner. Patient A further challenge for detoxification pro­ placement criteria, such as those published grams is to provide effective linkages to sub­ by the American Society of Addiction stance abuse treatment services. Patients Medicine (ASAM) in the Patient Placement often leave detoxification without followup to Criteria, Second Edition, Revised, represent the treatment needed to achieve long­term an effort to define how care settings may be abstinence. Each year at least 300,000 matched to patient needs and special charac­ patients with substance use disorders or acute teristics. These criteria—the five “Adult intoxication obtain inpatient detoxification in Detoxification” placement levels—define the general hospitals, while additional numbers most broadly accepted standard of care for obtain detoxification in other settings. Only detoxification services. The five levels of care 20 percent of people discharged from acute are care hospitals receive substance abuse treat­ 1. Level I­D: Ambulatory Detoxification ment during that hospitalization. Only 15 Without Extended Onsite Monitoring percent of people who are admitted to a detoxification program through an emergency 2. Level II­D: Ambulatory Detoxification With room and then discharged go on to receive Extended Onsite Monitoring treatment. 3. Level II.2­D: Clinically Managed Residential Detoxification The consensus panel recognizes that medical­ ly assisted withdrawal is not always necessary 4. Level III.7­D: Medically Monitored or desirable. A nonmedical approach can be Inpatient Detoxification highly cost­effective and provide inexpensive xvi Executive Summary access to treatment for individuals seeking medication or the psychiatric condition was aid. Young individuals in good health, with no clearly caused by substance use, then the history of previous withdrawal reactions, may rationale for discontinuing the medication is be well served by management of withdrawal strengthened. Finally, practitioners should without medication. However, personnel consider withholding medication that lowers supervising in this setting should be trained to the seizure threshold (e.g., bupropion, con­ identify life­threatening symptoms and solicit ventional antipsychotics) during the acute help through the emergency medical system as alcohol withdrawal period or at least pre­ needed. scribing a loading dose or scheduled taper of benzodiazepine. The consensus panel also agreed on several guidelines for nonmedical detoxification pro­ Further studies are needed to confirm the grams. Such programs should follow local gov­ clinical experience that psychiatric symptoms ernmental regulations regarding their licensing (including anxiety, depression, and personali­ and inspection. In addition, it is desirable that ty disorders) respond to specific treatment of all such programs have an alcohol and drug­ the addiction. For example, cognitive–behav­ free environment as well as personnel who are ioral techniques employed in the 12­Step familiar with the features of substance use treatment approach have been effective in the withdrawal syndromes, have training in basic management of anxiety and depression associ­ life support, and have access to an emergency ated with addiction. Although challenging, medical system that can transport patients to treatment of both addiction and co­occurring emergency departments and other sites for clin­ psychiatric conditions has proven cost­effec­ ical care. tive in some studies.

A major clinical question for detoxification is This TIP also provides medical information the appropriateness of the use of medication on detoxification protocols for specific sub­ in the management of an individual in with­ stances as well as considerations for individu­ drawal. This can be a difficult matter because als with co­occurring medical conditions protocols have not been firmly established including mental disorders. While the TIP is through scientific studies or evidence­based not intended to take the place of medical methods. Furthermore, the course of with­ texts, it provides the practitioner with an drawal is unpredictable and currently avail­ overview of common medical complications able techniques of screening and assessment seen in individuals who use substances. do not predict who will experience life­threat­ Disorders of several systems are discussed in ening complications. some detail: gastrointestinal (including the gastrointestinal tract, liver, and pancreas), Although it is the philosophy of some treat­ cardiovascular system, hematologic (blood) ment facilities to discontinue all medications, abnormalities, pulmonary (lung) diseases, dis­ this course of action is not always in the best eases of the central and peripheral nervous interest of the patient. Abrupt cessation of system, infectious diseases, and special mis­ psychotherapeutic medications may cause cellaneous disorders. The TIP presents a cur­ severe withdrawal symptoms or the re­emer­ sory overview of special conditions, modifica­ gence of a psychiatric disorder. As a general tions in protocols, and the use of detoxifica­ rule, therapeutic doses of medication should tion medications in patients with co­occurring be continued through any withdrawal if the medical conditions or mental disorders. patient has been taking the medication as pre­ Overall treatment of specific conditions is not scribed. Decisions about discontinuing the addressed unless modification of such treat­ medication should be deferred until after the ment is needed. individual has completed detoxification. If, however, the patient has been abusing the

Executive Summary xvii The setting in which detoxification occurs is unusual in a clinical treatment improvement also influenced by the existence of co­occur­ protocol to discuss issues related to how clini­ ring medical disorders. It is highly desirable cal services are reimbursed. In the field of that individuals undergoing detoxification be substance abuse and detoxification services, assessed by primary care practitioners (i.e., however, reimbursement issues have become physicians, physician assistants, nurse practi­ so intertwined with the delivery of services tioners) with some experience in substance that the consensus panel deemed it necessary abuse treatment. Such an assessment should to address the conflicts and misunderstand­ determine whether the patient is currently ings that sometimes arise between the care intoxicated and the degree of intoxication; the systems and the reimbursement systems. type and severity of the withdrawal syn­ drome; information regarding past with­ Third­party payors sometimes prefer to man­ drawals; and the presence of co­occurring age payment for detoxification separately psychiatric, medical, and surgical conditions from other phases of substance abuse treat­ that might require specialized care. ment, thus treating detoxification as if it Particular attention should be paid to those occurred in isolation from that treatment. individuals who have undergone multiple This “unbundling” of services can result in withdrawals in the past and for whom each the separation of services into scattered seg­ withdrawal appears worse than previous ments. In other instances, reimbursement and ones. Subjects with a history of severe with­ utilization policies dictate that only detoxifi­ drawals, multiple withdrawals, delirium cation can be authorized. This detoxification tremens (a potentially fatal syndrome associ­ often does not cover the nonmedical counsel­ ated with alcohol withdrawal), or seizures are ing that is an integral part of substance abuse not good candidates for detoxification pro­ treatment. grams in nonmedical settings. Finally, identifying and maintaining funding The setting in which detoxification is carried sources is a major issue in detoxification. out should be appropriate for the medical Substance abuse treatment in the United and psychological conditions present and States is financed through a diverse mix of should be adequate to provide the degree of public and private sources, with substantially monitoring needed to ensure safety (e.g., more being spent by the public sector. The oximetry [a measurement of the amount of existence of diverse funding streams in sub­ oxygen present in the blood], greater fre­ stance abuse treatment funding presents both quency of taking vital signs, etc.). Acute, life­ management challenges and opportunities for threatening conditions need to be addressed program independence and stability. concurrently with the withdrawal process and However, a program with only one major intensive care unit monitoring may be indicat­ funding source is financially and clinically ed. Detoxification staff providing support vulnerable to changes in its major source’s should be familiar with the signs and symp­ budget and priorities. This situation should toms of common co­occurring medical disor­ be avoided. The TIP suggests ways to diversi­ ders. Likewise, personnel at medical facilities fy funding sources to create a steady stream (e.g., emergency rooms, physicians’ offices) of resources that can withstand the loss of one should be aware of the signs of withdrawal particular funding source. and how it affects the treatment of the pre­ This TIP also makes recommendations for senting medical conditions. fostering relationships with reimbursement This TIP will also bring clinicians and admin­ organizations, such as managed care organi­ istrators up to date on administrative issues zations (MCOs). These positive working rela­ related to detoxification, including how the tionships are vital to successfully link the services themselves can be paid for. It is patient to the needed services. For example, xviii Executive Summary the MCO may use a wide variety of specific with each MCO’s appeal or exceptions process criteria and protocols to determine whether for those occasions when the outcome of a or not services may be authorized for sub­ first­level review is unsatisfactory. stance abuse, typically including the ASAM patient placement criteria and other level of Regardless of their role in providing detoxifi­ care or diagnosis­based criteria sets. cation services, all personnel should keep in Successfully addressing the needs of the staff mind that patients undergoing detoxification at MCOs that are responsible for authorizing are in the midst of a personal and medical the care provided to patients is a critical ele­ crisis. For many patients, this crisis repre­ ment in maintaining a relationship with an sents a window of opportunity to acknowledge MCO and the program’s clinical and financial their substance abuse problem and become viability. To do so, staff should understand willing to seek treatment. Physicians, nurses, what MCO staff do, be well trained in con­ substance abuse counselors, and administra­ ducting professional relationships over the tors are in a unique position, not only to telephone, be familiar with the criteria and ensure a safe and humane withdrawal from protocols used by the MCOs with which the substances of dependency, but also to foster program has contracts, and have easy access the path for the patient’s entry into substance to the abundance of clinical and service infor­ abuse treatment. This TIP suggests ways for mation required by an MCO in order to help clinicians and programs to prepare the them complete a review and authorize ser­ patient for treatment while addressing the vices. Maintaining thorough, clear, and accu­ complex psychosocial and medical variables rate records is essential to this process. involved in detoxification. Detoxification staff also should be familiar

Executive Summary xix 1 Overview, Essential Concepts, and Definitions in In This Chapter… Detoxification

Purpose of the TIP Audience

Scope Chapter 1 provides a brief historical overview of changes in the percep­ tions and provision of detoxification services. It also introduces the core History of Detoxification concepts of the detoxification field, discusses the primary goals of detoxifi­ Services cation services, clarifies the distinction between detoxification and treat­ Definitions ment, and highlights some of the broader issues involved with providing detoxification within systems of care. Guiding Principles in Detoxification and Substance Abuse Purpose of the TIP Treatment This TIP is a revision of TIP 19, Detoxification From Alcohol and Challenges to Providing Other Drugs (Center for Substance Abuse Treatment [CSAT] 1995d). Effective Detoxification Significant changes in the area of detoxification services since the publi­ cation of TIP 19 include •Refinement of patient placement procedures •Increased knowledge of the physiology of withdrawal •Pharmacological advances in the management of withdrawal •Changes in the role of detoxification in the continuum of services for patients with substance use disorders, and new issues in the management of detoxification services within comprehensive systems of care •Emerging issues regarding specific populations (e.g., women, cultural minorities, adolescents)

1 This TIP provides clinicians with up­to­date provide detoxification services—to be pre­ information in these areas. It also expands on pared to participate in the process of getting the administrative, legal, and ethical issues the patient who is in need of detoxification commonly encountered in the delivery of into a program as quickly as possible to detoxification services and suggests perfor­ potentially avoid the myriad possible negative mance measures for detoxification programs. consequences associated with substance abuse Like its predecessor, this TIP was created by (e.g., physiological and psychological distur­ a panel of experts with diverse experience in bances/disorders, criminal involvement, detoxification services—physicians, psycholo­ unemployment, etc.). Furthermore, it pro­ gists, counselors, nurses, and social workers, motes the latest strategies for retaining indi­ all with particular expertise to share. viduals in detoxification while also encourag­ ing the development of the therapeutic alliance to promote the patient’s entrance into Audience substance abuse treatment. This includes sug­ The primary audiences for this TIP include gestions on addressing psychosocial issues substance abuse treatment counselors; adminis­ that may affect detoxification services. trators of detoxification programs; Single State This TIP provides medical information on Agency directors; psychiatrists and other detoxification protocols for specific sub­ physicians working in the field; primary care stances, as well as considerations for individ­ providers such as physicians, nurse practition­ uals with co­occurring medical conditions ers, physician assistants, nurses, psychologists, including mental disorders. While the TIP is and other clinical staff members; staff of man­ not intended to take the place of medical aged care and insurance carriers; policymak­ texts, it provides the practitioner with an ers; and others involved in planning, evaluat­ overview of medical considerations. ing, and delivering services for detoxifying patients from substances of abuse. Secondary This TIP will also bring clinicians and adminis­ audiences include public safety/police and trators up­to­date on important aspects of criminal justice personnel, educational institu­ detoxification, including how the services are to tions, those involved with assisting workers be paid for. It is unusual in a clinical treatment (e.g., Employee Assistance Programs), shel­ improvement protocol to discuss issues related ters/feeding programs, and managed care orga­ to how clinical services are reimbursed. nizations. The TIP also should prove useful to However, in the field of substance abuse and providers of other services in comprehensive detoxification services, reimbursement issues systems of care (vocational counseling, occupa­ have become so intertwined with the delivery of tional therapy, and public housing/assisted liv­ services that the consensus panel deemed it ing), administrators, and payors (public, pri­ necessary to address the conflicts and misun­ vate, and managed care). derstandings that sometimes arise between the care systems and the reimbursement systems. Scope Among other issues covered in this TIP is the History of importance of detoxification as one compo­ Detoxification Services nent in the continuum of healthcare services for substance­related disorders. The TIP Prior to the 1970s, public intoxication was reinforces the urgent need for nontraditional treated as a criminal offense. People arrested settings—such as emergency rooms, medical for it were held in the “drunk tanks” of local and surgical wards in hospitals, acute care jails where they underwent withdrawal with clinics, and others that do not traditionally little or no medical intervention (Abbott et al.

2 Chapter 1 1995; Sadd and Young 1987). Shifts in the Just as the treatment and the conceptualiza­ medical field, in perceptions of addiction, and tion of addiction have changed, so too have in social policy changed the way that people the patterns of substance use and the accom­ with dependency on drugs, including alcohol, panying detoxification needs. The popularity were viewed and treated. Two notable events of cocaine, heroin, and other substances has were particularly instrumental in changing led to the need for different kinds of detoxifi­ attitudes. In 1958, the American Medical cation services. At Association (AMA) took the official position the same time, public that alcoholism is a disease. This declaration health officials have suggested that alcoholism was a medical prob­ increased invest­ The AMA’s lem requiring medical intervention. In 1971, ments in detoxifica­ the National Conference of Commissioners on tion services and position is that sub­ Uniform State Laws adopted the Uniform substance abuse Alcoholism and Intoxication Treatment Act, treatment, especially stance dependence which recommended that “alcoholics not be after 1985, as a subjected to criminal prosecution because of means to inhibit the is a disease, and it their consumption of alcoholic beverages but spread of HIV infec­ rather should be afforded a continuum of tion and AIDS encourages physi­ treatment in order that they may lead normal among people who lives as productive members of society” inject drugs. More cians and other (Keller and Rosenberg 1973, p. 2). While this recently, people with recommendation did not carry the weight of substance use disor­ law, it made a major change in the legal impli­ ders are more likely clinicians, health cations of addiction. With these changes came to abuse more than more humane treatment of people with addic­ one drug simultane­ organizations, and tions. ously (i.e., polydrug abuse) (Office of policymakers to Several methods of detoxification have evolved Applied Studies that reflect a more humanitarian view of people 2005). base all their activi­ with substance use disorders. In the “medical model,” detoxification is characterized by the The AMA continues use of physician and nursing staff and the to maintain its posi­ ties on this premise. administration of medication to assist people tion that substance through withdrawal safely (Sadd and Young dependence is a dis­ 1987). The “social model” rejects the use of ease, and it encour­ medication and the need for routine medical ages physicians and other clinicians, health care, relying instead on a supportive nonhospi­ organizations, and policymakers to base all tal environment to ease the passage through their activities on this premise (AMA 2002). withdrawal (Sadd and Young 1987). Today, it is As treatment regimens have become more rare to find a “pure” detoxification model. For sophisticated and polydrug abuse more com­ example, some social model programs use medi­ mon, detoxification has evolved into a com­ cation to ease withdrawal but generally employ passionate science. nonmedical staff to monitor withdrawal and conduct triage (i.e., sorting patients according to the severity of their disorders). Likewise, Definitions medical programs generally have some compo­ Few clear definitions of detoxification and nents to address social/personal aspects of related concepts are in general use at this addiction. time. Criminal justice, health care, substance abuse, mental health, and many other sys­

Overview, Essential Concepts, and Definitions in Detoxification 3 tems all define detoxification differently. This taken special care to note that detoxification TIP offers a clear and uniform set of defini­ is not substance abuse treatment and rehabil­ tions for the various components of detoxifi­ itation. For further explanation, see the text cation and substance abuse treatment that box below. may prove useful to the field of detoxifica­ tion. The consensus panel built on existing defini­ tions of detoxification as a broad process with three essential components that may take Detoxification place concurrently or as a series of steps: Detoxification is a set of interventions aimed • Evaluation entails testing for the presence at managing acute intoxication and withdraw­ of substances of abuse in the bloodstream, al. It denotes a clearing of toxins from the measuring their concentration, and screen­ body of the patient who is acutely intoxicated ing for co­occurring mental and physical and/or dependent on substances of abuse. conditions. Evaluation also includes a com­ Detoxification seeks to minimize the physical prehensive assessment of the patient’s medi­ harm caused by the abuse of substances. The cal and psychological conditions and social acute medical management of life­threatening situation to help determine the appropriate intoxication and related medical problems level of treatment following detoxification. generally is not included within the term Essentially, the evaluation serves as the detoxification and is not covered in detail in basis for the initial substance abuse treat­ this TIP. ment plan once the patient has been with­ drawn successfully. The Washington Circle Group (WCG), a body • Stabilization includes the medical and psy­ of experts organized to improve the quality chosocial processes of assisting the patient and effectiveness of substance abuse preven­ through acute intoxication and withdrawal tion and treatment, defines detoxification as to the attainment of a medically stable, fully “a medical intervention that manages an indi­ supported, substance­free state. This often vidual safely through the process of acute is done with the assistance of medications, withdrawal” (McCorry et al. 2000a, p. 9). though in some approaches to detoxification The WCG makes an important distinction, no medication is used. Stabilization however, in noting that “a detoxification pro­ includes familiarizing patients with what to gram is not designed to resolve the long­ expect in the treatment milieu and their standing psychological, social, and behavioral role in treatment and recovery. During this problems associated with alcohol and drug time practitioners also seek the involvement abuse” (McCorry et al. 2000a, p. 9). The con­ of the patient’s family, employers, and sensus panel supports this statement and has

Detoxification as Distinct From Substance Abuse Treatment

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. Supervised detoxification may prevent potentially life­threatening complications that might appear if the patient were left untreated. At the same time, detoxification is a form of palliative care (reducing the intensity of a disorder) for those who want to become abstinent or who must observe mandatory abstinence as a result of hospitalization or legal involvement. Finally, for some patients it represents a point of first con­ tact with the treatment system and the first step to recovery. Treatment/rehabilitation, on the other hand, involves a constellation of ongoing therapeutic services ultimately intended to promote recovery for substance abuse patients.

4 Chapter 1 other significant people when appropriate stance­induced disorders. According to the and with release of confidentiality. DSM­IV­TR, substance use disorders include • Fostering the patient’s entry into treatment both “substance dependence” and “substance involves preparing the patient for entry into abuse.” Substance dependence refers to “a substance abuse treatment by stressing the cluster of cognitive, behavioral, and physio­ importance of following through with the logical symptoms indicating that the individu­ complete substance abuse treatment contin­ al continues use of the substance despite sig­ uum of care. For patients who have demon­ nificant substance­related problems. There is strated a pattern of completing detoxifica­ a pattern of repeated self­administration that tion services and then failing to engage in can result in tolerance, withdrawal, and com­ substance abuse treatment, a written treat­ pulsive drug­taking behavior” (APA 2000, p. ment contract may encourage entrance into 192). Substance abuse refers to “a maladap­ a continuum of substance abuse treatment tive pattern of substance use manifested by and care. This contract, which is not legally recurrent and significant adverse conse­ binding, is voluntarily signed by patients quences related to the repeated use of sub­ when they are stable enough to do so at the stances” (APA 2000, p. 198). It should be beginning of treatment. In it, the patient noted that for purposes of this TIP, the term agrees to participate in a continuing care “substance abuse” is sometimes used to plan, with details and contacts established denote both substance abuse and substance prior to the completion of detoxification. dependence as they are defined by the DSM­ IV­TR. All three components (evaluation, stabiliza­ tion, and fostering a patient’s entry into This TIP also uses the DSM­IV­TR definitions treatment) involve treating the patient with for substance intoxication and substance compassion and understanding. Patients withdrawal. Substance intoxication is “the undergoing detoxification need to know that development of a reversible substance­specific someone cares about them, respects them as syndrome due to the recent ingestion of (or individuals, and has hope for their future. exposure to) a substance” whereas substance Actions taken during detoxification will withdrawal is “the development of a sub­ demonstrate to the patient that the provider’s stance­specific maladaptive behavioral recommendations can be trusted and fol­ change, with physiological and cognitive con­ lowed. comitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use” (APA 2000, pp. 199, 201). Figure 1­1 Other Relevant Terms (p. 6) defines these and other relevant terms. As defined by the Diagnostic and Statistical Treatment/rehabilitation includes an ongoing, Manual of Mental Disorders, 4th edition, continual assessment of the patient’s physical, Text Revision (DSM­IV­TR) (American psychological, and social status, as well as an Psychiatric Association [APA] 2000), a sub­ analysis of environmental risk factors that stance­related disorder is a “disorder related may be contributing to substance use and the to the taking of a drug of abuse (including identification of immediate relapse triggers as alcohol), to the side effects of a medication, well as prevention strategies for coping with and to toxin exposure” (APA 2000, p. 191). them. It also includes the delivery of primary The term substance “can refer to a drug of medical care and psychiatric care, if neces­ abuse, a medication, or a toxin” (APA 2000, sary, to help the patient abstain from sub­ p. 191). In this TIP, the term substance refers stance use and minimize the physical harm to alcohol as well as other drugs of abuse. caused by it. Ultimately, the goal of treat­ Substance­related disorders are divided into ment/rehabilitation is to attain a higher level two groups: substance use disorders and sub­ of social functioning by reducing risk factors,

Overview, Essential Concepts, and Definitions in Detoxification 5 Figure 1­1 DSM­IV­TR Definitions of Terms

Term Definition

Substance A drug of abuse, a medication, or a toxin.

Substance­related disorders Disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin expo­ sure.

Substance abuse (in this TIP, also A maladaptive (i.e., harmful to a person’s life) pattern of sub­ sometimes used to denote “substance stance use marked by recurrent and significant negative conse­ dependence”) quences related to the repeated use of substances.

Substance dependence (in this TIP, A cluster of cognitive, behavioral, and physiological symptoms “substance abuse” is sometimes used indicating that the individual is continuing use of the substance to include “dependence”) despite significant substance­related problems. A person experi­ encing substance dependence shows a pattern of repeated self­ administration that usually results in tolerance, withdrawal, and compulsive drug­taking behavior.

Substance intoxication The development of a reversible substance­specific syndrome as the result of the recent ingestion of (or exposure to) a substance.

Substance withdrawal The development of a substance­specific maladaptive behavioral change, usually with uncomfortable physiological and cognitive consequences, that is the result of a cessation of, or reduction in, heavy and prolonged substance use.

Source: APA 2000.

enhancing protective factors, and thus patients to emphasize that these persons are decreasing the possibility of relapse. coming into contact with physicians, nurses, physician assistants, and medical social work­ Maintenance includes the continuation of ers in a medical setting in which the patient counseling and support specified in the treat­ often is physically ill from the effects of with­ ment plan, refinement and strengthening of drawal from specific substances. In some strategies to avoid relapse, and engagement in social setting detoxification programs, the ongoing relapse prevention, aftercare, and/or terms “client” or “consumer” may be used in domiciliary care (Lehman et al. 2000). place of “patient.” As a final note, in this TIP persons in need of detoxification services and subsequent sub­ stance abuse treatment are referred to as

6 Chapter 1 Guiding Principles in empirically measurable and agreed upon by all parties. The consensus panel developed guide­ Detoxification and lines (listed in Figure 1­2) that serve as the Substance Abuse foundation for the TIP. Treatment The consensus panel recognizes that the suc­ cessful delivery of detoxification services is dependent on standards that are to some extent

Figure 1­2 Guiding Principles Recognized by the Consensus Panel 1. Detoxification does not constitute substance abuse treatment but is one part of a continuum of care for substance­related disorders. 2. The detoxification process consists of the following three sequential and essential components: •Evaluation •Stabilization •Fostering patient readiness for and entry into treatment A detoxification process that does not incorporate all three critical components is considered incomplete and inadequate by the consensus panel. 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. Persons seeking detoxification should have access to the components of the detoxification process described above, no matter what the setting or the level of treatment intensity. 5. 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 a substance abuse treat­ ment program after detoxification, if they are not going to be engaged in a treatment service provided by the same program that provided them with detoxification services. There can be “no wrong door to treatment” for substance use disorders (CSAT 2000a). 6. Ultimately, insurance coverage for the full range of detoxification services is cost­effective. If reim­ bursement systems do not provide payment for the complete detoxification process, patients may be released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical com­ plications ultimately drive up the overall cost of health care. 7. Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as unique health needs and life situations. Organizations that provide detoxification services need to ensure that they have standard practices in place to address cultural diversity. It also is essential that care providers possess the special clinical skills necessary to provide culturally competent compre­ hensive assessments. Detoxification program administrators have a duty to ensure that appropriate training is available to staff. (For more information on cultural competency training and specific competencies that clinicians need to be “culturally competent” see the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [SAMHSA in development a]). 8. A successful detoxification process can be measured, in part, by whether an individual who is sub­ stance dependent enters, remains in, and is compliant with the treatment protocol of a substance abuse treatment/rehabilitation program after detoxification.

Overview, Essential Concepts, and Definitions in Detoxification 7 Challenges to Finally the average length of stay for people undergoing detoxification and treatment in Providing Effective 1997 was only 7.7 days (Mark et al. 2002). Given that “research has shown that patients Detoxification who receive continuing care have better out­ It is an important challenge for detoxification comes in terms of drug abstinence and read­ service providers to find the most effective mission rates than those who do not receive way to foster a patient’s recovery. Effective continuing care,” the report authors conclude detoxification includes not only the medical that there is a pronounced need for better stabilization of the patient and the safe and linkage between detoxification services and humane withdrawal from drugs, including the treatment services that are essential for alcohol, but also entry into treatment. full recovery (Mark et al. 2002, p. 3). Successfully linking detoxification with sub­ stance abuse treatment reduces the “revolving Reimbursement systems can present another door” phenomenon of repeated withdrawals, challenge to providing effective detoxification saves money in the medium and long run, and services (Galanter et al. 2000). Third­party delivers the sound and humane level of care payors sometimes prefer to manage payment patients need (Kertesz et al. 2003). Studies for detoxification separately from other phas­ show that detoxification and its linkage to the es of addiction treatment, thus treating detox­ appropriate levels of treatment lead to ification as if it occurred in isolation from increased recovery and decreased use of addiction treatment. This “unbundling” of detoxification and treatment services in the services has promoted the separation of all future. In addition, recovery leads to reduc­ services into somewhat scattered segments tions in crime, general healthcare costs, and (Kasser et al. 2000). In other instances, some expensive acute medical and surgical treat­ reimbursement and utilization policies dictate ments consequent to untreated substance that only “detoxification” currently can be abuse (Abbot et al. 1998; Aszalos et al. 1999). authorized, and “detoxification” for that poli­ While detoxification is not treatment per se, cy or insurer does not cover the nonmedical its effectiveness can be measured, in part, by counseling that is an integral part of sub­ the patient’s continued abstinence. stance abuse treatment. Many treatment pro­ grams have found substance abuse counselors Another challenge to providing effective to be of special help with resistant patients, detoxification occurs when programs try to especially for patients with severe underlying develop linkages to treatment services. A shame over the fact that their substance use is study (Mark et al. 2002) conducted for the out of control. Yet some payors will not reim­ Substance Abuse and Mental Health Services burse for nonmedical services such as those Administration highlights the pitfalls of the provided by these counselors, and therefore service delivery system. According to the the use of such staff by a detoxification or authors, each year at least 300,000 patients treatment service may be impossible, in spite with substance use disorders or acute intoxi­ of the fact that they are widely perceived as cation obtain inpatient detoxification in gen­ useful for patients. eral hospitals while additional numbers obtain detoxification in other settings. Only Payors are gradually beginning to understand about one­fifth of people discharged from that detoxification is only one component of a acute care hospitals for detoxification receive comprehensive treatment strategy. Patient substance abuse treatment during that hospi­ placement criteria, such as those published talization. Moreover, only 15 percent of peo­ by the American Society of Addiction ple who are admitted through an emergency Medicine (ASAM) in the Patient Placement room for detoxification and then discharged Criteria, Second Edition, Revised (ASAM receive any substance abuse treatment. 2001), have come to the fore as clinicians and

8 Chapter 1 insurers try to reach agreements on the level for resolving conflicts as well as clearly defin­ of treatment required by a given patient, as ing terms used in patient placement and treat­ well as the medically appropriate setting in ment settings as a step toward clearer under­ which the treatment services are to be deliv­ standing among interested parties. ered. Accordingly, the TIP offers suggestions

Overview, Essential Concepts, and Definitions in Detoxification 9 2 Settings, Levels of Care, and Patient Placement In This Chapter… Establishing criteria that take into account all the possible needs of patients receiving detoxification and treatment services is an extraordi­ Role of Various narily complex task. This chapter discusses the criteria for placing Settings in the patients in the appropriate treatment settings and offering the required Delivery of Services intensity of services (i.e., level of care).

Other Concerns Regarding Levels of Role of Various Settings in the Care and Placement Delivery of Services 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 cost­effective 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 third­party 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.

11 Least Restrictive Care

Least restrictive refers to patients’ civil rights and their right to choice of care. There are four spe­ cific themes of historical and clinical importance:

1. Patients should be treated in those settings that least interfere with their civil rights and freedom to participate in society. 2. Patients should be able to disagree with clinician recommendations for care. While this includes the right to refuse any care at all, it also includes the right to obtain care in a setting of their choice (as long as considerations of dangerousness and mental competency are satisfied). It implies a patient’s right to seek a higher or different level of care than that which the clinician has planned. 3. Patients should be informed participants in defining their care plan. Such planning should be done in collaboration with their healthcare providers. 4. Careful consideration of State laws and agency policies is required for patients who are unable to act in their own self­interests. Because the legal complexities of this issue will vary from State to State the TIP cannot provide definitive guidance here, but providers need to consider whether or not the person is “gravely” incapacitated, suicidal, or homicidal; likely to commit grave bodily injury; or, in some States, likely to cause injury to property. In such cases, State law and/or case law may hold providers responsible if they do not commit the patient to care, but in other cases programs may be open to lawsuits for forcibly holding a patient.

In spite of the impediments, some progress has 2. Biomedical Conditions and Complications been made in developing comprehensive 3. Emotional, Behavioral, or Cognitive patient placement criteria. Because the choice Conditions and Complications of a treatment setting and intensity of treat­ 4. Readiness to Change ment (level of care) are so important, the American Society of Addiction Medicine 5. Relapse, Continued Use, or Continued (ASAM) created the Patient Placement Problem Potential Criteria, Second Edition, Revised (PPC­2R) a 6. Recovery/Living Environment consensus­based clinical tool for matching patients to the appropriate setting and level of The ASAM PPC­2R describes both the settings care. The ASAM PPC­2R represents an effort in which services may take place and the inten­ to define how care settings may be matched to sity of services (i.e., level of care) that patients patient needs and special characteristics. These may receive in particular settings. It is impor­ criteria currently define the most broadly tant to reiterate, however, that the ASAM accepted standard of care for the treatment of PPC­2R criteria do not characterize all the substance use disorders. ASAM criteria are details that may be essential to the success of intended to provide flexible clinical guidelines; treatment (Gastfriend et al. 2000). Moreover, these criteria may not be appropriate for par­ traditional assumptions that certain treatment ticular patients or specific care settings. can be delivered only in a particular setting may not be applicable or valuable to patients. The PPC­2R identifies six “assessment dimen­ Clinical judgment and consideration of the sions to be evaluated in making placement patient’s particular situation are required for decisions” (ASAM 2001, p. 4). They are as appropriate detoxification and treatment. follows: In addition to the general placement criteria 1. Acute Intoxication and/or Withdrawal for treatment for substance­related disorders, Potential ASAM also has developed a second set of place­

12 Chapter 2 ment criteria, which are more important for should increase the patient’s readiness for the purposes of this TIP—the five “Adult and commitment to substance abuse treat­ Detoxification” placement levels of care within ment and foster a solid therapeutic alliance Dimension 1 (ASAM 2001). These “Adult between the patient and care provider. Detoxification” levels of care are It is important to note that ASAM PPC­2R 1. Level I­D: Ambulatory Detoxification criteria are only guidelines, and that there Without Extended Onsite Monitoring (e.g., are no uniform protocols for determining physician’s office, home health care agen­ which patients are placed in which level of cy). This level of care is an organized out­ care. For further information on patient patient service monitored at predeter­ placement, readers are advised to consult mined intervals. TIP 13, The Role and Current Status of 2. Level II­D: Ambulatory Detoxification Patient Placement Criteria in the Treatment With Extended Onsite Monitoring (e.g., of Substance Use Disorders (Center for day hospital service). This level of care is Substance Abuse Treatment [CSAT] 1995h). monitored by appropriately credentialed Because this TIP is geared to audiences that and licensed nurses. may or may not be familiar with the ASAM 3. Level III.2­D: Clinically Managed PPC­2R levels of care, this section discusses Residential Detoxification (e.g., nonmedi­ the services and staffing specific to the care cal or social detoxification setting). This settings that are familiar to a broad audience. level emphasizes peer and social support and is intended for patients whose intoxi­ cation and/or withdrawal is sufficient to Physician’s Office warrant 24­hour support. It has been estimated that nearly one half of 4. Level III.7­D: Medically Monitored the patients who visit a primary care provider Inpatient Detoxification (e.g., freestanding have some type of problem related to sub­ detoxification center). Unlike Level stance use (Miller and Gold 1998). Indeed, III.2.D, this level provides 24­hour medi­ because the physician may be the first point cally supervised detoxification services. of contact for these people, initiation of treat­ 5. Level IV­D: Medically Managed Intensive ment often begins in the family physician’s Inpatient Detoxification (e.g., psychiatric office (Prater et al. 1999). Physicians should hospital inpatient center). This level pro­ use prudence in determining which patients vides 24­hour care in an acute care inpa­ may undergo detoxification safely on an out­ tient settings. patient basis. As a general rule, outpatient treatment is just as effective as inpatient As described by the ASAM PPC­2R, the treatment for patients with mild to moderate domain of detoxification refers not only to the withdrawal symptoms (Hayashida 1998). reduction of the physiological and psychologi­ cal features of withdrawal syndromes, but For physicians treating patients with sub­ also to the process of interrupting the momen­ stance use disorders, preparing the patient to tum of compulsive use in persons diagnosed enter treatment and developing a therapeutic with substance dependence (ASAM 2001). alliance between patient and clinician should Because of the force of this momentum and begin as soon as possible. This includes pro­ the inherent difficulties in overcoming it even viding the patient and his family with infor­ when there is no clear withdrawal syndrome, mation on the detoxification process and sub­ this phase of treatment frequently requires a sequent substance abuse treatment, in addi­ greater intensity of services initially to estab­ tion to providing medical care or referrals if lish participation in treatment activities and necessary. Staffing should include certified patient role induction. That is, this phase interpreters for the deaf and other language

Settings, Levels of Care, and Patient Placement 13 interpreters if the program is serving patients under a defined set of policies and procedures in need of those services. Physicians should or medical protocols. Outpatient services are be able to accommodate frequent followup designed to treat the patient’s level of clinical visits during the management of acute with­ severity and to achieve safe and comfortable drawal. Medications should be dispensed in withdrawal from mood­altering drugs, includ­ limited amounts. ing alcohol, and to effectively facilitate the patient’s entry into ongoing treatment and recovery (ASAM 2001). Level of care Ambulatory detoxification without extended onsite monitoring Staffing This level of detoxification (ASAM’s Level I­ Although they need not be present in the D) is an organized outpatient service, which treatment setting at all times, physicians and may be delivered in an office setting, health­ nurses are essential to office­based detoxifica­ care or addiction treatment facility, or in a tion. In States where physician assistants, patient’s home by trained clinicians who pro­ nurse practitioners, or advance practice clini­ vide medically supervised evaluation, detoxi­ cal nurse specialists are licensed as physician fication, and referral services according to a extenders, they may perform the duties ordi­ predetermined schedule. Such services are narily carried out by a physician (ASAM provided in regularly scheduled sessions. 2001). These services should be delivered under a Because detoxification is conducted on an defined set of policies and procedures or med­ outpatient basis in these settings, it is impor­ ical protocols (ASAM 2001). Ambulatory tant for medical and nursing personnel to be detoxification is considered appropriate only readily available to evaluate and confirm that when a positive and helpful social support detoxification in the less supervised setting is network is available to the patient. In this safe. All clinicians who assess and treat level of care, outpatient detoxification ser­ patients should be able to obtain and inter­ vices should be designed to treat the patient’s pret information regarding the needs of these level of clinical severity, to achieve safe and persons, and all should be knowledgeable comfortable withdrawal from mood­altering about the biomedical and psychosocial dimen­ drugs, and to effectively facilitate the sions of alcohol and illicit drug dependence. patient’s transition into treatment and recov­ Requisite skills and knowledge base include ery. the following: Ambulatory detoxification with •Understanding how to interpret the signs and extended onsite monitoring symptoms of alcohol and other drug intoxica­ Essential to this level of care—and distin­ tion and withdrawal guishing it from Ambulatory Detoxification •Understanding the appropriate treatment Without Extended Onsite Monitoring—is the and monitoring of these conditions availability of appropriately credentialed and •The ability to facilitate the individual’s entry licensed nurses (such as registered nurses into treatment [RNs] or licensed practical nurses [LPNs]) who monitor patients over a period of several It is essential that medical consultation is hours each day of service (ASAM 2001). readily available in emergencies. It is desir­ Otherwise, this level of detoxification able that medical staff link patients to treat­ (ASAM’s Level II­D) also is an organized out­ ment services, although this may be an unrea­ patient service. Like Level I­D, in this level of sonable expectation that cannot be met in a care detoxification services are provided in busy office setting. Linkage to treatment ser­ regularly scheduled sessions and delivered vices may be provided by the physician or by

14 Chapter 2 designated counselors, psychologists, social only when there are serious concerns about a workers, and acupuncturists who are avail­ patient’s safety. able either onsite or through the healthcare system (ASAM 2001). A timely and accurate assessment in an emer­ gency department is of the highest impor­ tance. This will permit the rapid transfer of Freestanding Urgent Care the patient to a setting where complete care Center or Emergency can be provided. Ideally, personnel in Department the emergency Although they There are several distinctions between urgent department will have care facilities and emergency rooms (ERs). at least a small need not be Urgent care often is used by patients who amount of experi­ cannot or do not want to wait until they see ence and expertise in their doctor in his or her office, whereas identifying critically present in the emergency rooms are utilized more often by ill substance­using patients who perceive themselves to be in a patients who may be treatment setting crisis situation. Unlike emergency depart­ about to experience ments, which are required to operate 24 or are already expe­ at all times, hours a day, freestanding urgent care centers riencing withdrawal usually have specific hours of operation. symptoms. Three physicians and Staffing for urgent care centers generally is essential rules apply more limited than for an ER. Standard to emergency depart­ nurses are staffing includes only a physician, an RN, a ments and their han­ technician, and a secretary. Despite these dis­ dling of intoxicated essential to tinctions, in actual practice there is consider­ patients and patients able overlap between the two—the ER will see who have begun to medical problems that could be handled by experience with­ office­based visits to offices, and urgent care facilities will drawal: detoxification. handle some cases of emergency medicine. •Emergency depart­ A freestanding urgent care center or emergen­ ments and their cy department reasonably can be expected to clinicians should provide assessment and acute biomedical never simply (including psychiatric) care. However, these administer medications to intoxicated persons settings often are unable to provide satisfacto­ and then send them home. ry psychosocial stabilization or complete •No intoxicated patient should ever be allowed biomedical stabilization (which includes both to leave a hospital setting. All such persons the initiation and taper of medications used in should be referred to the appropriate detoxi­ the treatment of substance withdrawal syn­ fication setting if possible, although there are dromes). Appropriate triage and successful legal restrictions that forbid holding persons linkage to ongoing detoxification services is against their will under certain conditions essential. The ongoing detoxification services (Armenian et al. 1999). may be provided in an inpatient, residential, •A clear distinction must be made between or outpatient setting. Patients with more than acute intoxication on the one hand and with­ moderate biomedical or psychosocial compli­ drawal on the other. Acute intoxication, it cations are more likely to require treatment must be remembered, creates special issues in an inpatient setting. Care in these settings and challenges that need to be addressed. can be quite costly and should be accessed The risk of suicidality in patients who pre­ sent in a state of intoxication needs to be

Settings, Levels of Care, and Patient Placement 15 carefully assessed. Because of their volatility biomedical issues, is recommended wherever and often risky behavior, patients who are possible. intoxicated, as well as those patients who have begun to experience withdrawal, merit Appreciation of the value of multidimensional special attention. For more on treating intox­ patient assessment is central to the clinician’s icated patients, see chapter 3. ability to decide which triage (linkage) options are least restrictive and most cost­effective Level of care for a given patient. Care is provided to Inpatient patients whose with­ Staffing drawal signs and Both emergency departments and freestanding detoxification symptoms are suffi­ urgent care units are staffed by physicians. ciently severe to The same rules regarding who may provide provides 24­hour require primary care apply here as they did in the discussion of medical and nursing staffing of office­based detoxification (ASAM supervision, care services. The 2001). An RN or other licensed and creden­ services are deliv­ tialed nurse is available for primary nursing observation, and ered under a care and observation. Psychologists, social defined set of physi­ workers, addiction counselors, and acupunc­ support for cian­managed pro­ turists usually are not available in these set­ cedures or medical tings. The physician or attending nurse usually protocols. Both set­ facilitates linkage to substance abuse treat­ patients who are tings provide medi­ ment. cally directed assess­ intoxicated or ment and acute care that includes the ini­ Freestanding Substance Abuse experiencing tiation of detoxifica­ Treatment or Mental Health tion for substance Facility withdrawal. use withdrawal. Neither setting is Freestanding substance abuse treatment facili­ likely to offer satis­ ties may or may not be equipped to provide factory biomedical adequate assessment and treatment of co­ stabilization or 24­ occurring psychiatric conditions and biopsy­ hour observation. Generally speaking, triage to chosocial problems, as the range of services inpatient care can easily be facilitated from varies considerably from one facility to anoth­ either setting. er. Inpatient mental health facilities, on the other hand, are able generally to provide treat­ Freestanding urgent care centers and emer­ ment for substance use disorders and co­occur­ gency departments are outpatient settings ring psychiatric conditions. Nonetheless, like that are uniquely designed to address the substance abuse treatment facilities, the range needs of patients in biomedical crisis. For of available services varies from one mental patients with substance use disorders, care in health facility to another. these settings is not complete until successful linkage is made to treatment that is focused General guidelines for considering patient specifically on the substance use disorder. To placement in either of these settings are pro­ accomplish this, a comprehensive assessment, vided below; however, it should be empha­ taking into account psychosocial as well as sized that a clear understanding of the specif­ ic services that a given setting provides is

16 Chapter 2 indispensable to identifying the least restric­ Clinically Managed Residential tive and most cost­effective treatment option Detoxification that may be available. Concern for safety is Residential settings vary greatly in the level of of primary importance, and the final decision care that they provide. Those with intensive regarding placement always rests with the medical supervision involving physicians, nurse treating physician. practitioners, physician assistants, and nurses can handle all but the most demanding compli­ Level of care cations of intoxication and withdrawal. On the other hand, some residential settings have min­ Medically Monitored Inpatient imally intensive medical oversight. Residential Detoxification detoxification in settings with limited medical Inpatient detoxification provides 24­hour oversight often is referred to as “social detoxifi­ supervision, observation, and support for cation.” (Though the “social detoxification” patients who are intoxicated or experiencing model is not limited to residential facilities.) withdrawal. Since this level of care is relatively Facilities with lower levels of care should have more restrictive and more costly than a resi­ clear procedures in place for implementing and dential treatment option, the treatment mission pursuing appropriate medical referral and in this setting should be clearly focused and linkage, especially in the case of emergencies. limited in scope. Primary emphasis should be For example, a patient who is in danger of placed on ensuring that the patient is medically seizures or delirium tremens needs to be stable (including the initiation and tapering of referred to the appropriate medical facility for medications used for the treatment of sub­ acute care of presenting symptoms, possibly stance use withdrawal); assessing for adequate medicated, and then returned to a social detox­ biopsychosocial stability, quickly intervening to ification setting for continuing monitoring and establish this adequately; and facilitating effec­ observation. The establishment of this kind of tive linkage to and engagement in other appro­ collaborative relationship between institutions priate inpatient and outpatient services. provides a good example of a cost­effective way to provide adequate care to patients. Inpatient settings provide medically managed intensive inpatient detoxification. At this level Residential detoxification programs provide of care, physicians are available 24 hours per 24­hour supervision, observation, and sup­ day by telephone. A physician should be port for patients who are intoxicated or expe­ available to assess the patient within 24 hours riencing withdrawal. They are characterized of admission (or sooner, if medically neces­ by an emphasis on peer and social support sary) and should be available to provide (ASAM 2001). Standards published by such onsite monitoring of care and further evalua­ groups as the Joint Commission on tion on a daily basis. An RN or other quali­ Accreditation of Healthcare Organizations fied nursing specialist should be present to (JCAHO) and the Commission on administer an initial assessment. A nurse will Accreditation of Rehabilitation Facilities be responsible for overseeing the monitoring (CARF) provide further information on quali­ of the patient’s progress and medication ty measures for residential detoxification. administration on an hourly basis, if needed. Appropriately licensed and credentialed staff should be available to administer medications in accordance with physician orders.

Settings, Levels of Care, and Patient Placement 17 Staffing have biomedical needs that exceed the capaci­ ty of the facility and to identify which pro­ Inpatient detoxification programs employ grams will likely have a need for transferring licensed, certified, or registered clinicians who such patients to more appropriate treatment provide a planned regimen of 24­hour, profes­ settings. sionally directed evaluation, care, and treat­ ment services for patients and their families. An interdisciplinary team of appropriately Intensive Outpatient and trained clinicians (such as physicians, RNs and Partial Hospitalization LPNs, counselors, social workers, and psychol­ ogists) should be available to assess and treat Programs the patient and to obtain and interpret infor­ An intensive outpatient program (IOP) or par­ mation regarding the patient’s needs. The num­ tial hospitalization program (PHP) is appropri­ ber and disciplines of team members should be ate for patients with mild to moderate with­ appropriate to the range and severity of the drawal symptoms. Thorough psychosocial patient’s problems (ASAM 2001). assessment and intervention should be avail­ able in addition to biomedical assessment and Residential detoxification programs are stabilization. Many of these programs have staffed by appropriately credentialed person­ close clinical and/or administrative ties to hos­ nel who are trained and competent to imple­ pital centers. When needed, triage to a higher ment physician­approved protocols for level of care should be easy to accomplish. patient observation and supervision. These Outpatient treatment should be delivered in persons also are responsible for determining conjunction with all components of detoxifica­ the appropriate level of care and facilitating tion. the patient’s transition to ongoing care. Medical evaluation and consultation should be available 24 hours a day, in accordance Level of care with treatment/transfer practice guidelines. This level of detoxification is an organized out­ All clinicians who assess and treat patients patient service that requires patients to be pre­ should be able to obtain and interpret infor­ sent onsite for several hours a day. It is thus mation regarding the needs of these persons similar to a physician’s office in that ambulato­ and should be knowledgeable about the ry detoxification with extended onsite monitor­ biomedical and psychosocial dimensions of ing is provided. Unlike the physician’s office, in alcohol and other drug dependence. Such the IOP and PHP it is standard practice to knowledge includes awareness of the signs have a multidisciplinary team available to pro­ and symptoms of alcohol and other drug vide or facilitate linkage to a range of medically intoxication and withdrawal, as well as the supervised evaluation, detoxification, and appropriate treatment and monitoring of referral services. those conditions and how to facilitate the individual’s entry into ongoing care. Staff Detoxification services also are provided in should ensure that patients are taking medi­ regularly scheduled sessions and delivered cations according to their physician’s orders under a defined set of policies and procedures and legal requirements (ASAM 2001). or medical protocols. These outpatient ser­ vices are designed to treat the patient’s level Some residential detoxification programs are of clinical severity, to achieve safe and com­ staffed to supervise self­administered medica­ fortable withdrawal from mood­altering drugs tions for the management of withdrawal. All (including alcohol), and to effectively facili­ such programs should rely on established clinical protocols to identify patients who

18 Chapter 2 tate the patient’s engagement in ongoing treat­ as an interdisciplinary team to assess and ment and recovery (ASAM 2001). care for the patient with a substance­related disorder, as well as patients with both a sub­ A partial hospitalization program may occupy stance use disorder and a co­occurring the same setting (i.e., physical space) as an biomedical, emotional, or behavioral condi­ acute care inpatient treatment program. tion. Successful linkage to treatment for the Although occupying the same space, the levels substance use disorder (in addition to of care provided by these two programs are biomedical stabilization) is central to the mis­ distinct yet complementary. Acute care inpa­ sion of an intensive tient programs provide detoxification services outpatient or partial to patients in danger of severe withdrawal hospitalization pro­ and who therefore need the highest level of gram (ASAM 2001). Successful linkage medically managed intensive care, including For more informa­ access to life support equipment and 24­hour tion, see the TIP to treatment for medical support. In contrast, partial hospital­ Substance Abuse: ization programs provide services to patients Clinical Issues in the substance use with mild to moderate symptoms of withdraw­ Intensive Outpatient al that are not likely to be severe or life­ Treatment [SAMHSA disorder (in threatening and that do not require 24­hour in development d]. medical support. The transition from an acute care inpatient program to either a par­ addition to tial hospitalization or intensive outpatient Acute Care program sometimes is referred to as a “step­ Inpatient biomedical down.” Typically, whether these programs share space and staff with an acute care inpa­ Settings stabilization) is tient program or are physically distinct from There are several a hospital structure, they have close clinical types of acute care central to the and/or administrative ties to hospital centers. inpatient settings. Collaborative working relationships are indis­ They include mission of an pensable in pursuing the goal of providing •Acute care general patients with the most appropriate level of hospitals intensive out­ care in the most cost­effective setting. •Acute care addic­ tion treatment units patient or partial Staffing in acute care gener­ al hospitals IOPs and PHPs should be staffed by physi­ hospitalization cians who are available daily as active mem­ •Acute care psychi­ bers of an interdisciplinary team of appropri­ atric hospitals program. ately trained professionals and who medically •Other appropriately manage the care of the patient. An RN or licensed chemical other licensed and credentialed nurse should dependency special­ be available for primary nursing care and ty hospitals observation during the treatment day. Addiction counselors or licensed or registered These settings share the ready availability of addiction clinicians should be available to acute care medical and nursing staff, life sup­ administer planned interventions according to port equipment, and ready access to the full the assessed needs of the patient. The multi­ resources of an acute care general hospital or disciplinary professionals (such as physicians, its psychiatric unit. This level of care provides nurses, counselors, social workers, psycholo­ medically managed intensive inpatient detoxifi­ gists, and acupuncturists) should be available cation (ASAM 2001).

Settings, Levels of Care, and Patient Placement 19 Level of care in the field, outpatient detoxification is becom­ ing the standard for treatment of symptoms of Acute inpatient care is an organized service withdrawal from substance dependence in that provides medically monitored inpatient many locales. Most alcohol treatment programs detoxification that is delivered by medical and have found that more than 90 percent of nursing professionals. Medically supervised patients with withdrawal symptoms can be evaluation and withdrawal management in a treated as outpatients (Abbott et al. 1995). permanent facility with inpatient beds is pro­ Careful screening of these patients is essential vided for patients whose withdrawal signs and to reserve for inpatient treatment those clients symptoms are sufficiently severe to require 24­ with possibly complicated withdrawal; for hour inpatient care. Services should be deliv­ example, patients with subacute medical or ered under a set of policies and procedures or psychiatric conditions (that in and of them­ clinical protocols designated and approved by a selves would not require hospitalization) and qualified physician (ASAM 2001). those in danger of seizures or delirium tremens should receive inpatient care. Inpatient addic­ Staffing tion treatment programs will vary in the level of acute medical or psychiatric care that can be Acute care inpatient detoxification programs provided. Figure 2­1 presents an overview of typically are staffed by physicians who are issues to consider in deciding between inpatient available 24 hours a day as active members of and outpatient detoxification. an interdisciplinary team of appropriately trained professionals and who medically man­ ASAM criteria are being adopted extensively age the care of the patient. In some States, on the basis of their “face validity,” though these duties may be performed by an RN or their outcome validity has yet to be clinically physician assistant. An RN or LPN, as usual, is proven. Early studies of more versus less available for primary nursing care and obser­ restrictive and intensive treatment settings on vation 24 hours a day. Facility­approved addic­ randomized samples generally have failed to tion counselors or licensed or registered addic­ show group differences, and studies continue tion clinicians should be available 8 hours a to show this pattern (Gastfriend et al. 2000). day to administer planned interventions Whether patients undergoing detoxification according to the assessed needs of the patient. will have better results as outpatients rather An interdisciplinary team of appropriately than as inpatients remains to be established trained clinicians (such as physicians, nurses, (Hayashida 1998). counselors, social workers, and psychologists) should be available to assess and treat the Another consideration is that ASAM place­ patient with a substance­related disorder, or a ment guidelines are not always the best guide patient with co­occurring substance use, to placing a patient in the proper setting at biomedical, psychological, or behavioral condi­ the proper level. For example, what is the tions (ASAM 2001). clinician to do with the patient who qualifies for outpatient treatment according to the ASAM guidelines but is homeless in sub­zero Other Concerns temperatures? No provision is made for such cases. The ASAM guidelines are to be regard­ Regarding Levels of ed as a “work in progress,” as their authors Care and Placement readily admit (ASAM 2001, p. 19). Nevertheless, they are an important set of In part because of the need to keep costs to a guidelines that are of great help to clinicians. minimum and in part as the result of research For administrators, the standards published

20 Chapter 2 Figure 2­1 Issues To Consider in Determining Whether Inpatient or Outpatient Detoxification Is Preferred

Considerations Indications

Ability to arrive at clinic on a daily basis Necessary if outpatient detoxification is to be car­ ried out

History of previous delirium tremens or withdraw­ Contraindication to outpatient detoxification: al seizures recurrence likely; specific situation may suggest that an attempt at outpatient detoxification is pos­ sible

No capacity for informed consent Protective environment (inpatient) indicated

Suicidal/homicidal/psychotic condition Protective environment (inpatient) indicated

Able/willing to follow treatment recommendations Protective environment (inpatient) indicated if unable to follow recommendations

Co­occurring medical conditions Unstable medical conditions such as diabetes, hypertension, or pregnancy: all relatively strong contraindications to outpatient detoxification

Supportive person to assist Not essential but advisable for outpatient detoxifi­ cation

Source: Consensus Panelist Sylvia Dennison, M.D.

by such groups as JCAHO and CARF offer episode should provide an opportunity for guidance for overall program operations. biomedical (including psychiatric) assess­ ment, referral for appropriate services, and It has become clear that detoxification linkage to treatment services. Chapter 3 pro­ involves much more than simply medically vides an overview of the psychosocial and withdrawing a patient from alcohol or other biomedical issues relevant to detoxification, drugs. Detoxification, whether done on an strategies to engage the patient, and an inpatient, residential, or outpatient basis, fre­ overview of providing adequate linkage to fol­ quently is the initial therapeutic encounter low up treatment and services. between patient and clinician. Irrespective of the substance involved, a detoxification

Settings, Levels of Care, and Patient Placement 21 3 An Overview of Psychosocial and Biomedical Issues In This During Detoxification Chapter…

Evaluating and Addressing Regardless of setting or level of care, the goals of detoxification are to provide safe and humane withdrawal from substances and to foster Psychosocial and the patient’s entry into long­term treatment and recovery. Biomedical Issues Detoxification presents a unique opportunity to intervene during a Strategies for period of crisis and move a client to make changes in the direction of Engaging and health and recovery. Hence, a primary goal of the detoxification staff should be to build the therapeutic alliance and motivate the patient to Retaining Patients enter treatment. This process should begin even as the patient is being in Detoxification medically stabilized (Onken et al. 1997).

Referrals and Psychological dependence, co­occurring psychiatric and medical con­ Linkages ditions, social supports, and environmental conditions critically influ­ ence the probability of successful and sustained abstinence from sub­ stances. Research indicates that addressing psychosocial issues during detoxification significantly increases the likelihood that the patient will experience a safe detoxification and go on to participate in sub­ stance abuse treatment. Staff members’ ability to respond to patients’ needs in a compassionate manner can make the difference between a return to substance abuse and the beginning of a new (and more posi­ tive) way of life.

This chapter addresses the psychosocial and biomedical issues that may affect detoxification and ensuing treatment. It highlights evaluation pro­ cedures for patients undergoing detoxification, discusses strategies for engaging and retaining patients in detoxification and preparing them for treatment, and presents an overview for providing linkages to other services.

23 Overarching Principles for Care During Detoxification Services

•Detoxification services do not offer a “cure” for substance use disorders. They often are a first step toward recovery and the “first door” through which patients pass to treatment. •Substance use disorders are treatable, and there is hope for recovery. •Substance use disorders are brain disorders and not evidence of moral weaknesses. •Patients are treated with respect and dignity at all times. •Patients are treated in a nonjudgmental and supportive manner. •Services planning is completed in partnership with the patient and his or her social support network, including such persons as family, significant others, or employers. •All health professionals involved in the care of the patient will maximize opportunities to promote rehabili­ tation and maintenance activities and to link her or him to appropriate substance abuse treatment imme­ diately after the detoxification phase. •Active involvement of the family and other support systems while respecting the patient’s rights to privacy and confidentiality is encouraged. •Patients are treated with due consideration for individual background, culture, preferences, sexual orien­ tation, disability status, vulnerabilities, and strengths.

Evaluating and General Guidelines for Addressing Addressing Immediate Psychosocial and Medical Concerns Because substance abuse affects all systems of Biomedical Issues the body and is associated with lack of self­ Patients entering detoxification are undergoing care, it is not unusual for detoxification to be profound personal and medical crisis. complicated by medical problems. Health pro­ Withdrawal itself can cause or exacerbate cur­ fessionals should screen for medical problems rent emotional, psychological, or mental prob­ that may put the client at risk for a medical cri­ lems. The detoxification staff needs to be sis or expose other clients or staff to contagious equipped to identify and address potential diseases. This section outlines important con­ problems. siderations for both nonmedical and medical staff. Chapter 5 provides a clinical overview of co­occurring medical conditions and is geared Considerations for Conducting primarily toward medical personnel. the Initial Evaluation An initial evaluation will help detoxification Co­occurring medical staff foresee any variables that might compli­ conditions cate a safe and effective withdrawal. Figure 3­1 lists the biomedical and psychosocial domains The initial consultation should include an eval­ that can affect the stabilization of the patient. uation of the expected signs, symptoms, and severity of the withdrawal. Detoxification is not The following sections include some general an exact science, but any significant deviation guidelines and important considerations to from the expected course of withdrawal should follow when providing detoxification services. be observed closely. Figure 3­2 (p. 26) provides

24 Chapter 3 Figure 3­1 Initial Biomedical and Psychosocial Evaluation Domains

Biomedical Domains

•General health history—What is the patient’s medical and surgical history? Are there any psychi­ atric or medical conditions? Are there known medication allergies? Is there a history of seizures? •Mental status—Is the patient oriented, alert, cooperative? Are thoughts coherent? Are there signs of psychosis or destructive thoughts? •General physical assessment with neurological exam—This will ascertain the patient’s general health and identify any medical or psychiatric disorders of immediate concern. •Temperature, pulse, blood pressure—These are important indicators and should be monitored throughout detoxification. •Patterns of substance abuse—When did the patient last use? What were the substances of abuse? How much of these substances was used and how frequently? •Urine toxicology screen for commonly abused substances. •Past substance abuse treatments or detoxification—This should include the course and number of previous withdrawals, as well as any complications that may have occurred.

Psychosocial Domains

•Demographic features—Gather information on gender, age, ethnicity, culture, language, and educa­ tional level. •Living conditions—Is the patient homeless or living in a shelter? What is the living situation? Are sig­ nificant others in the home (and, if so, can they safely supervise)? •Violence, suicide risk—Is the patient aggressive, depressed, or hopeless? Is there a history of vio­ lence? •Transportation—Does the patient have adequate means to get to appointments? Do other arrange­ ments need to be made? •Financial situation—Is the patient able to purchase medications and food? Does the patient have adequate employment and income? •Dependent children—Is the patient able to care for children, provide adequate child care, and ensure the safety of children? •Legal status—Is the patient a legal resident? Are there pending legal matters? Is treatment court ordered? •Physical, sensory, or cognitive disabilities—Does the client have disabilities that require considera­ tion?

a list of signs and symptoms of conditions that Seizures are of special concern. Practitioners require immediate medical attention. All staff should interview the patient and family about members who work with patients should be seizure disorders and seizure history. In addi­ aware of these and seek medical consultation tion, nonmedical staff should be aware of signs for the patients as necessary. of impending seizures such as tremors,

An Overview of Psychosocial and Biomedical Issues During Detoxification 25 Figure 3­2 Symptoms and Signs of Conditions That Require Immediate Medical Attention

•Change in mental status •Increasing anxiety and panic •Hallucinations •Seizures •Temperature greater than 100.4° F (these patients should be considered potentially infectious) •Significant increases and/or decreases in blood pressure and heart rate •Insomnia •Abdominal pain •Upper and lower gastrointestinal bleeding •Changes in responsiveness of pupils •Heightened deep tendon reflexes and ankle clonus, a reflex beating of the foot when pressed rostrally (i.e., toward the mouth of the patient), indicating profound central nervous system irritability and the potential for seizures

increased blood pressure, overactive reflexes, HIV, viral hepatitis, abscesses, and sepsis (the and high temperature and pulse. It is essential spreading of infection from its original site in that nonmedical staff be trained in protocols to the body). Intrapulmonary (within the lungs) prevent injury in the event of a seizure. administration can cause lung disorders Competence in carrying out these protocols (Dackis and Gold 1991). Nonmedical detoxifi­ should be evaluated by a physician or nurse cation staff also should be aware of the medi­ clinician. For more information on seizures, cations used in detoxification, medications for see chapter 4. common medical and psychiatric disorders, and signs of common medication reactions All staff working with patients should be and interactions. familiar with medical disorders that are asso­ ciated with various addictive substances or routes of administration. Alcoholism has mul­ Infectious disease tiple organ effects involving the liver, pan­ Standard precautions should be used with all creas, central nervous system, cardiovascular patients to protect the staff and patients against system, and endocrine system. Cocaine pro­ the transmission of infectious diseases, includ­ duces many of its medical complications ing HIV and hepatitis A, B, and C. All open through vasoconstriction (i.e., narrowing of wounds should be cultured and treated to pre­ the blood vessels), including myocardial vent the spread of infections. Providers should infarction (heart attack), stroke, renal dis­ use HIV/blood and respiratory infection pre­ ease, spontaneous abortion, and even bowel cautions until HIV and respiratory infectious infarction (death of tissue). Cocaine also can status are known. Patients with respiratory cause seizures and cardiac arrhythmia (irreg­ infections should be carefully evaluated. The ular heartbeat). A heroin overdose can lead panel suggests that tuberculin testing be per­ to a fatal respiratory depression. Intravenous formed or recent test results obtained on all drug use is particularly likely to increase the patients to screen for active tuberculosis. A risk of infectious complications, including chest x­ray is recommended if indicated by the

26 Chapter 3 patient’s history and physical assessments. important, when interacting with patients at Nonmedical detoxification staff should be risk for suicide, staff should avoid harsh con­ trained to watch for the signs of common infec­ frontation and judgment and instead focus on tious diseases passed through casual contact, the treatable nature of substance use disor­ including infestation with scabies and lice. ders and the rehabilitation options available. These interactions offer an opportunity to start a dialog with the patient regarding the General Guidelines for impact of substance use on mental illness and Addressing Immediate Mental vice versa. Health Needs The following section provides general guide­ Anger and aggression lines for treating patients who have immediate Alcohol, cocaine, amphetamine, and hallu­ mental health needs. For more detailed infor­ cinogen intoxication may be associated with mation on the treatment of patients with co­ increased risk of violence. Symptoms associ­ occurring psychiatric conditions see TIP 42, ated with this increased risk for violence Substance Abuse Treatment for Persons With include hallucinations, paranoia, anxiety, and Co­Occurring Disorders (Center for depression. As a precaution, all patients who Substance Abuse Treatment [CSAT] 2005c). are intoxicated should be considered poten­ tially violent (Miller et al. 1994). Programs Suicide should have in place well­developed plans to promote staff and patient safety, including Those who are users of multiple illicit sub­ protocols for response by local law enforce­ stance are more likely to experience psychiatric ment agencies or security contractors. Staff disorders, and the risk is highest among those working in detoxification programs should be who use both opiates and benzodiazepines trained in techniques to de­escalate anger and and/or alcohol (Marsden et al. 2000). aggression. In many cases, aggressive behav­ Depression is more common among those who iors can be defused through verbal and envi­ abuse a combination of these substances, and ronmental means (Reilly and Shopshire women are at higher risk than men. Among 2002). For the protection of the staff and the those patients who are positive for depression, patient, physical restraint should be used as a the risk of suicide is high. Marsden and col­ last resort and programs should be aware of leagues’ 2000 study of 1,075 clients entering local laws and regulations pertaining to physi­ treatment showed that 29 percent reported sui­ cal restraint. Figure 3­3 (p. 28) lists some use­ cidal ideation in the past 3 months. ful ways of managing patients who are angry During acute intoxication and withdrawal, it and aggressive. Readers may refer to the is important to provide an environment that standards published by such groups as the minimizes the opportunities for suicide Joint Commission on Accreditation of attempts. As a precaution, locations not Healthcare Organizations (JCAHO) and the clearly visible to staff should be free of items Commission on Accreditation of that might be used for suicide attempts. Rehabilitation Facilities (CARF) for further Frequent safety checks should be implement­ guidance. The Substance Abuse and Mental ed; the frequency of these checks should be Health Services Administration (SAMHSA) increased when signs of depression, shame, also has published guidelines on the use of guilt, helplessness, worthlessness, and hope­ seclusion and restraint, which call for the lessness are present. When feasible, patients reduction and possible elimination of their at risk for suicide should be placed in areas use (SAMHSA 2002). that are easily monitored by staff. Most

An Overview of Psychosocial and Biomedical Issues During Detoxification 27 Figure 3­3 Strategies for De­escalating Aggressive Behaviors

•Speak in a soft voice. •Isolate the individual from loud noises or distractions. •Provide reassurance and avoid confrontation, judgments, or angry tones. •Enlist the assistance of family members or others who have a relationship of trust. •Offer medication when appropriate. •Separate the individual from others who may encourage or support the aggressive behaviors. •Enlist additional staff members to serve as visible backup if the situation escalates. •Have a clearly developed plan to enlist the support of law enforcement or security staff if necessary. •Establish clear admission protocols in order to help screen for potentially aggressive/violent patients. •Determine one’s own level of comfort during interaction with the patient and respect personal limits. •Ensure that neither the clinician’s nor the patient’s exit from the examination room is blocked.

Co­occurring mental General Guidelines for disorders Addressing Nutritional With the patient’s consent, a review of the Concerns patient’s mental health history with the patient Malnutrition is a major concern for patients and family is useful in identifying co­occurring entering detoxification because the nutrient psychiatric conditions. Mental health profes­ deficiencies associated with substance abuse sionals caring for the client should be consult­ can interfere with or even prolong the detoxifi­ ed. If a pharmacy profile on the patient is cation process (Nazrul Islam et al. 2001). available, it should be copied for review (within Longstanding irregular eating habits and poor the confines of State and Federal confidentiali­ dietary intake only exacerbate the problem ty laws). (Pelican et al. 1994). The detoxification process Diagnosis of co­occurring substance­related itself is stressful to the body and may result in disorders and mental conditions is difficult increased nutrient requirements. Proper nutri­ during acute intoxication and withdrawal tion during recovery improves to a significant because it often is impossible to be precise until extent the adverse effects of the substance the clinical picture allows for the full assess­ abuse (Nazrul Islam et al. 2001). ment of both the effects of substance use and of the symptoms of mental disorders. As the indi­ Nutritional evaluation vidual moves from severe to moderate with­ drawal symptoms, attention to differential An evaluation of nutritional status should be a diagnosis of substance use disorders and other core component of detoxification. It should be psychiatric disorders becomes a priority (First noted, however, that for patients who abuse et al. 2002). The American Psychiatric alcohol, the administration of fluids to address Association (APA) and the American Society of dehydration should be the first step, with Addiction Medicine (ASAM) guidelines recom­ nutritional evaluation occurring after the mend a period of 2 to 4 weeks of abstinence patient is adequately hydrated. before attempting to diagnose a psychiatric dis­ order (APA 2000; ASAM 2001).

28 Chapter 3 The nutritional evaluation should consist of with a substance use disorder may lead to dras­ laboratory and anthropometric indices, a tic mood changes. When blood glucose levels detailed nutritional history, and nutrition drop below a certain threshold, these patients counseling (Simko et al. 1995). The interven­ usually feel depressed, anxious, or moody and tion begins in the initial acute phase of with­ may experience cravings for their drug of drawal and continues through detoxification choice. and subsequent substance abuse treatment. If the patient consents, family members or signifi­ cant others may be included in the nutritional Nutritional deficits evaluation and counseling. associated with specific Weight is an important consideration in deter­ substances mining the nutritional status of the person with As noted, the abuse of drugs can interfere with a substance use disorder. Substance abuse may nutrient utilization and storage. Detoxification result in a reduction in food intake and disrup­ personnel should be familiar with the nutrition­ tion in the patient’s metabolism that may in al deficits associated with specific substances. turn have caused an eating disorder, weight Opioids are known to decrease calcium absorp­ loss, and malnutrition. Conversely, weight gain tion and to increase cholesterol and body may be related to inactivity and an excessive potassium levels. Magnesium deficiency often is intake of highly refined carbohydrates (Zador seen in chronic alcohol dependence. Other et al. 1996). Patients should be asked whether nutrient deficiencies seen in alcohol abuse there have been any recent changes in their include protein, fat, zinc, calcium, iron, vita­ weight. While a patient may appear to be ade­ mins A and E, and the water­soluble vitamins quately nourished, a skinfold caliper (an pyridoxine, thiamine, folate, and vitamin B12 instrument that measures the thickness of a (Nazrul Islam et al. 2001). Alcohol also con­ fold of skin with its underlying layer of fat) can tains calories (7 kcal/gm) that when consumed determine body density (the relationship of the in excessive amounts may displace nutrient­ body’s mass to its volume), though the body dense foods. Cocaine is an appetite suppressant mass index may be a better indicator of nutri­ and may interfere with the absorption of calci­ tional status (Simko et al. 1995). um and vitamin D. Laboratory tests for pro­ tein, vitamins, and iron and the other elec­ Other questions to ask during the initial evalu­ trolytes are recommended to determine the ation concern appetite, eating patterns, food extent of liver function as well as supplementa­ preferences, snacking habits, food allergies, tion (Fontaine et al. 2001). Caution should be food intolerance, special diets, and foods to be exercised when using supplements because of avoided because of cultural or religious beliefs. their potential interactions with other drugs A food frequency questionnaire, food diary, or and treatments. 24­hour food recall may be of use. Many drug addictions are associated with Addressing nutritional abnormal glucose (sugar) metabolism. This abnormality means that the body is unable to deficits maintain a stable concentration of glucose in Detoxification should include efforts to address the blood. Abnormally high or low blood sugar nutritional deficits and to begin the patient on levels easily can be confused with the signs and a course of improved eating habits. It is crucial symptoms of alcohol intoxication or withdraw­ to switch the paradigm from ingesting sub­ al; consequently, a check of blood glucose level stances harmful to the body to taking in foods is particularly important in patients with a his­ that heal the body (Nebelkopf 1981, 1987, tory of blood sugar abnormalities. Hypogly­ 1988). The regularity of meal times, taste, and cemia (low levels of blood sugar) in the person presentation are important considerations.

An Overview of Psychosocial and Biomedical Issues During Detoxification 29 Attractively arranged, pleasant­tasting food milk products and eggs). If a vegan enters may inspire the patient to consume vital nutri­ detoxification with marginal or low nutrient ents and adequate calories. It is important that stores, his or her diet should be augmented during the detoxification process, the patient with legumes, meat analogs, textured vegetable avoid substituting one addiction for another. protein, nuts, and seeds. Many other medical Consuming excessive amounts of caffeine or conditions (e.g., ulcers, heart disease, food sugar can compromise the process and lead to allergies, etc.) may require special diets. At relapse. Patients should be offered only decaf­ intake, any special dietary considerations feinated beverages and healthful snacks instead should be noted. of refined carbohydrates such as sugar­based sweets like candy, cookies, or donuts. Fresh fruits, vegetables, and other whole foods can Considerations for contribute to the individual’s health and well­ Intoxication and Withdrawal ness. in Adolescents Gastrointestinal disturbances (i.e., nausea, Generally, detoxification is the same for adoles­ vomiting, and diarrhea) may accompany the cents as it is for adult clients. However, there first phase of detoxification. Such distur­ are a few important and unique considerations bances can worsen dehydration and may dis­ for adolescent patients. For one, adolescents turb blood chemistry balance, which in turn are more likely than adults to drink large can lead to mental status changes, neurologi­ quantities of alcohol in a short period of time, cal or heart problems, and other potentially making it is especially important that detoxifi­ dangerous medical conditions. Patients with cation providers be alert to escalating blood gastrointestinal disturbances may only be alcohol levels in these patients. Moreover, ado­ able to tolerate clear liquids. When solid lescents are more likely than adults to use foods are tolerated, balanced meals consisting drugs they cannot identify, to combine multiple of low­fat foods, with an increased intake of substances with alcohol, to ingest unidentified protein (meat, dairy products, legumes), com­ substances, and to be unwilling to disclose drug plex carbohydrates (whole grain bread and use (Westermeyer 1997). As a result, the con­ cereals), and dietary fiber are recommended sensus panel recommends routinely screening (Duyff 1996). Patients undergoing detoxifica­ adolescent patients for illicit drug intoxication. tion may also experience constipation. It also is important for staff to be trained in Increasing the fiber content of the diet will how to assess for the use of PCP, which can help to alleviate this discomfort. present with psychosis­like symptoms. Staff should ask the adolescent directly whether he has used PCP within the 12­hour period before Considerations for patients entering the clinic or treatment center. with special dietary Adolescents should be placed in a secure, requirements clean environment with observation and sup­ Patients with special dietary requirements need portive care. If alcohol, heroin, or other additional nutrition therapy. A person with drugs associated with vomiting are suspected, diabetes, for example, should follow the dietary protecting the individual’s airway and posi­ guidelines of the American Diabetes tioning the patient on his or her side to avoid Association, which emphasizes individualized aspiration (inhaling) of stomach contents are meal planning (American Diabetes Association critical. In severe cases of ingestion of respi­ 2004). A patient who is a vegetarian may have ratory depressants, respiratory support may additional nutritional deficiencies, especially if be needed. If the individual is severely com­ she or he is a vegan (i.e., a person who avoids bative or belligerent, physical restraint may eating all foods derived from animals, including be needed as a last resort when allowed and

30 Chapter 3 appropriate. In milder cases, observation in a Considerations for Victims of quiet, secure room with compassionate reas­ surance may be sufficient. Additionally, ado­ Domestic Violence lescents served in adult settings should be While both men and women are victims of separated from the adult population and domestic abuse, women’s substance use is asso­ observed closely to ensure that they are not ciated with increased risk of intimate partner victimized (i.e., verbally, physically, or sexu­ violence (Cunradi et al. 2002). Staff should ally) by adult clients. Finally, adolescents in know the signs of domestic violence and be pre­ detoxification settings should always be pared to follow proce­ screened carefully for suicide potential and dures to ensure the co­occurring psychiatric problems. safety of the patient. It sometimes is challenging to establish rap­ If a patient discloses port with adolescents, as their experience a history of domestic Ensuring that with adults may be marked by adverse conse­ violence, trained quences. Asking open­ended questions and staff can help the children have a using street terminology for drugs and other victim create a long­ term safety plan or expressions commonly used by teenagers can safe place to stay be helpful both in establishing rapport and in make a proper refer­ obtaining an accurate substance use history. ral. If a safety plan For more information on working with ado­ is made or phone while their lescents, see TIP 31, Screening and Assessing numbers for domes­ Adolescents for Substance Use Disorders tic violence help are mothers are in (CSAT 1999d), and TIP 32, Treatment of provided, related Adolescents With Substance Use Disorders information should detoxificaton is of (CSAT 1999f). be labeled carefully so as not to disclose vital importance. its purpose (e.g., list­ Considerations for Patients ed as women’s health Who Are Parents With resources) since the Dependent Children abuser may go through all personal For parents—especially women—entering belongings. All print­ detoxification programs, the safety of children ed information about domestic violence also often is a concern and one of the biggest barri­ should be disguised and none should be kept ers to retention. Even if women do not have by the patient when she leaves the safe facili­ custody of their children they often are the ty. If the victim needs to press charges or ones who continue to care for them. Some chil­ obtain a restraining order, this should be dren may show extreme need for their mother done from a safe setting (e.g., inpatient detox­ while separated from her, and their demands ification). If at all possible, the victim should could trigger unauthorized leave from detoxifi­ be escorted to a safety shelter. It may be cation. Thus, ensuring that children have a important that the abused person, whether safe place to stay while their mothers are in male or female, not be allowed to talk to the detoxification is of vital importance. Working abuser while in detoxification. Parents who with women and men to identify supportive are victims of domestic violence may need family or friends may identify temporary child­ help with parenting skills and securing coun­ care resources. A consult or referral to the seling and childcare. Therefore, it is impor­ treatment facility’s social services while the tant for detoxification providers to be famil­ patient is being detoxified is indicated when the iar with local childcare resources. For more care of children is uncertain.

An Overview of Psychosocial and Biomedical Issues During Detoxification 31 information see TIP 25, Substance Abuse of detoxification, their feelings about the Treatment and Domestic Violence (CSAT healthcare system generally, and their social 1997b). and community support structures vary according to their cultural backgrounds. In working with any specific population, the prac­ Considerations for Culturally titioner should avoid defining the patient in Diverse Patients terms of his culture, since over­ or underem­ In providing psychosocial supports for cultur­ phasizing the patient’s race or ethnicity can be ally diverse patients, cultural sensitivity is of detrimental (Clark et al. 1998). Figure 3­4 pro­ tremendous importance. Clients’ expectations

Figure 3­4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural Framework

•What language do you prefer we use? •Therapists and clients sometimes have different ideas about diseases, can you tell me more about your idea of why you are in detoxification now? •Do you require assistance for daily living activities (such as personal hygiene, shopping, paying bills, etc.)? •What do you call your present condition/situation (as it relates to substance use)? How does your family view your present condition/situation (as it relates to substance use)? •What is the role of alcohol or drugs in your family? •How does your community view your present condition/situation (as it relates to substance use)? Or what is the role of alcohol or drugs in your community? •How has your present condition/situation (as it relates to substance use) altered your status in the community? •What experiences have you had with the healthcare system? •Do you think your substance use is a problem for you? •What do you think caused your present condition/situation (as it relates to substance use)? •Why do you think it started? •What is going on in your body? •How has your present condition/situation (as it relates to substance use) altered your life? •How have you tried to solve the problem(s) associated with substance use in the past? Was it helpful? What worked/didn’t work? •Why are you coming now? •Are you on any herbal medications or special foods for this problem? •What concerns or fears do you have about your present condition/situation (as it relates to substance use)? •What concerns or fears do you have about this treatment?

Source: Adapted from Tang and Bigby 1996; Thurman et al. 1995.

32 Chapter 3 vides clinicians with some helpful questions to Educate the Patient on the guide their discussions. Withdrawal Process During intoxication and withdrawal, it is useful Considerations for Chronic to provide information on the typical with­ Relapsers drawal process based on the particular drug of abuse. Usually withdrawal includes symptoms A patient who recently relapsed after a period that are the opposite of the effects of the partic­ of extended abstinence may feel especially ular drug. This rebound effect can cause anxi­ hopeless and vulnerable (an abstinence viola­ ety and concern for patients. Providing infor­ tion effect). In this situation, clinicians can mation about the common withdrawal symp­ acknowledge progress that had been made toms of the specific drugs of abuse may reduce prior to relapse and reassure the patient that discomfort and the likelihood that the individu­ the internal gains from past recovery work al will leave detoxification services prematurely have not all been lost (despite the feeling at the (for a list of withdrawal symptoms, see chapter moment that they have), perhaps reframing the 4). Settings that routinely encounter individu­ severity of emotional pain as an indicator of als in withdrawal should have written materials how important recovery is to the patient. available on drug effects and withdrawal from specific drugs, and have staff who are well Strategies for versed in the signs and symptoms of withdraw­ al. An additional consideration is providing Engaging and such information to non–English­speaking Retaining Patients in patients and their families. Detoxification Interventions that assist the client in identify­ ing and managing urges to use also may be It is essential to keep patients who enter detoxi­ helpful in retaining the client in detoxification fication from “falling through the cracks” and ensuring initiation of rehabilitation. (Kertesz et al. 2003). Successful providers These interventions may include cognitive– acknowledge and show respect for the patient’s behavioral approaches that help the individu­ pain, needs, and joys, and validate the al identify thoughts or urges to use, the devel­ patient’s fears, ambivalence, expectation of opment of an individualized plan to resist recovery, and positive life changes. It is essen­ these urges, and use of medications such as tial that all clinicians who have contact with naltrexone to reduce craving (Anton 1999; patients in withdrawal continually offer hope Miller and Gold 1994). and the expectation of recovery. An atmo­ sphere that conveys comfort, relaxation, clean­ liness, availability of medical attention, and Use Support Systems security is beneficial to patients experiencing The use of client advocates to intervene with the discomforts of the withdrawal process. clients wishing to leave early often can be an Throughout the detoxification experience, effective strategy for promoting retention in detoxification staff should be unified in their detoxification. Visitors should be instructed message that detoxification is only the begin­ about the importance of supporting the individ­ ning of the substance abuse treatment process ual in both detoxification and substance abuse and that rehabilitation and maintenance activi­ treatment. If available, and if the patient is sta­ ties are critical to sustained recovery. ble, he or she can attend onsite 12­Step or other support group meetings while receiving detoxification services. These activities rein­ force the need for substance abuse treatment

An Overview of Psychosocial and Biomedical Issues During Detoxification 33 and maintenance activities and may provide a services goal of promoting initiation in reha­ critical recovery­oriented support system once bilitation and maintenance activities. Use of detoxification services are completed. these techniques in the detoxification setting increases the likelihood that patients will seek treatment by helping them understand the Maintain a Drug­Free adverse consequences of continued substance Environment use. It also establishes a supportive and non­ Maintaining a safe and drug­free environment judgmental relationship between the sub­ is essential to retaining clients in detoxifica­ stance abuse counselor and the patient—this tion. Providers should be alert to drug­seek­ therapeutic alliance is an important factor in ing behaviors, including bringing alcohol or the patient’s choice to seek treatment services other drugs into the facility. Visiting areas (Miller and Rollnick 2002). TIP 35, should be easy for the staff to monitor closely, Enhancing Motivation for Change in and staff may want to search visiting areas Substance Abuse Treatment (CSAT 1999c), and other public areas periodically to reduce covers specific interventions and techniques the opportunities for acquiring substances. It to increase motivation to change substance­ is important to note, however, that personnel related behaviors. TIP 35 also includes some should be respectful in their efforts to main­ basic principles common to motivational tain a drug­free environment. It is important interventions (CSAT 1999c, p. xvii): to explain to patients (prior to treatment) and •Focus on the patient’s strengths. visitors why substances are not allowed in the •Show respect for a patient’s decisions and facility. autonomy; respect should be maintained at all times, even when the patient is Consider Alternative intoxicated. Approaches •Avoid confrontation. •Individualize treatment. Alternative approaches such as acupuncture are safe, inexpensive, and increasingly popular •Do not use labels that depersonalize the in both detoxification and substance abuse patient, such as “addict” or “alcoholic.” treatment. Although the effectiveness of alter­ •Empathize with the patient, making an native treatments in detoxification and treat­ attempt to understand the patient’s perspec­ ment has not been validated in well­controlled tive and accept his or her feelings. clinical trials, if an alternative therapy brings •Accept treatment goals that involve small patients into detoxification and keeps them steps toward ultimate goals. there, it may have utility beyond whatever spe­ •Assist the patient in developing an awareness cific therapeutic value it may have of discrepancies between her or his goals or (Trachtenberg 2000). Other treatments that values and current behavior. reside outside the Western biomedical system, typically grouped together under the heading of •Listen reflectively to the patient’s immediate Complementary or Alternative Medicine, also concerns and ask open­ended questions. may be useful for retaining patients. Indeed, In addition, the detoxification team can lever­ given the great cultural diversity in the United age the relationship the patient has with sig­ States, other culturally appropriate practices nificant others. Using interventions such as should be considered. Community Reinforcement and Family Training (CRAFT) (Miller et al. 1999), the Enhancing Motivation detoxification team can help significant others in the patient’s life capitalize on moments Motivational enhancements are particularly when the patient is ready for change and well­suited to accomplishing the detoxification

34 Chapter 3 assist the patient in preparing for change in a transtheoretical model, also known as the nonthreatening, nonconfrontational manner. stages of change model (DiClemente and The consensus panel does not recommend Prochaska 1998). The interventions to that clinicians use direct confrontation in increase patient motivation for substance helping a person with a substance use disor­ abuse treatment described in TIP 35, der begin the process of detoxification and Enhancing Motivation for Change in subsequent substance abuse treatment. Substance Abuse Techniques that involve purposefully con­ Treatment (CSAT fronting patients about their substance use 1999c) are based on behavior, such as the Johnson Intervention, this model. where significant others are taught to con­ front the individuals using substances According to the Clinicians, (Liepman 1993), have been shown to be high­ model, a client is considered to be at ly effective when significant others implement groups, and them. However, subsequent studies of clini­ one of five stages of readiness to change cians, groups, and programs that rely on con­ programs that frontational techniques have yielded poor his substance­abus­ outcomes (Miller et al. 1995). Moreover, the ing behavior, each vast majority of significant others do not wish stage being progres­ rely on to use these techniques, and for that reason sively closer to sus­ these techniques are not recommended (Miller tained recovery. confrontational et al. 1999). Those stages are pre­ contemplation, con­ techniques have Care should be taken to ensure that any sig­ templation, prepara­ nificant other who is involved in motivating tion, action, and yielded poor the patient for therapy is appropriate for this maintenance. The task. Only significant others who have been model assumes that appropriately introduced to the intervention individuals may outcomes. by a clinician should participate. The pres­ move back and forth ence of a trained facilitator is recommended, between different either for coaching or for facilitating the stages over time. A intervention. It also is important to have the corollary to this recommended treatment option readily avail­ assumption is that an able so if the patient agrees, admission can be individual’s level of motivation is definitely swift and seamless. Those individuals selected not a permanent characteristic. Rather, moti­ to intervene should support the patient’s vation to change can be influenced by others, abstinence from substances of abuse. including detoxification treatment staff. Furthermore, if the patient places consider­ able value on her or his relationships with In general, the basic concept is to try to move these significant others, success is more likely patients to the next stage of change. The clini­ (Longabaugh et al. 1993). cian needs to identify any potential obstacles that might hinder the patient’s progress through the stages of change. The transtheo­ Tailoring Motivational retical model is illustrated in Figure 3­5 Intervention to Stage of (p. 36) and the details of each stage are described in the text below. Change Perhaps the most well­known and empirically validated model of “readiness to change” that has been applied to substance abuse is the

An Overview of Psychosocial and Biomedical Issues During Detoxification 35 Figure 3­5 The Transtheoretical Model (Stages of Change)

Source: DiClemente and Prochaska 1998.

In the precontemplation stage, the individual expressed by the patient toward substance­ is not considering any change in substance­ related behaviors. Such ambivalence may be using behavior in the foreseeable future. more likely to emerge during initial detoxifi­ Typically, a patient in this stage either is cation, before the patient has returned to a unaware that his substance use is a problem relative zone of comfort and greater denial. or is unwilling or too discouraged to make a For patients who are determined to remain in change. Often, a person in the precontempla­ the precontemplation stage, the main goal is tion stage has not experienced serious conse­ to get the patient to begin to consider chang­ quences from substance use. During the pre­ ing. To accomplish this, the clinician might contemplation stage, the clinician should be express concern, listen to the patient’s per­ attentive for and seize upon any ambivalence

36 Chapter 3 spective, and keep the door open for further cal that the clinician respond quickly to any communication regarding treatment options. requests for treatment to capitalize on this motivation before it wanes. One of the most In the contemplation stage, the individual has critically important roles the clinician can some awareness that substance use presents a play in this stage is to assist the patient in problem. In this stage, the patient may developing a plan of action or a behavioral express a desire or willingness to change, but contract, taking into account the individual has no definite plans to do so in the near needs of the patient. As part of this process future, which generally is considered to be the clinician should help the patient enlist the next 2 to 6 months. Whether it is explicit­ social support. Exploring the patient’s expec­ ly stated or not, it is thought that most indi­ tations regarding treatment and her role in it viduals in this stage are ambivalent about is important. Finally, because of the common­ changing. That is, side­by­side with any ly experienced difficulty in accessing treat­ desire to change is a desire to continue the ment, the clinician should discuss with the current behavior. For patients in the contem­ patient ways of maintaining motivation for plation stage, clinicians are advised to use change during a possible wait for entry into a “decisional balancing strategies” to help the treatment program, should the patient be patient move to the action stage (Carey et al. placed, for example, on a waiting list. 1999). In this approach, the clinician helps the patient to consider the positive and nega­ In the action stage, the patient is taking tive aspects of her substance abuse and has active steps to change substance use behav­ the patient weigh them against each other iors. This includes making modifications to with the expectation that the scale of balance his habits and environment, such as not tips in favor of adopting new behavior. spending time in places or with people associ­ Psychoeducation on the interaction of sub­ ated with drug taking behavior. These stance abuse with other problems, including changes may even continue to be made 3 to 6 health, legal, employment, parenting, and months after substance abuse has ceased. mental illness, can be part of this procedure. Helping the patient understand that ambiva­ In the maintenance stage, the patient is work­ lent feelings about changing substance use ing to maintain the changes initiated in the behaviors are normal and expected can be action phase. particularly useful at this stage. In the preparation stage, the patient is aware Fostering a Therapeutic that his substance use presents a significant Alliance problem and desires change. Moreover, the The therapeutic alliance refers to the quality of patient has made a conscious decision to com­ the relationship between a patient and his care mit himself to a behavior change. This stage is providers and is the “nonspecific factor” that defined as one in which the individual pre­ predicts successful therapy outcomes across a pares for the upcoming change in specific variety of different therapies (Horvath and ways, such as deciding whether a formal Luborsky 1993). A therapeutic alliance should treatment program is needed and, if so, which be developed in the context of an ability to one. This stage is characterized by goal set­ form an alliance to a group of helping individu­ ting and making commitments to stop using, als—such as a healthy support network or such as informing coworkers, friends, and therapeutic community. A clinically appropri­ family of treatment plans. For patients in the ate relationship between the clinician and preparation stage, clinicians should elicit the patient that is supportive, empathic, and non­ patient’s goals and strategies for change and judgmental is the hallmark of a strong thera­ be on the alert for signs that the patient is peutic alliance. ready to move into the action stage. It is criti­

An Overview of Psychosocial and Biomedical Issues During Detoxification 37 Readiness to change predicts a positive thera­ recovery is difficult. He also advises being peutic alliance (Connors et al. 2000). Strong consistent, dependable, trustworthy, and alliances, in turn, have been associated with available, even when the patient is not. The positive outcomes in patients who are depen­ clinician should remain calm and cool even if dent on alcohol (Connors et al. 1997), as well the patient becomes noticeably upset. as patients involved in methadone mainte­ Practitioners should be confident yet humble nance, on such measures as illicit drug use, and should set limits in a respectful manner employment status, and psychological func­ without engaging in a power struggle. See tioning. In addition, the practitioner’s exper­ Figure 3­6 for a list of characteristics most tise and competence instill confidence in the valuable to a clinician in strengthening the treatment and strengthen the therapeutic therapeutic alliance. alliance. Emphasis also should be given to the alliance with a social support network, which can be a powerful predictor of whether the Referrals and Linkages patient stays in treatment (Luborsky 2000). Once an individual passes through the most severe of the withdrawal symptoms and is safe Given the importance of the therapeutic and medically stable, the focus of the psychoso­ alliance and the fact that detoxification often cial interventions shifts toward actively prepar­ is the entry point for patients into substance abuse treatment services, work on establish­ ing her for substance abuse treatment and maintenance activities. These interventions ing a therapeutic alliance ideally will begin include (1) assessment of the patient’s charac­ upon admission. Many of the guidelines listed teristics, strengths, and vulnerabilities that will above for enhancing motivation apply to influence recommendations for substance establishing this rapport. Newman (1997) abuse treatment; (2) preparing the patient to makes some additional recommendations for participate in treatment; and (3) successfully developing the therapeutic alliance, such as linking the patient to treatment as well as other discussing the issue of confidentiality with needed services and resources. patients and acknowledging that the road to

Figure 3­6 Clinician’s Characteristics Most Important to the Therapeutic Alliance

•Is supportive, empathic, and nonjudgmental •Knows which patients can be engaged and which should be referred to another treatment provider •Can establish rapport with any client •Remembers to discuss confidentiality issues •Acknowledges challenges on the road to recovery •Is consistent, trustworthy, and reliable •Remains calm and cool even when a client is upset •Is confident but humble •Sets limits without engaging in a power struggle •Recognizes the client’s progress toward a goal •Encourages self­expression on the part of the client

38 Chapter 3 Ensuring that patients with substance use dis­ 5. Relapse, Continued Use, or Continued orders enter substance abuse treatment fol­ Problem Potential lowing detoxification often is difficult. Many 6. Recovery/Living Environment patients believe that once they have eliminat­ ed the substance or substances of abuse from Due to the limited time patients stay in detoxifi­ their bodies, they have achieved abstinence. cation settings, it is challenging for programs to Moreover, some insurance policies may not conduct a complete assessment of the rehabili­ cover treatment, or only offer partial cover­ tation needs of the individual. With this in age. The patient may have to go through cum­ mind, detoxification programs should focus on bersome channels to determine if treatment is those areas that are essential to make an covered, and if so, how much. appropriate linkage to substance abuse treat­ ment services. The assessment of the psychoso­ Preparation should focus on eliminating cial needs affecting the rehabilitation process administrative barriers to entering substance itself may have to be left to the professionals abuse treatment prior to discussing treatment providing substance abuse treatment. Other options with the patient. Discussions with the assessment considerations include patient should be consistent with the patient’s •Special needs, such as co­occurring psychi­ improving ability to process and assess infor­ atric and medical conditions that may com­ mation in such a way that the patient appears plicate treatment or limit access to available to be acting with his or her own interests in rehabilitation services mind. •Pregnancy, physical limitations, and cogni­ tive impairments that limit the settings suit­ Evaluation of the Patient’s able for the individual Rehabilitation Needs •Support system issues such as family sup­ To make appropriate recommendations for port, domestic violence, and isolation that ongoing treatment and recovery activities, influence recommendations about residen­ detoxification staff need to determine the tial versus outpatient settings individual characteristics of clients and their •The needs of dependent children environments that are likely to influence the •The need for gender­specific treatment (for level of care, setting, and specialized services more information see the forthcoming TIPs needed for recovery. ASAM’s Patient Substance Abuse Treatment: Addressing Placement Criteria, Second Edition, Revised the Specific Needs of Women [SAMHSA in (PPC­2R) (ASAM 2001) provides one widely development e] and Substance Abuse used model for determining the level of ser­ Treatment: Men’s Issues [SAMHSA in vices needed to address substance­related dis­ development g]). orders. The levels of treatment services range from community­based early intervention Figure 3­7 (p. 40) outlines the areas the consen­ groups to medically managed intensive inpa­ sus panel recommends for assessment to deter­ tient services. As noted in chapter 2, mine the most appropriate rehabilitation plan. providers need to make a placement decision based on six dimensions: Appendix C lists a variety of instruments use­ ful in characterizing the addiction and related 1. Acute Intoxication and/or Withdrawal disorders (for example, the Addiction Potential Severity Index [ASI]), measuring motivation­ 2. Biomedical Conditions and Complications al willingness to change (Stages of Change 3. Emotional, Behavioral, or Cognitive Readiness and Treatment Eagerness Scale Conditions or Complications [SOCRATES] and University of Rhode Island 4. Readiness to Change Change Assessment [URICA]), and evaluating co­occurring psychiatric conditions and social

An Overview of Psychosocial and Biomedical Issues During Detoxification 39 Figure 3­7 Recommended Areas for Assessment To Determine Appropriate Rehabilitation Plans

Domain Description

Medical Conditions and Infectious illnesses, chronic illnesses requiring intensive or specialized treat­ Complications ment, pregnancy, and chronic pain

Motivation/Readiness to Degree to which the client acknowledges that substance use behaviors are a Change problem and is willing to confront them honestly

Physical, Sensory, or Physical conditions that may require specially designed facilities or staffing Mobility Limitations

Relapse History and Historical relapse patterns, periods of abstinence, and predictors of absti­ Potential nence; client awareness of relapse triggers and craving

Substance Frequency, amount, and duration of use; chronicity of problems; indicators of Abuse/Dependence abuse or dependence

Developmental and Ability to participate in confrontational treatment settings, and benefit from Cognitive Issues cognitive interventions and group therapy

Family and Social Degree of support from family and significant others, substance­free friends, Support involvement in support groups

Co­Occurring Psychiatric Other psychiatric symptoms that are likely to complicate the treatment of the Disorders substance use disorder and require treatment themselves, concerns about safety in certain settings (note that assessment for co­occurring disorders should include a determination of any psychiatric medications that the patient may be taking for the condition)

Dependent Children Custody of dependent children or caring for noncustodial children and options for care of these children during rehabilitation

Trauma and Violence Current domestic violence that affects the safety of the living environment, co­ occurring posttraumatic stress disorder or trauma history that might compli­ cate rehabilitation

Treatment History Prior successful and unsuccessful rehabilitation experiences that might influ­ ence decision about type of setting indicated

Cultural Background Cultural identity, issues, and strengths that might influence the decision to seek culturally specific rehabilitation programs, culturally driven strengths or obstacles that might dictate level of care or setting

Strengths and Resources Unique strengths and resources of the client and his or her environment

Language Language or speech issues that make it difficult to communicate or require an interpreter familiar with substance abuse

40 Chapter 3 and family factors. Administering these highly intensive substance abuse counseling instruments requires varying degrees of and clients may participate in the upkeep of sophistication on the part of the clinician. All facilities. Peer support is critical to the instruments should be considered for their treatment delivered. As a general rule, cultural, linguistic, level of cognitive compre­ patients will stay at a residential treatment hension, and developmental appropriateness facility for 7 to 30 days. for each patient. For further information on •Therapeutic communities (TCs) usually patient placement see TIP 13, The Role and have 24­hour supervision by nonmedical Current Status of Patient Placement Criteria staff or clients who have sustained recov­ in the Treatment of Substance Use Disorders ery. They tend to provide highly intensive (CSAT 1995h). counseling services and rely on peer sup­ port and confrontation to shape behaviors Settings for Treatment of clients. The TC is based on concepts of self­help. Residence in a TC is longer than a Just as with settings for detoxification, set­ patient’s stay in a residential program— tings where substance abuse treatment is pro­ patients usually stay for a period of at least vided often are confused with the level of 30 days and often 6 months to a year. In intensity of the services. It is increasingly some special situations, such as a criminal clear that although level of intensity of ser­ justice setting, TC residence can last 2 vices and setting are both critical to success­ years or more. ful recovery, they are two separate dimen­ •Transitional residential programs and sions to be considered when linking clients to halfway houses ordinarily have 24­hour treatment. This process has been called “de­ supervision from nonmedical staff or clients linking” or “unbundling” and generally who have sustained recovery. Patients in involves determining the need for social ser­ these programs often are working and par­ vices independently from the clinical intensity ticipate in counseling and peer support dur­ (Gastfriend and McLellan 1997; McGee and ing the evening and weekend hours. Mee­Lee 1997). •Partial hospitalization and day treatment Treatment and maintenance activities are programs use a combination of medical and offered in a variety of settings. These include nonmedical staff to deliver a high intensity settings specifically designed to deliver sub­ of counseling services during daytime stance abuse treatment, such as freestanding hours. Patients return home in the substance abuse treatment centers, as well as evenings. settings operating for other purposes, includ­ •Intensive outpatient programs usually are ing mental health centers, jails and prisons, delivered by nonmedical staff in a clinic and community corrections facilities. location. Patients receive 6 to 9 hours of Descriptions of these settings appear below: counseling services each week in two or •Inpatient programs for treatment of sub­ three contacts. stance abuse generally are delivered in hos­ •Traditional outpatient services typically are pitals and freestanding clinics and provide delivered by counselors in a clinic or office 24­hour nursing care in addition to inten­ setting and provide fewer hours of services sive treatment for substance­related prob­ than the “intensive outpatient” programs. lems. •Recovery maintenance activities are not •Residential treatment programs normally treatment but are highly valuable for ongo­ provide 24­hour supervision by nonmedical ing sobriety maintenance. They include 12­ staff and the availability of medical staff Step and other support groups aimed at may be limited. These programs deliver maintaining the gains accomplished in treat­

An Overview of Psychosocial and Biomedical Issues During Detoxification 41 ment settings. Oxford House establishments behavioral health carve­out and lower cost­ and other “clean and sober” living environ­ sharing requirements are more likely to enter ments are among the resources that clini­ treatment than those who do not (Mark et al. cians should explore and perhaps incorpo­ 2003b). Kleinman and associates (2002) fol­ rate in maintenance activities. lowed 279 opioid­ and cocaine­dependent patients who had been in detoxification pro­ Provide Linkage to Treatment grams to determine how many had entered substance abuse treatment 30 days after leav­ and Maintenance Activities ing the detoxification program. They found Approximately half of those making an that those who were on parole, homeless, or appointment for treatment do not appear for who had been using drugs for less than 20 their first appointment and another 20 per­ years were more likely than others to have cent or more fail to appear for the second entered treatment. appointment (Gottheil et al. 1997; Parker 2002). As patients near completion of detoxi­ Research indicates that patients are more fication, whether they take the next step and likely to initiate and remain in rehabilitation enter treatment is dependent on a number of if they believe the services will help them with variables. Patients who are employed, are specific life problems (Fiorentine et al. 1999). motivated beyond the precontemplation stage, Figure 3­8 suggests strategies that detoxifica­ and have family and social support, as well as tion personnel can use with their patients to those with co­occurring psychiatric condi­ promote the initiation of treatment and main­ tions, are more likely to initiate treatment. tenance activities. Conversely, those who have severe drug dependence and those who are older are less Provide Access to Wraparound likely to follow through and enter treatment (Kirchner et al. 2000; Weisner et al. 2001). Services Women are more likely to initiate treatment Patients are more likely to engage in treatment after detoxification than men, and individuals if they believe the full array of their problems who have health insurance that features a

Figure 3­8 Strategies To Promote Initiation of Treatment and Maintenance Activities

•Perform assessment of urgency for treatment. •Reduce time between initial call and appointment. •Call to reschedule missed appointments. •Provide information about what to expect at the first session. •Provide information about confidentiality. •Offer tangible incentives. •Engage the support of family members. •Introduce the client to the counselor who will deliver rehabilitation services. •Offer services that address basic needs, such as housing, employment, and childcare.

Source: Carroll 1997; Fehr et al. 1991.

42 Chapter 3 will be addressed, including those needs typi­ these programs includes more than a phone cally addressed by wraparound services (e.g., number; detoxification staff should assist housing, vocational assistance, childcare, patients in scheduling initial appointments transportation) (Fiorentine et al. 1999). and arranging for transportation. Moreover, patients receiving needed wraparound services remain in substance Linkage to primary health and prenatal care abuse treatment longer and improve more than as well as to community resources is essential people who do not receive such services (Hser for individuals with substance use disorders. et al. 1999). Linkages can be an effective mechanism to assist the patient in accessing these services if As the individual passes through acute intoxi­ they are not available as a part of the detoxi­ cation and withdrawal, it is important to fication program. Formalized referral ensure that the basic needs of the patient are arrangements through contracts or memoran­ met after discharge. These needs include da of understanding can be useful to specify access to a safe, stable, and drug­free living organizational obligations (D’Aunno 1997). environment if possible; physical safety; food and clothing; ongoing health and prenatal care; financial assistance; and childcare. Minimize Access Barriers Ensuring access to these basic needs may be An integral part of the process of linking an problematic, and staff must be flexible and individual with rehabilitation and treatment creative in finding the means to meet the resources is to address access barriers. basic needs of the patient. Transportation, child care during treatment, the potential for relapse between detoxification Clearly, services planning should extend discharge and treatment admission, housing beyond the issues of substance dependence to needs, and safety issues such as possible other areas that may affect compliance with domestic violence should be addressed through rehabilitation. Detoxification providers an individualized plan prior to discharge. should be familiar with available resources for legal assistance, dental care, support The problem of a patient’s placement on a groups, interpreters, housing assistance, waiting list presents a special barrier to treat­ trauma treatment, recovery­sensitive parent­ ment. The solution lies in developing strate­ ing groups, spiritual and cultural support, gies to maintain motivation for treatment dur­ employment assistance, and other assistance ing the waiting period. programs for basic needs. Family and other support systems also can be helpful to the For pregnant women and patients with depen­ patient in accessing services and should take dent children, the threat of Child Protective part in the services planning as often as possi­ Services removing their children for abuse ble, always with the patient’s consent. and neglect due to drug use can be a barrier to entering a treatment program. To address the needs of homeless and indigent patients, detoxification providers should be Additionally, interacting with hostile or familiar with emergency shelters, cash assis­ unfriendly practitioners and encountering tance, and food programs in their communi­ resistance from family, partners, or friends ties and should have established referral rela­ can be barriers to treatment entry. tionships. Assessing women, teenagers, older Detoxification staff should be knowledgeable adults, and other vulnerable individuals for about State laws regarding drug use during victimization by another member of the pregnancy and definitions of child abuse and household also is important. Patients should neglect in order to be able to reassure and be linked with prenatal and primary health encourage women to enter treatment. care for domestic violence. Ideally, linkage to

An Overview of Psychosocial and Biomedical Issues During Detoxification 43 People who identify as having a physical or mental health and substance abuse treatment cognitive disability also face special barriers for those with co­occurring conditions (Drake to treatment. The reader is referred to TIP and Mueser 2000). 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998g) and TIP 36, Linkage to Ongoing Substance Abuse Treatment for Persons With Psychiatric Services Child Abuse and Neglect Issues (CSAT Although it is important to make referrals for 2000d), for more information on these topics. ongoing psychiatric attention, the presence of For racial/ethnic minorities, access barriers psychological symptoms should not prevent can be compounded by language, cultural, detoxification staff from referring patients to and financial factors. The ability of programs substance abuse treatment. Individuals with to develop culturally specific interventions, co­occurring psychiatric conditions appear to train staff and interpreters to respond to the be able to initiate and benefit from substance specific needs of these individuals, and be abuse treatment like individuals without psy­ aware of cultural differences in the manifesta­ chiatric conditions (Joe et al. 1995). tion of symptoms is critical to improving Since some psychiatric illnesses may affect access to care. Supervision of staff and train­ drug cravings in patients who are substance ing in cross­cultural issues is equally impor­ dependent, it is important to ensure that both tant to all programs serving diverse patient the psychiatric condition and the substance populations. The forthcoming TIP Improving use disorder are addressed in rehabilitation Cultural Competence in Substance Abuse (Anton 1999). Individuals who are taking psy­ Treatment (SAMHSA in development a) con­ chotropic medications should be counseled tains more information on this topic. about the importance of continuing on these medications. Whenever possible, discharge Use Case Management from the detoxification services should be coordinated with the patient’s mental health Case management presents an opportunity to provider in the community, and the patient tailor services to individual client needs and should have an appointment scheduled at the to minimize barriers to these services time of discharge from the detoxification (Gastfriend and McLellan 1997). Case man­ facility. Detoxification providers should agement is a set of services managed to assist request that the patient sign appropriate the client in accessing needed resources. It is releases of information to provide assessment a useful strategy to ensure that access to and other material to the mental health wraparound services such as employment, provider to promote continuity of care. This housing, health care, and basic needs are met should only occur when the patient is medi­ along with minimizing barriers to accessing cally stabilized and is in such a state of mind substance abuse treatment. As outlined in that he or she can make coherent decisions in TIP 27, Comprehensive Case Management for this regard (e.g., while intoxicated, patients Substance Abuse Treatment (CSAT 1998a), should not be permitted to sign releases). the common functions of case management are defined as assessment, planning, linkage, For individuals with serious co­occurring psy­ monitoring, and advocacy. Case managers chiatric conditions, integrated treatment for can facilitate the critical linkage between substance use disorders and mental illness is detoxification services and rehabilitation by recommended. Case management services as providing transportation to the rehabilitation described above may be especially important facility, arranging for childcare, or assisting for individuals with severe mental illness with housing needs. Additionally, case man­ impeding their ability to access services on agement is a widely used strategy to integrate their own. Increasingly, substance abuse and

44 Chapter 3 mental health providers are implementing approaches may not be effective. In some models using clinicians trained to deliver both cases, addressing other needs may provide an substance abuse and mental health treatment avenue to engage the individual with chronic concurrently (Drake and Mueser 2000). For substance dependence in treatment. Case more information, see TIP 42, Substance management approaches can be successful at Abuse Treatment for Persons With Co­ addressing the need for housing, health care, Occurring Disorders (CSAT 2005c). and basic needs even though the individual is not yet willing to confront the issue of drink­ ing or other drug use (Cox et al. 1998). TIP Linkage to Followup 27, Comprehensive Case Management for Medical Care Substance Abuse Treatment (CSAT 1998a), The patient’s consent should be sought to provides additional information about deliv­ involve her or his primary healthcare provider ery of case management services to homeless in the coordination of care. Patients with individuals with substance use disorders and chronic medical conditions and those in need of those with other complex problems. followup care should have an appointment Documentation of repetitive inappropriate made for followup medical care before leaving use of voluntary detoxification services may the detoxification setting (Luborsky et al. help pave the way for civil commitment to 1997). involuntary treatment where this is an option, and, where detoxification resources are limit­ ed, treatment systems need to be creative in Considerations for Individuals designing care plans for patients seeking fre­ With Chronic Substance quent detoxification without evidence of any therapeutic benefit. Dependence For individuals with substance abuse prob­ lems who detoxify regularly but have limited periods of abstinence, traditional treatment

An Overview of Psychosocial and Biomedical Issues During Detoxification 45 4 Physical In This Chapter… Detoxification Psychosocial and Services for Biomedical Screening and Assessment Withdrawal From Alcohol Intoxication and Specific Substances Withdrawal Opioids This chapter highlights specific treatment regimens for specific sub­ Benzodiazepines stances and provides guidance on the medical, nursing, and social ser­ and Other vices aspects of these treatments. It also includes considerations for spe­ Sedative­ cific populations. Although it is written principally for healthcare profes­ Hypnotics sionals, some professionals without medical training may find it of use. Stimulants To accommodate a broad audience, the chapter includes definitions for Inhalants/Solvents technical terms that may be unfamiliar to some readers—for example, “the patient was afebrile (without fever).” Nicotine Marijuana and Other Drugs Psychosocial and Biomedical Containing THC Screening and Assessment Anabolic Steroids This section covers more complex psychosocial and biomedical assess­ Club Drugs ments that may occur after initial contact as an individual undergoes Management of detoxification. Psychosocial and biomedical screening and services are Polydrug Abuse: closely associated: neither is likely to succeed without the other, as the An Integrated case study below illustrates. Approach Although the medical issues in this case indicate that the patient could Alternative successfully be managed as an outpatient, careful assessment of psy­ Approaches chosocial and biomedical aspects of the patient’s condition, including lack of transportation, the risk of violence, and his inability to carry out Considerations for routine medical instructions, strongly indicated that the patient remain Specific in a 24­hour supervised setting such as a residential detoxification or Populations treatment program. For an illustration of some of the fundamental

47 Case Study

A 44­year­old Caucasian male with a fifth­grade education presented to an emergency clinic in mild alcohol withdrawal with no alcohol for 9 hours. The patient was mildly tremulous with some nausea and insomnia; blood pressure was 142/94; pulse was 96. The patient was afebrile [i.e., without fever], and Clinical Institute Withdrawal Assessment for Alcohol (CIWA­Ar) (see below) score = 12, indicating mild withdrawal. A treatment plan was recommended that called for an outpatient 3­day fixed­dose taper of lorazepam (a benzodiazepine medication) plus multivitamins and oral thiamine. The patient was instructed to return daily for brief assessment by nursing personnel. The social worker assigned to this client pointed out that there was no reliable transportation to the clinic, there had been domestic violence on the parts of both spouses, and the patient’s ability to carry out routine medical instructions was questionable.

aspects of the patient’s health and psychosocial rehabilitation, and treatment are being status that should be covered in screening and promoted. assessment, see Figure 3­1, p. 25. Clinicians also can use the presentation of Figure 4­1 lists several instruments useful in information from biochemical markers to characterizing the intensity of specific with­ patients as an effective tool in motivational drawal states (see appendix C for more infor­ enhancement. For example, information mation on these instruments and how to obtain regarding liver transaminases (specific kinds them). of enzymes that perform chemical reactions within the liver) helps provide the patient with objective information on the level of Biochemical Markers and recent alcohol use and potential acute hepatic Their Use damage. This may help the patient move from This section focuses on biochemical laborato­ contemplating treatment to actually beginning ry tests that detect the presence or absence of treatment. For a more detailed discussion of alcohol or another substance of abuse, may biological markers in substance abuse, see be able to quantify the level of present use, or Javors and colleagues (1997). may be able to quantify cumulative use over the past few weeks. Tests in all of these areas Blood alcohol content are reasonably well developed and validated for alcohol. This is not the case for most Blood alcohol content (BAC) can be determined other substances of abuse. Biochemical mark­ by highly sensitive laboratory procedures that ers are not adequate screening or assessment generally are available in most emergency instruments alone, but rather are used to departments, hospitals, and clinical chemistry support a more comprehensive clinical assess­ laboratories. Alcohol elimination undergoes, ment. Common uses of these biochemical for the most part, zero­order kinetics (decreas­ markers are: ing a set amount per unit of time rather than a set percentage), so the concept of half­life is not 1. In the initial screening setting to support really accurate. However, first­order kinetics or refute other information that leads to and half­life do occur when BAC is low (i.e., proper diagnosis, assessment, and manage­ below 10mg percent), and the half­life is on the ment. order of about 15 minutes at that point. 2. For forensic purposes (e.g., evaluating a Though disappearance rates of 15mg percent driver after an automobile accident). per hour are probably average for moderate 3. In detecting occult (secretive or hidden) drinkers, higher values were seen in a group of use of alcohol and other substances in Swedish drivers apprehended for driving while therapeutic settings where abstinence, intoxicated (19mg/dL/hr) (Jones and Andersson

48 Chapter 4 Figure 4­1 Assessment Instruments for Dependence and Withdrawal From Alcohol and Specific Illicit Drugs

Drug of Dependence Instrument Reference Notes

Alcohol CIWA­Ar Sullivan et 10 items that take 2 to 5 minutes to com­ al. 1989 plete; scores 0–67, with 10 or greater as clinically significant; requires training to administer

Cocaine Cocaine Selective Kampman et 18 items that take 10 minutes to com­ Severity al. 1998 plete; high scores correlated with poor Assessment (CSSA) outcome

Opioids Subjective Opiate Handelsman 16­item questionnaire; using a scale of Withdrawal Scale et al. 1987 0–4, respondents rate to what extent (SOWS) they are currently experiencing each of 16 characteristics; higher scores indicate more severe withdrawal

Objective Opiate Handelsman Rater observes patient for about 10 min­ Withdrawal Scale et al. 1987 utes and indicates if any of 13 manifesta­ (OOWS) tions of withdrawal are present; scores can range from 0 to 13, with higher scores indicating more severe withdraw­ al; staff must be familiar with withdraw­ al signs

1996). The rate of metabolism of alcohol range (about 15 or higher), the clinician can increases with dependence—some alcoholics reasonably predict that the withdrawal will be can metabolize 20–25mg/dL/hr (Jones and relatively severe. As noted, however, the rate Andersson 1996), and Jones and Sternebring of metabolism of alcohol increases with (1992) have found that alcohol­dependent dependence. The diagnosis of alcohol intoxi­ patients may metabolize 22mg/dL/hr during cation is a clinical diagnosis and not based detoxification. simply on a BAC. A person with a BAC of 200mg percent could be in withdrawal, intoxi­ When knowledge of BAC is combined with cated (showing related signs and symptoms), clinical information, the healthcare provider or showing no signs and symptoms of either can make some predictions regarding the intoxication or withdrawal. A BAC above acuteness of withdrawal. For example, in an 100mg percent does not necessarily indicate individual whose blood alcohol level is 200mg clinical intoxication. Like all laboratory pro­ percent but who is already showing tremu­ cedures, the blood alcohol levels test has limi­ lousness (shakiness of the hands), brisk tations. Usually, patient permission must be reflexes, tachycardia (rapid heart rate), obtained prior to testing, the testing itself can diaphoresis (excessive sweating), and perhaps be expensive, and forensic testing may be a CIWA­Ar score in the moderate or high subject to specific legal procedures.

Physical Detoxification Services for Withdrawal From Specific Substances 49 Reading Blood Alcohol Concentrations

Blood alcohol concentrations are measured in milligrams (mg) of alcohol per deciliter (dL) of blood. This figure is converted to a percentage. One hundred mg/dL equals 100mg percent or 0.1 percent. Thus, a BAC of .1mg percent is equivalent to a concentration of 100mg of alcohol per deciliter of blood.

Source: Center for Substance Abuse Treatment (CSAT) 1995a.

Breath alcohol levels chromatography, urine alcohol concentration, and gas chromatography­mass spectrometry. Although the initial cost of small breath alcohol instruments may be relatively high, the recur­ Informed clinicians also should be aware of ring costs (of disposable mouthpieces and peri­ which drugs are screened for by the laboratory odic recalibration) are low. The technique is they use, the relative time window of detection less invasive than blood testing and health (a substance’s metabolic half­life, or approxi­ providers can follow breath alcohol levels mately how long a drug can be detected once repeatedly at low expense during the course of ingested), and whether cross­reactivity with assessment and detoxification. The detection of other interfering substances may alter out­ rapidly rising, high levels of alcohol over a comes. Many laboratories perform more specif­ short period of time may indicate alcohol poi­ ic confirmation testing on positive screening soning overdose. Breath alcohol levels provide tests, which can largely eliminate false­posi­ useful guidance in determining whether to hos­ tives. It is important to clarify which type of pitalize these patients. test result is being reported. Interfering and cross­reactive substances leading to false­posi­ Limitations on breath alcohol determinations tive tests frequently are discussed in bulletins are that patient cooperation is required and and publications periodically published by the that some patients with lung diseases are not National Institute on Drug Abuse (NIDA) and able to muster a sufficient tidal volume (force­ the Centers for Disease Control and Prevention ful breath) to give an accurate reading to the (CDC). Usually, the senior laboratory supervi­ machine. On occasion, patients whose breath sor has up­to­date information in this area and alcohol levels indicate recent alcohol use will often can be consulted via e­mail or telephone assert that they have recently gargled with in an emergency. Limitations of urine drug mouthwash that contained alcohol. Having the screening include consent and privacy issues, patient rinse his mouth with water several expense, the inability to screen for some drugs times and then making another breath alcohol of abuse, and the inability of urine drug determination in 15 to 30 minutes usually will screens to provide information on the current resolve whether the patient’s assertion is valid. level of intoxication.

Urine testing should at a minimum test for the Urine drug screens presence of Urine drug screens vary widely in their meth­ •Benzodiazepines ods of detection, sensitivity and specificity, expense, and availability. The healthcare •Barbiturates provider assessing patients for detoxification •Cocaine should be familiar with the type of assay (test •Amphetamines measurement) being used; some examples are •Opioids enzyme multiple assay techniques, thin layer chromatography, high performance liquid •PCP

50 Chapter 4 It also should be noted that current testing for insults to the liver from toxins (such as chemi­ opioids primarily refers to “organic” drugs that cals, alcohol, prescribed or over­the­counter are derived from opium (i.e., heroin, codeine, medications). In any form of hepatitis, GGT and morphine). Synthetic opioids like may be elevated, indicating damage to liver hydrocodone and methadone are not detected cells. Therefore, GGT elevation does not by the usual tests; this is true of oxycodone as automatically mean liver damage from alcohol well. If the use of these drugs is suspected, spe­ use, although this is certainly one of the most cial tests can be ordered. Most important, each common reasons for elevated GGT levels in program should tailor its urine screening tests patients hospitalized in North America. The to reflect the substance use patterns prevalent use of GGT levels along with carbohydrate­ in the community. deficient transferrin (CDT) levels is a rela­ tively sensitive and specific indicator of alco­ hol use. The CDT test is discussed below. Gamma­glutamyltransferase (GGT) Carbohydrate­deficient GGT has been measured in serum (the portion of the blood that has neither red nor white transferrin blood cells) for many years as a marker for CDT has been developed over the past 20 years liver damage. More recently, GGT has been as a marker of cumulative alcohol consumption advocated as a measure of cumulative alcohol but is just now becoming widely available as a use (Dackis 2001). Sensitivity of the test is in clinical tool. Sensitivities appear to be in the 70 the 60 to 70 percent range and specificity (its to 80 percent range, and specificities of greater ability not to misidentify or confuse alcohol use than 90 percent have been found. Sensitivity with other disorders) is in the 40 to 50 percent and specificity are somewhat lower among range. In general, both sensitivity and specifici­ females than males. Most therapeutic drugs or ty are lower in females than males. GGT does drugs of abuse do not appear to affect CDT correlate with alcohol intake but often requires levels. When CDT and GGT levels are com­ heavy drinking (more than six drinks per day) bined, sensitivity and specificity rise to more to elevate it, and only about half of individuals than 90 percent (Anton 2001). CDT testing is will show elevations. The half­life of elevated limited by its relatively high cost, lack of clini­ serum GGT after the onset of abstinence is said cal availability in some laboratories, and false­ to be 2 to 3 weeks with alcoholic liver disease. positive results in abstaining individuals who Chlorpromazine, phenobarbital, and have endstage liver disease from causes other acetaminophen can all raise serum GGT levels. than alcohol use (DiMartini et al. 2001). GGT is limited by its expense and its relative­ ly low specificity, which sometimes leads to Mean corpuscular false­positive evaluations. GGT is helpful as a volume (MCV) motivational enhancer in patients with a high degree of denial during detoxification. Erythrocyte (red blood cell) size is measured in Evidence of liver damage, as measured by the a Coulter counter and often is part of a com­ GGT, provides patients with objective feed­ plete blood count; therefore, it is widely avail­ back concerning the consequences of their able to clinicians. Sensitivity and specificity are alcohol use and thus plays a very important in the 30 to 50 percent range. Hence, caution role in enhancing motivation. should be exercised when interpreting an ele­ vated MCV in relation to drinking behavior. Hepatitis is a general term that refers to This lab test should be considered complemen­ inflammation of the liver with damage to liver tary to other biological markers that are more cells (hepatocytes). Hepatitis may be due to specific and sensitive, such as GGT or CDT. viruses (such as in hepatitis A, B, C) or Advanced age, nutritional status, cigarette

Physical Detoxification Services for Withdrawal From Specific Substances 51 smoking, and co­occurring disease states with­ in monitoring vital functions, protecting respi­ out the presence of alcoholism may make test ration, and observing aspiration, hypo­ results abnormal. glycemia, and thiamin deficiency. Screening for other drugs that may contribute to the coma, as well as other sources of coma induction, Alcohol Intoxication should be done. Agitation is best managed with and Withdrawal interpersonal and nursing approaches rather than additional medications, which may only complicate and delay the elimination of the Intoxication Signs and alcohol. Symptoms The clinical presentation of intoxication from Withdrawal Signs and alcohol varies widely depending in part on Symptoms blood alcohol level and level of previously developed tolerance. At alcohol concentrations Hippocrates, writing around 400 B.C., gave us between 20mg percent and 80mg percent, loss our first written clinical picture of alcohol with­ of muscular coordination, changes in mood, drawal when he wrote that if the patient is “in personality alteration, and [increases in motor the prime of life and if from drinking he has activity] begin. At levels from 80 to 200mg per­ trembling hands,” it may well be the case that cent, more progressive neurologic impairment the patient is showing withdrawal signs and occurs with ataxia (inability to coordinate mus­ symptoms. To this day, alcohol withdrawal cular activity) and slurring of speech being remains underrecognized and undertreated. prominent. A variety of cognitive functions also The signs and symptoms of acute alcohol with­ are impaired. At blood alcohol levels between drawal generally start 6 to 24 hours after the 200 and 300mg percent nausea and vomiting patient takes his last drink. Alcohol withdrawal may occur, which along with sedation may may begin when the patient still has significant place patients at grave risk for aspiration of blood alcohol concentrations. The signs and stomach contents. At levels greater than 300mg symptoms may include the following: percent, hypothermia (low body temperature) •Restlessness, irritability, anxiety, agitation with impairment of level of consciousness is •Anorexia (lack of appetite), nausea, vomiting likely except in all but the most tolerant indi­ viduals. Coma begins to be seen at levels of 400 •Tremor (shakiness), elevated heart rate, to 600mg percent, but this is variable, again increased blood pressure depending on tolerance. Although exceptions •Insomnia, intense dreaming, nightmares are found, BACs between 600 and 800mg per­ •Poor concentration, impaired memory and cent are fatal. At this point, respiratory, car­ judgment diovascular, and body temperature controls •Increased sensitivity to sound, light, and tac­ fail. See Figure 4­2 for more symptoms of alco­ tile sensations hol intoxication. •Hallucinations (auditory, visual, or tactile) Since the elimination rate of alcohol from the •Delusions, usually of paranoid or persecutory body generally is 10 to 30mg percent per hour, varieties the goals for the treatment of alcohol intoxica­ tion are to preserve respiration and cardiovas­ •Grand mal seizures (grand mal seizures rep­ cular function until alcohol levels fall into a resent a severe, generalized, abnormal elec­ safe range. Patients who are severely intoxicat­ trical discharge of the major portions of the ed and comatose as the result of alcohol use brain, resulting in loss of consciousness, brief should be managed in the same manner as all cessation of breathing, and muscle rigidity comatose patients, with particular care taken followed by muscle jerking; a brief period of

52 Chapter 4 Figure 4­2 Symptoms of Alcohol Intoxication*

Blood Alcohol Level Clinical Picture

20–100mg percent •Mood and behavioral changes •Reduced coordination •Impairment of ability to drive a car or operate machinery

101–200mg percent •Reduced coordination of most activities •Speech impairment •Trouble walking •General impairment of thinking and judgment

201–300mg percent •Marked impairment of thinking, memory, and coordination •Marked reduction in level of alertness •Memory blackouts •Nausea and vomiting

301–400mg percent •Worsening of above symptoms with reduction of body temperature and blood pressure •Excessive sleepiness •Amnesia

401–800mg percent •Difficulty waking the patient (coma) •Serious decreases in pulse, temperature, blood pressure, and rate of breath­ ing •Urinary and bowel incontinence •Death

*Varies greatly with level of tolerance (chronic users of alcohol may show less effect at any given blood alcohol level).

Source: Consensus Panelist Robert Malcolm, M.D.

sleep, awakening later with some mild to even the heading Management of Delirium and severe confusion, generally occurs) Seizures (p. 63). •Hyperthermia (high fever) Mild alcohol withdrawal generally consists of •Delirium with disorientation with regard to anxiety, irritability, difficulty sleeping, and time, place, person, and situation; fluctua­ decreased appetite. Severe alcohol withdrawal tion in level of consciousness usually is characterized by obvious trembling of the hands and arms, sweating, elevation of For a discussion of seizures and delirium, pulse (above 100) and blood pressure (greater including delirium tremens, see below under

Physical Detoxification Services for Withdrawal From Specific Substances 53 than 140/90), nausea (sometimes with vomit­ the number of previous withdrawals (treated ing), and hypersensitivity to noises (which seem or untreated) experienced, with three or four louder than usual) and light (which appears being a particularly significant number for brighter than usual). Brief periods of hearing the appearance of severe withdrawal reac­ and seeing things that are not present (auditory tions unless adequate medical care is provid­ and visual hallucinations) also may occur. A ed. This assumption that this phenomenon fever greater than 101° F also may be seen, will manifest itself, which has been referred though care should be taken to determine to as the “kindling hypothesis,” is well­estab­ whether the fever is the result of an infection. lished in the research literature (Booth and Seizures and true delirium tremens, as dis­ Blow 1993; Wojnar et al. 1999). cussed elsewhere, represent the most extreme Uncomplicated or mild to moderate with­ forms of severe alcohol withdrawal. Moderate drawal is characterized by restlessness, irri­ alcohol withdrawal is defined more vaguely, tability, anorexia (lack of appetite), tremor but represents some features of both mild and (shakiness), insomnia, impaired cognitive severe withdrawal. functions, and mild perceptual changes. Complicated or severe medical withdrawal The course of these symptoms is extremely has one or more elements of delirium, halluci­ variable. An individual may progress partial­ nations, delusions, seizures, and disturbances ly through some of the symptoms noted above of body temperature, pulse, and blood pres­ and then have a slow improvement. Other sure. individuals may have mild to moderate symp­ toms with almost abrupt resolution. Yet another group may present with a grand mal Medical Complications of seizure or with hallucinations. Some people Alcohol Withdrawal: Possible with alcohol dependence, regardless of their pattern of drinking or the extent of drinking, Fatal Outcomes appear to develop minor symptoms or show Seizures; delirium tremens (severe delirium no symptoms of withdrawal. Infrequent binge with trembling); and dysregulation of body drinkers seem less likely to have withdrawal temperature, pulse, and blood pressure are symptoms than individuals who are heavy outcomes in severe alcohol dependence that can regular users of alcohol who then abruptly lead to fatal consequences. Other medical com­ cease their alcohol use, but this is not well plications of alcohol withdrawal include infec­ substantiated. As previously discussed in the tions, hypoglycemia, gastrointestinal (GI) assessment section, the use of a standardized bleeding, undetected trauma, hepatic failure, clinical rating instrument for withdrawal such cardiomyopathy (dilation of the heart with as the CIWA­Ar is valuable because it guides ineffective pumping), pancreatitis (inflamma­ the clinician through multiple domains of tion of the pancreas), and encephalopathy alcohol withdrawal and allows for semi­quan­ (generalized impaired brain functioning). The titative assessment of nausea, tremor, auto­ suspicion of impending complications or their nomic hyperactivity, anxiety, agitation, per­ appearance will require hospitalization of the ceptual disturbances, headache, and disorien­ client and possible intensive care unit level of tation. Age, general health, nutritional fac­ management. Consultation with internists spe­ tors, and possible co­occurring medical or cializing in infectious disease, pulmonary care, psychiatric conditions all appear to play a and hepatology; surgeons; neurologists; psychi­ role in increasing the severity of the symp­ atrists; anesthesiologists; and other specialists toms of alcohol withdrawal. also may be warranted, depending on the nature of the complications. The most useful clinical factors to assess the likelihood and the extent of a current with­ drawal is the patient’s last withdrawal and

54 Chapter 4 Management of Withdrawal withdrawal. The consensus panel has found that in actual practice, social detoxification Without Medication programs vary greatly in their approach and The management of an individual in alcohol scope. Some programs offer some medical and withdrawal without medication is a difficult nursing onsite supervision, while others pro­ matter because the indications for this have not vide access to medical been established firmly through scientific stud­ and nursing evalua­ ies or any evidence­based methods. tion through clinics, For alcohol, Furthermore, the course of alcohol withdrawal urgent care pro­ is unpredictable and currently available tech­ grams, and emergen­ sedative­hypnotic, niques of screening and assessment do not cy departments. allow us to predict with confidence who will or Some social detoxifi­ and opioid with­ will not experience life­threatening complica­ cation programs only tions. Severe alcohol withdrawal may be associ­ offer basic room and ated with seizures due to relative impairment of board for a “cold drawal syndromes, gamma­aminobutyric acid (GABA) and relative turkey” detoxifica­ over­activity of N­methyl­D­aspartate systems tion, while other pro­ hospitalization (or (a subtype of the excitatory glutamate receptor grams offer super­ system) (Moak and Anton 1996). The failure to vised use of medica­ some form of treat incipient convulsions is a deviation from tions. Sometimes the established general standard of care. medications are pre­ 24­hour medical scribed at the onset of Positive aspects of the nonmedication withdrawal by health­ approach are that it is highly cost­effective care) is generally the care professionals in and provides inexpensive access to detoxifica­ an outpatient setting, tion for individuals seeking aid. Observation preferred setting for while the staff in the is generally better than no treatment, but social detoxification people in moderate to severe withdrawal will detoxification, based program supervises be best served at a higher level of care. Young the administration of individuals in good health, with no history of these medications. on principles of previous withdrawal reactions, may be well Whatever the partic­ served by management of withdrawal without ular situation might safety and humani­ medication. However, personnel supervising be, there should in this setting should possess assessment abili­ always be medical tarian concerns. ties and be able to summon help through the surveillance, includ­ emergency medical system. Methods of with­ ing monitoring of drawal management without medication vital signs, as part of every social detoxification include frequent interpersonal support, pro­ program. vision of adequate fluids and food, attention to hygiene, adequate sleep, and the mainte­ The consensus panel agrees that for alcohol, nance of a no­alcohol/no­drug environment. sedative­hypnotic, and opioid withdrawal syn­ dromes, hospitalization (or some form of 24­ hour medical care) is generally the preferred Social Detoxification setting for detoxification, based on principles of Social detoxification programs are defined as safety and humanitarian concerns. When hos­ short­term, nonmedical treatment services for pitalization cannot be provided, a setting that individuals with substance use disorders. A provides a high level of nursing and medical social detoxification program offers room, backup 24 hours a day, 7 days a week is desir­ board, and interpersonal support to intoxicat­ able. The panel readily acknowledges that ed individuals and individuals in substance use social detoxification programs are, for some

Physical Detoxification Services for Withdrawal From Specific Substances 55 communities, the only available resources for The consensus panel acknowledges that, for a uninsured, homeless individuals. Social detoxi­ substantial group of individuals, substance fication is preferable to detoxification in unsu­ use withdrawal syndromes do not lead to fatal pervised settings such as the street, shelters, or outcomes or even significant morbidity. jails. The panel also notes that in some large Determining which individuals will have urban areas, social detoxification programs benign outcomes often is difficult, and in fact have longstanding, excellent reputations of pro­ this determination prior to social detoxifica­ viding high­quality supervision and nurturance tion referral frequently is not made. Some for their clients. incorrect beliefs have sprung up in the con­ Social detoxification text of social detoxification: Individuals programs are orga­ undergoing opioid withdrawal often are con­ For a substantial nized and funded by sidered to require hospitalization to alleviate a variety of sources, suffering, while individuals undergoing alco­ group of including faith­based hol withdrawal sometimes are, for a variety of organizations, com­ reasons, denied hospital­level treatment for individuals, munity charities, detoxification, even though alcohol withdraw­ and municipal and al produces suffering and may have fatal con­ substance use other local govern­ sequences. ments. The consensus panel agreed on several guide­ withdrawal The genesis of social lines for social detoxification programs: detoxification is syndromes do not •Such programs should follow local govern­ complex. Often, mental regulations regarding their licensing these programs grew and inspection. lead to fatal out of community •It is highly desirable that individuals entering needs when no other social detoxification be assessed by primary outcomes or even alternatives were care practitioners (physicians, physician available. Early assistants, nurse practitioners) with some reports (Whitfield et significant experience in substance abuse treatment. al. 1978) indicated •Such an assessment should determine morbidity. that many individu­ als in alcohol with­ whether the patient currently is intoxicated drawal could be and the degree of intoxication, the type of managed successful­ withdrawal syndrome, severity of the with­ ly without medications in a social detoxification drawal, information regarding past with­ setting. Subsequent reviews that have revisited drawals, and the presence of co­occurring the topic (Lapham et al. 1996) have reached psychiatric, medical, and surgical conditions similar conclusions. Critical analysis of these that might well require specialized care (see reports by the consensus panel indicates that chapter 3, Figure 3­1, p. 25). some of the scientific issues were oversimplified •Particular attention should be paid to those and misleading. A number of these studies, in individuals who have undergone multiple fact, excluded many seriously ill clients from withdrawals in the past and for whom each their surveys prior to referral to social detoxifi­ withdrawal appears to be worse than previ­ cation. Some of these surveys had a very high ous ones—this is the so­called “kindling staff­to­client ratio during social detoxification, effect” (Ballenger and Post 1978; Booth and thus providing an unusually high level of psy­ Blow 1993; Malcolm et al. 2000; Shaw et al. chological support. This level of staffing is not 1998; Wojnar et al. 1999; Worner 1996). frequently found today in social detoxification Subjects with a history of severe with­ programs. drawals, multiple withdrawals, delirium

56 Chapter 4 tremens, or seizures are not good candidates sion, been abstinent for a few hours and have for social detoxification programs. not developed signs or symptoms of withdraw­ •All social detoxification programs should al. A decision regarding medication for this have an alcohol­ and drug­free environment, group should be in part based on age, num­ have personnel who are familiar with the fea­ ber of years of alcohol dependence, and the tures of substance use withdrawal syn­ number of previously treated or untreated dromes, have training in basic life support, severe withdrawals (three or four appears to and have access to an emergency medical sys­ be a significant threshold in predicting future tem that can provide transportation to emer­ serious withdrawal) (Shaw 1995). If there is gency departments and other sites of clinical an opportunity to observe the patient in the care. emergency department of the clinic or similar setting over the next 6 to 8 hours, then it is possible to delay a decision regarding treat­ Management of Withdrawal ment and periodically reevaluate a client of With Medications this category. If this is not possible, then the Over the last 15 years several reviews and posi­ return of the patient to a setting in which tion papers (Fuller and Gordis 1994; Lejoyeux there is some supervision by family, signifi­ et al. 1998; Mayo­Smith 1997; Nutt et al. 1989; cant others, or in a social detoxification pro­ Shaw 1995) have asserted that only a minority gram is desirable. of patients with alcoholism will in fact go into The decision as to whether to give the patient significant alcohol withdrawal requiring medi­ a single medication dose prior to discharge cations. Identifying that significant minority and perhaps provide one or two additional sometimes is problematic, but there are signs medication doses to be administered in the and symptoms of impending problems that can referral setting rests on adequacy of supervi­ alert the caretaker to seek medical attention. sion, the probability of whether the patient Deciding on whether to use medical manage­ will drink while undergoing treatment, and ment for the treatment of alcohol withdrawal whether the patient can or will return for requires that patients be separated into three assessments the following day. In some cir­ groups. The first and most obvious group cumstances, no treatment may be safer than comprises those clients who have had a previ­ treatment with medication. Mayo­Smith ous history of the most extreme forms of with­ (1997) has shown that benzodiazepines confer drawal, that of seizures and/or delirium. This protection against alcohol withdrawal seizures group is discussed in more detail below, but and thus patients with previous seizures in general, the medication treatment of this should be treated early. The same applies to group in early abstinence, whether or not delirium. Both of these topics will be explored they have had the initiation of withdrawal in greater detail in the next section. symptoms, should proceed as quickly as pos­ Extremely heavy drinking in the weeks prior sible. to complete cessation also predicts more severe withdrawal (Lejoyeux et al. 1998), but The second group of patients requiring imme­ confirming such a history often is difficult. diate medication treatment includes those patients who are already in withdrawal and A less accepted and more controversial posi­ demonstrating moderate symptoms of with­ tion on the indications for medication treat­ drawal. ment for alcohol withdrawal springs from studies that attempt to measure oxidative The third group of patients includes those stress, which is the formation of oxidative who may still be intoxicated and therefore free radicals (chemicals that damage pro­ have not had time to develop withdrawal teins), and stress hormones during alcohol symptoms or who have, at the time of admis­ withdrawal (Dupont et al. 2000; Tsai et al.

Physical Detoxification Services for Withdrawal From Specific Substances 57 1998). These studies have asserted that indi­ benzodiazepines have side effects and limita­ viduals who are undergoing mild withdrawal tions. These limitations are far more prominent without treatment still have the formation of when treating alcohol withdrawal in an outpa­ toxic oxidative products which have the hypo­ tient setting. thetical potential of producing neuronal dam­ age and perhaps some cell death. Lending Loading dose of a benzodiazepine support to this argument is the fact that alco­ Medical or nursing administration of a slowly hol withdrawal appears to be progressive in metabolized benzodiazepine, frequently intra­ that it worsens with each successive episode venously, but sometimes orally, may be carried (Malcolm et al. 2000) and that some patients out every 1 to 2 hours until significant clinical dependent on alcohol develop evidence of improvement occurs (such as reducing the dementia over time. On the other hand, age, CIWA­Ar score to 10 or less) or the patient nutritional status, trauma, co­occurring con­ becomes sedated (Sellers and Naranjo 1985). ditions, and other unspecified events also Patients at grave risk for the most severe com­ probably contribute to this process. plications of alcohol withdrawal or who are already experiencing severe withdrawal should The decision to treat a patient in alcohol be hospitalized and can be treated with this withdrawal or at potential risk for alcohol regimen. In general, patients with severe with­ withdrawal will in great part rest on the clini­ drawal may receive 20mg of diazepam or cal judgment of the practitioner, relying on 100mg of chlordiazepoxide every 2 to 3 hours the factors noted above in addition to the until improvement or sedation prevails. issue of whether treatment may in fact actual­ Oversedation, ataxia (lack of muscular coordi­ ly do more harm than good. This topic is dis­ nation), and confusion, particularly in elderly cussed below under the heading Limitations patients, may occur with this protocol. The of Benzodiazepines in Outpatient Treatment treatment staff should closely monitor hemody­ (p. 60). For more information about medica­ namic (blood pressure and pulse) and respira­ tion­assisted treatment, see TIP 43, tory features. They should particularly be pre­ Medication­Assisted Treatment for Opioid pared to detect and rapidly treat apnea (no Addiction in Opioid Treatment Programs breathing) with assisted ventilation. Having (CSAT 2005d). experienced staff with adequate time to fre­ quently monitor the patient and provide intra­ Benzodiazepine treatment of venous medication is necessary. alcohol withdrawal Symptom­triggered therapy Depending upon the clinical setting and the Using the CIWA­Ar or similar alcohol with­ patient circumstances, there are several accept­ drawal rating scales, medical personnel can be able regimens for treating alcohol withdrawal trained to recognize signs and symptoms of that make use of benzodiazepines. These drugs alcohol withdrawal, make a rating, and based remain the medication class of choice for treat­ on that rating administer benzodiazepines to ing alcohol withdrawal. The early recognition their patients only when signs and symptoms of alcohol withdrawal and prompt administra­ reach a particular threshold score. Studies tion of a suitable benzodiazepine usually will have demonstrated that appropriate training of prevent the withdrawal reaction from proceed­ nurses in the application of the CIWA­Ar dra­ ing to serious consequences. Patients suspected matically reduces the number of patients who of alcohol withdrawal should be seen promptly need to receive symptom­triggered medication by a primary care provider (physician, nurse (Saitz et al. 1994; Wartenberg et al. 1990). This practitioner, physician assistant) who has expe­ regimen has been used successfully with short, rience in diagnosing and managing alcohol intermediate, and long half­life benzodi­ withdrawal. Practitioners are reminded that azepines.

58 Chapter 4 The training of staff in a standardized proce­ drug response) according to severity of symp­ dure of administering rating scales is impor­ toms. An alternative regimen might be the tant and periodic retraining to ensure contin­ administration of 1 to 2mg lorazepam two or ued reliability among raters is essential. A three times a day the first day, followed by typical routine of administration of symptom­ gradual reduction over the next 3 to 5 days. triggered therapy is as follows: Administer The general approach to tapering is to estab­ 50mg of chlordiazepoxide (Librium) for lish an acute dose in the first 24 hours, then CIWA­Ar > 9 and reassess in 1 hour. to reduce it over the next three days: for Continue administering 50mg chlordiazepox­ example, 400 chlordiazepoxide total on day 1, ide every hour until CIWA­Ar is < 10. Dosage then 300, 200, 100, amount and frequency can be modified and off on day 5. depending on the individual clinical situation This has to be as determined by the medical provider. extended if Patients with a history of withdrawal seizures lorazepam is used. should receive scheduled doses of a long­act­ Doses of withdrawal Benzodiazepines ing benzodiazepine (e.g., diazepam [Valium], medication are omit­ 20mg every 6 hours for 3 days) regardless of ted if the patient is remain the CIWA­Ar score, and should receive addition­ sleeping soundly, al doses if indicated by elevated CIWA­Ar showing signs of medication class score. It must be noted here that symptom­ oversedation, or triggered therapy is not recommended for exhibiting marked of choice for outpatient detoxification. Symptom­triggered ataxia. therapy requires monitoring and decision­ making by a healthcare professional. The use of gradual, treating alcohol tapering doses is Gradual, tapering doses appealing in settings withdrawal. Before beginning any tapering regimen, the where trained nurs­ patient must be fully stabilized; that is, all signs ing or medical and symptoms of withdrawal must be observations cannot improved. Without proper stabilization, no be made frequently; tapering scheme will succeed. Once the patient however, this in has been stabilized, oral benzodiazepines can itself is a pitfall. be administered on a predetermined dosing Under­ or overmedication with this regimen schedule for several days and gradually can occur depending on benzodiazepine toler­ tapered over time. This is a commonly used ance; the presence of chronic cigarette smok­ regimen. ing, which induces benzodiazepine metabolism; liver function; age; and the pres­ Dosing protocols vary widely among treat­ ence of co­occurring medical or psychiatric ment facilities based on the needs of the conditions. The use of this regimen may be patient population. One example is that problematic in the outpatient settings in patients might receive 50mg of chlordiazepox­ which it frequently is applied. Supplying the ide or 10mg of diazepam every 6 hours during patient with 4 to 5 days of a benzodiazepine the first day of treatment and 25mg of chlor­ and facing the probability that the patient diazepoxide or 5mg of diazepam every 6 may drink and take the benzodiazepine is a hours on the second and third days. This hazard. It is important to enforce strict limi­ approach to dosing, that is, every 6 hours, is tations on driving automobiles, climbing, or not as accurate in tailoring medications to operating hazardous machinery. counter symptoms; a more precise dosing reg­ imen is titrating (adjusting dosage in light of

Physical Detoxification Services for Withdrawal From Specific Substances 59 Single daily dosing protocol ataxia, and on rare occasions, confusion may Jauhar and Anderson (2000) compared single ensue. daily dosing of diazepam to multiple daily dos­ Lorazepam ing of chlordiazepoxide in inpatients being treated for alcohol withdrawal. Patients in the Lorazepam (Ativan) has an intermediate half­ diazepam single daily dose group did as well as life of about 8–15 hours, and although it usual­ the chlordiazepoxide multiple dosing group. ly is administered in multiple doses each day, it The authors suggest that this regimen might be can be given approximately twice per day. attractive in community or social detoxification Lorazepam, with its shorter half­life and lack settings, particularly if patients could be moni­ of storage in adipose (fatty) tissue, actually has tored between administered doses. Further to be given more frequently than the long­act­ study with a larger group of patients is needed. ing preparations, not less. It is absorbed easily orally, intramuscularly, and intravenously. The choice of the specific benzodiazepine for Older patients and patients with severe liver any particular regimen depends on a number disease tolerate it well and it is an effective of factors, but the most significant factor is that anticonvulsant in blocking a second alcohol the clinician administer one that she has the withdrawal seizure (D’Onofrio et al. 1999). most experience using. Despite 30 years of However, it has been suggested that seizures research, no single benzodiazepine has emerged may occur late in detoxification with short­act­ as the number one drug of choice in treating ing benzodiazepines such as lorazepam and alcohol withdrawal. All benzodiazepines stud­ oxazepam (Shaw 1995). ied have worked better than placebo but have been roughly equivalent with each other. Many Oxazepam clinicians prefer long half­life benzodiazepines Oxazepam (Serax) often is favored by internists such as chlordiazepoxide and diazepam, desir­ and hepatologists treating alcohol withdrawal ing less frequent daily dosing, relatively steady in patients with severe liver failure. It has a rel­ serum levels, and the ability of these drugs to atively short half­life of 6 to 8 hours. Its self­taper based on their long half­lives. metabolism is very simple and it has no metabolites. The agent is relatively limited in Diazepam and chlordiazepoxide that its oral absorption is quite slow compared Both diazepam and chlordiazepoxide have to other benzodiazepines, it must be given excellent rapid oral absorption and are avail­ three to four times a day, and is only available able for intravenous (IV) use. Intramuscular in the United States in an oral form. use of these drugs is to be discouraged since muscle absorption is erratic. One study sug­ Ultimately, the experience of the treating clini­ gests that if chlordiazepoxide (Librium) is cian, characteristics of the patient, and the set­ taken in overdose with alcohol, it is less likely ting in which he will be treated will determine to be fatal than diazepam (Valium) (Serfaty the choice of drug. Although all benzodi­ and Masterton 1993). Detractors of the use of azepines are now generic in the United States, these two drugs point out that they have long costs vary and this too may be a factor in half­lives (although some clinicians see this as choice. an advantage because it prevents the emer­ Limitations of benzodiazepines in gence of withdrawal symptoms between doses), outpatient treatment have multiple active metabolites, and go through many oxidative metabolic steps in the Although benzodiazepines remain the mainstay liver. Older patients or patients with liver dis­ of treatment for alcohol withdrawal, they have ease are likely to accumulate these medications limitations that are particularly pronounced quickly without being able to metabolize them. when treating outpatients. Benzodiazepines’ Possible consequences include oversedation or potential interactions with alcohol can lead to coma and respiratory suppression, motor inco­

60 Chapter 4 ordination (leading to falls and automobile the majority of these studies, patients were accidents), and abuse of the medications. treated with benzodiazepines, although in a Abuse usually is in the context of the concur­ few, phenobarbital was used. rent use of alcohol, opioids, or stimulants. A second, and at present more hypothetical, There are two other limitations of benzodi­ concern about benzodiazepine use to treat out­ azepines that may be relevant in some clinical patients in alcohol withdrawal is that they may settings for some patients. First, although ben­ “prime” or reinstate alcohol use during their zodiazepines have been studied for more than administration. Two preclinical studies support 30 years and are effective for suppressing alco­ this premise (Deutsch and Walton 1977; hol withdrawal symptoms at any one episode, Hedlund and Wahlstrom 1998). A recent ran­ their ability to halt the progressive worsening domized, blinded, clinical trial comparing car­ of each successive alcohol withdrawal reaction bamazepine to lorazepam for the outpatient is in question. There are now at least nine stud­ treatment of alcohol withdrawal found that the ies that have found that an ever­increasing outpatients on lorazepam were three times as number of previous alcohol withdrawals likely to drink as those on carbamazepine. The increases the severity of withdrawal, particu­ lorazepam group drank about twice as much larly seizures and delirium tremens, and alcohol in the immediate post­detoxification decreases responsiveness to benzodiazepines period than the carbamazepine group (Malcolm (Ballenger and Post 1978; Booth and Blow et al. 2002). 1993; Brown et al. 1988; Gross et al. 1972; Lechtenberg and Worner 1990, 1992; Malcolm For a list of potential contraindications to using et al. 2000; Shaw et al. 1998; Worner 1996). A benzodiazepines to treat alcohol withdrawal in tenth study (Wojnar et al. 1999) found that certain patients, see Figure 4­3. increasing severity of alcohol withdrawal symp­ toms was observed only in a minority (22 per­ Other medications cent) of 418 repeatedly treated clients. However, within this group of one in five indi­ Barbiturates viduals, seizures were three times more com­ Barbiturates have been used for nearly a cen­ mon than in the larger, nonprogressive group tury for the treatment of alcohol withdrawal. and premature age of death was 7 years Most barbiturates, other than phenobarbital, younger than for the nonprogressive group. In have fallen into disfavor because of severe

Figure 4­3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal

•Previous allergic reaction •Previous paradoxical disinhibition (e.g., violence, agitation, self­harm) •Previous serious adverse outcomes that could have medico­legal consequences if they re­occur (e.g., fractured hip, status epilepticus [continuous seizures of several minutes]) •Severe alterations in mental status with low dose of benzodiazepines (e.g., confusion, delirium) •An outpatient setting where benzodiazepine use with alcohol has occurred previously with extreme intox­ ication leading to injuries, coma, or apnea

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 61 lethal interactions Other agents Delirium and with alcohol, death Beta blockers and alpha adrenergic agonists from overdose of the such as clonidine have been used in the treat­ agents alone, rapid seizures are the ment of alcohol withdrawal. They do not pre­ tolerance, and high vent seizures in delirium and have only modest abuse potential. two most benefits for ameliorating symptoms of with­ Barbiturates are drawal. However, some patients will have highly addictive. In tachycardia (rapid heartbeat) and hyperten­ pathological clinical practice, the sion (high blood pressure) that will not be con­ medication is effec­ trolled by benzodiazepines, and beta blockers responses seen in tive both for the and alpha adrenergic agonists can be of use in treatment of alcohol these patients. Calcium channel antagonists will alcohol withdrawal and also ameliorate some symptoms of alcohol with­ sedative­hypnotic drawal. As with beta blockers and clonidine, withdrawal. withdrawal although calcium channel antagonists should be consid­ few controlled trials ered adjunctive therapy primarily to manage have been conduct­ extreme hypertension during withdrawal. ed with it (Wilbur and Kulik 1981). Phenobarbital has a long Antipsychotics half­life and may rapidly accumulate. Antipsychotics have long been used to control Overdoses with phenobarbital also can be fatal. extreme agitation, hallucinations, delusions, Members of the consensus panel recommend its and delirium during alcohol withdrawal. Older, use only in highly supervised settings. low­potency drugs such as chlorpromazine gen­ Anticonvulsants erally are avoided since they can reduce the seizure threshold. High­potency drugs such as Anticonvulsants have been used in Europe for haloperidol (Haldol) also can reduce the a quarter of a century for the treatment of seizure threshold, but less commonly. alcohol withdrawal. Carbamazepine (Atretol, Haloperidol and related agents are available Tegretol) has been shown in at least three trials for oral, intramuscular, and IV administration. to be as effective as various benzodiazepines in Clinicians should note that since antipsychotics mild to moderate alcohol withdrawal (Malcolm can lower the seizure threshold, their use dur­ et al. 2001). Although less well studied, val­ ing alcohol withdrawal should be undertaken proic acid also has been shown to be effective with great care and close supervision of the (Reoux et al. 2001). Older, first­generation patient is required. anticonvulsants have limitations in that they only have been studied in mild to moderate Relapse prevention agents withdrawal, can on rare occasions have serious Relapse prevention agents such as naltrexone hepatic and bone marrow toxicities, interact and acamprosate are under consideration as with several other classes of medication, and additional therapies during late withdrawal are only available in oral forms. They are not, treatment, although they are not effective for however, controlled substances, are not alcohol detoxification. Since one­third to one­ abused, and as previously noted, carba­ half of outpatients detoxifying with benzodi­ mazepine may have the propensity to reduce azepines will either drink or leave treatment some of the indices of drinking behavior imme­ prematurely, naltrexone and acamprosate may diately in the post­withdrawal treatment of out­ be valuable in assisting in reducing the proba­ patients. Newer drugs such as tiagabine, oxcar­ bility of the individual drinking during late bazepine, and gabapentin do not appear to detoxification. High­dose naltrexone therapy have these liabilities, but sufficient studies have has been associated with some liver toxicity, not been done to confirm their effectiveness but this has not been reported in individuals and safety. taking therapeutic doses to enhance relapse

62 Chapter 4 prevention. Acamprosate may produce diar­ weeks prior to treatment, the severity of the rhea and this may be already present in some last withdrawal episodes, and the number of individuals in alcohol withdrawal. Thus far no previously treated or untreated withdrawal well­controlled studies have been conducted to episodes. Other factors such as increasing age; provide guidelines as to when these medications the patient’s general health, including nutri­ should be introduced during detoxification or tional status; the presence of co­occurring med­ whether it would be better to wait until the ical, surgical, and psychiatric disorders; and early phase of rehabilitation. For an extended the use of medications (prescription, over­the­ review, see Kranzler and Jaffe (2003). counter, or herbal) also can amplify severity of withdrawal symptoms. Early proper medical Other medications management of alcohol withdrawal reduces the Abecarnil (Anton et al. 1997), and more recent­ probability of these complications, assuming ly baclofen (Addolorato et al. 2002), have both early recognition. shown promise in the treatment of alcohol with­ drawal. However, insufficient information has For patients with a history of DTs or seizures, been accumulated on these drugs, and there­ early benzodiazepine treatment is indicated at fore they are not recommended for use in clini­ the first clinical contact setting (e.g., doctor’s cal patient settings. Their use in alcohol with­ office, clinic, urgent care, emergency depart­ drawal should be considered experimental and ment). Patients with severe withdrawal symp­ premature for the present. toms, multiple past detoxifications (more than three), and co­occurring unstable medical and psychiatric conditions should be managed simi­ Management of Delirium and larly. Seizures Once an initial clinical screening and assess­ Delirium and seizures are the two most patho­ ment have been made, and the diagnosis is rea­ logic responses seen in alcohol withdrawal. The sonably certain, medication should be given. major goal of medical management is to avoid Giving the patient a benzodiazepine should not seizures and a special state of delirium called be delayed by waiting for the return of labora­ delirium tremens (DTs) with aggressive use of tory studies, transportation problems, or the the primary detoxification drug (e.g., higher availability of a hospital bed. Early thiamine doses of a benzodiazepine). Prevention is and multivitamin administration also should be essential where DTs are concerned. DTs do not done at this time. Once full DTs have devel­ develop suddenly but instead progress from oped, they tend to run their course despite earlier withdrawal symptoms. Properly admin­ medication management, and there is little evi­ istered symptom­triggered medication dence in the medical literature to suggest that approaches will prevent DTs and limit over­ any medication treatment can immediately medication that can occur when high­dose ben­ abort DTs. zodiazepines are administered without regard to clinical response. It can be challenging clini­ Patients presenting in severe DTs should have cally to differentiate impending DTs versus emergency medical transport to a qualified benzodiazepine toxicity on day 3 of detoxifica­ emergency department and generally will tion. When in doubt, in most cases it is safer to require hospitalization. If the DTs are severe, overmedicate than to undertreat and allow DTs patients may need to be placed in an intensive to develop. Flumazenil (Romazicon) can be care unit (ICU), and in such settings continu­ used to reverse benzodiazepine overdose. ous monitoring of cardiac rhythm, pulse, blood pressure, oxygen saturation, temperature, and Death and disability may result from DTs or respiration rates begins with the emergency seizures without medical care. Several factors medical system and continues in the emergency are related to severity of alcohol withdrawal: department and ICU. high amounts of alcohol being consumed in the

Physical Detoxification Services for Withdrawal From Specific Substances 63 Early care will depend on medical and surgical sists of jerking of head, neck, arms, and legs. complications and may involve protocols from Breathing resumes during this clonic phase of advanced cardiac life support (ACLS) and/or the seizure but may be irregular. During the advanced trauma life support. Correction of clonic phase, the lips, tongue, or inside of the fluids and electrolytes (salts in the blood), cheeks may be bitten. Involuntary urination or hyperthermia (high fever), and hypertension a bowel movement may occur. Immediately are vital. Loading doses (rapid administration after the jerking ceases, the patient generally of initial high doses) of IV diazepam or has a period of what appears to be sleep with lorazepam are recommended, as are IV thi­ more regular breathing. Vomiting may occur at amine (prior to IV glucose) and multiple vita­ this time. The period of sleep may be a few sec­ mins. The physician should consider intramus­ onds with awakening or a few minutes. Rarely, cular or intravenous haloperidol (Haldol and the patient may appear not to waken at all and others) to treat agitation and hallucinations. have a second period of rigidity followed by Nursing care is vital, with particular attention muscle jerking. This is known as status epilep­ to medication administration, patient comfort, ticus. Upon awakening, the individual usually soft restraints, and frequent contact with ori­ is mildly confused as to what has happened and enting responses and clarification of environ­ may be disoriented as to where she or he is. mental misperceptions. This period of post­seizure confusion generally lasts only for a few minutes but may persist for Alcohol withdrawal seizures represent another several hours in some patients. Headache, management challenge (Ahmed et al. 2000), sleepiness, nausea, and sore muscles may per­ since no large­scale clinical studies have been sist in some individuals for a few hours. See the conducted to establish firmly best treatment text box on the next page for what to do in the practices. The majority of alcohol withdrawal event of a seizure. seizures occur within the first 48 hours after cessation or reduction of alcohol, with peak Patients who start to retch or vomit should be incidence around 24 hours (Victor and Adams gently placed on their side so that the vomitus 1953). Most alcohol withdrawal seizures are (stomach contents vomited) may exit the mouth singular, but if more than one occurs they tend and not be taken into the lungs. Vomitus taken to be within several hours of each other. While into the lungs is a severe medical condition alcohol withdrawal seizures can occur several leading to immediate difficulty breathing and, days out, a higher index of suspicion for other within hours, severe pneumonia. causes is prudent. Someone experiencing an alcohol withdrawal seizure is at greater risk for Predicting who will have a seizure during alco­ progressing to DTs, whereas it is extremely hol withdrawal cannot be accomplished with unlikely that a patient already in DTs will also any great certainty. There are some factors then experience a seizure. that clearly increase the risk of a seizure, but even in individuals with all of these factors, The occurrence of an alcohol withdrawal most patients will not have a seizure. Out of seizure happens quickly, usually without warn­ 100 people experiencing alcohol withdrawal ing to the individual experiencing the seizure or only two or three of them will have a seizure. anyone around him. The patient loses con­ The best single predictor of a future alcohol sciousness, and if seated usually slumps over, withdrawal seizure is a previous alcohol with­ but if standing will immediately fall to the floor. drawal seizure. Individuals who have had three The patient’s body is rigid, and breathing ceas­ or more documented withdrawal episodes in es. This part of the seizure is called the tonic the past are much more likely to have a seizure phase, which usually lasts for a few seconds regardless of other factors including age, gen­ and rarely more than a minute. der, or overall medical health. However, cer­ tain other factors may increase the risk of The next part of the seizure (more dramatic seizures for all patients: and generally remembered by witnesses) con­

64 Chapter 4 What To Do in the Event of a Seizure

•At the first sign of what appears to be a seizure, lay witnesses should summon trained medical personnel. •Depending on the setting, this may mean calling 911 or calling the nurse or physician who is on duty for the clinic or hospital unit. •While awaiting medical help, a layperson witnessing an alcohol withdrawal seizure should gently attempt to prevent injury to the person as he or she slumps or falls to the floor by protecting the individual’s head and body from hard or sharp objects. Often, though, the initial loss of consciousness and fall is not seen by anyone. •In the jerking phase of the seizure, if the jerking is extreme, it is important to protect the head from extreme head­banging by placing a soft object under the head and neck. Sometimes placing one’s hand or shoe under the head is adequate. •No attempt should be made to insert anything in the mouth (such as spoons, pencils, pens, tongue blades). Such attempts at object insertion may cause damage to the teeth and tongue, or objects may get partially swallowed and obstruct the airway. •Patients who start to retch or vomit should be gently placed on their side so that the vomitus (stomach contents vomited) may exit the mouth and not be taken into the lungs. Vomitus taken into the lungs is a severe medical condition leading to immediate difficulty breathing and, within hours, severe pneumonia. •Even if the individual appears to become fully awake, alert, and oriented without any harm following a seizure, it is strongly recommended that he be referred for medical evaluation. •Individuals who awaken confused and disoriented should be given brief reassuring and soothing messages to reorient them as to what happened and where they are.

•Having drunk for more than two decades preferably with IV administration. The study •Having poor general medical health and poor by D’Onofrio and colleagues (1999) indicated nutritional status that a single dose of 1mg of IV lorazepam reduced recurrent seizure risk, reduced rates •Having had previous head injuries of return to emergency departments, and low­ •Having had disturbances of serum calcium, ered hospitalization rates. Despite this sodium, potassium, or magnesium report, the consensus panel agrees that hospi­ talization for further detoxification treatment Patients having a witnessed seizure can be is strongly advised to monitor and ameliorate treated with IV diazepam or lorazepam and other withdrawal symptoms, reduce suffering, ACLS protocol procedures. This reduces but and stabilize the patient for rehabilitation does not completely prevent the likelihood of a treatment. second seizure (D’Onofrio et al. 1999). In the rare patient with recurrent multiple seizures or The addition of anti­epileptic drugs (AEDs) status epilepticus (continuous seizures of sever­ has not been established as effective (Chance al minutes) an anesthesiology consultation may 1991; Hillbom and Hjelm­Jager 1984; Rathlev be required for general anesthesia. Evaluation et al. 1994). This is primarily based on evalu­ of electrolyte disturbances, central nervous sys­ ations of phenytoin (Dilantin and others). tem (CNS) trauma, and consideration of seda­ Newer AEDs have not been studied extensive­ tive­hypnotic withdrawal should be reviewed. ly for preventing alcohol withdrawal seizures. The consensus panel suggests that AED thera­ Patients who have had a single witnessed or py should be considered in alcohol withdraw­ suspected alcohol withdrawal seizure should al patients with multiple past seizures (of any be immediately given a benzodiazepine, cause), a history of recent head injury, past

Physical Detoxification Services for Withdrawal From Specific Substances 65 meningitis, encephalitis, or family history of mine whether the patient is using aspirin or seizures. Further evaluation of a first seizure nonsteroidal anti­inflammatory medications often warrants neurologic evaluation (com­ (for example, Motrin or Advil, both containing puterized tomography and electroencephalo­ ibuprofen) in conjunction with alcohol use. gram), even if the seizure may be suspected to Antidiabetic agents in concert with alcohol may have been due to alcohol withdrawal. produce hypoglycemia (low blood sugar) and lactic acidosis (blood that has become too acidic). The therapeutic efficacy and margin of Patient Care and Comfort safety for the use of anti­anxiety medications, Interpersonal support and hygienic care along antidepressants, and antipsychotic medication with adequate nutrition should be provided. is thought by some to be lessened by alcohol Staff assisting patients in detoxification should use, but this is based largely on anecdotal provide whatever assistance is necessary to information. Alcohol interacts with numerous help get patients cleaned up after entering the other classes of medications that lead to less facility and bathed thoroughly as soon as they serious results. Some important examples are have been medically stabilized. Attention to the sedatives, tranquilizers, antiseizure medica­ treatment of scabies, body lice, and other skin tions, and anticoagulants (blood thinners) such conditions should be given. Screening for as Coumadin. Patients who may be taking such tuberculosis should be done. Dental and oral medications need to be carefully observed and care should be made available. The patient have their medications carefully monitored. should be screened for physical trauma, including bruises and lacerations. Tetanus immunization may be necessary. Patients with Opioids an altered mental status or altered level of con­ Opioids are highly addicting, and their chronic sciousness should be seen in emergency depart­ use leads to withdrawal symptoms that, ments, evaluated, and possibly hospitalized. although not medically dangerous, can be high­ Staff should continue to observe patients for ly unpleasant and produce intense discomfort. head injuries after admission because some All opioids (e.g., heroin, morphine, hydromor­ head injuries, such as subdural hematomas, phone, oxycodone, codeine, and methadone) may not immediately be evident and cost con­ produce similar effects by interacting with siderations may preclude obtaining a brain endogenous (produced by the body itself) opi­ scan in some settings. oid (:, *, and 6) receptors (that is, specific sites on cells where these substances bind to the Other Immediate Concerns cell). Opioid agonists stimulate these receptors and opioid antagonists block them, preventing Alcohol may interact with several classes of their action. medicine to produce serious CNS depression. Some examples include benzodiazepines, barbi­ turates, meprobamate, and other sedative hyp­ Opioid Withdrawal Symptoms notic groups. Metoclopramide and sedating All opioid agents produce similar withdrawal antipsychotic medicines such as phenothiazines signs and symptoms with some variance in also can produce CNS suppression. A disulfi­ severity, time of onset, and duration of symp­ ram­like (Antabuse) reaction characterized by tomatology, depending on the agent used, the flushing, sweating, tachycardia, nausea, and duration of use, the daily dose, and the interval chest pain has been reported for metronidazole between doses. For instance, heroin withdrawal and several antibiotics including, but not limit­ typically begins 8 to 12 hours after the last ed to, cefamandole, cefoperazone, and cefote­ heroin dose and subsides within a period of 3 tan. Acetaminophen in low doses may act to 5 days. Methadone withdrawal typically acutely with alcohol to produce hepatotoxicity begins 36 to 48 hours after the last dose, peaks (liver damage). Clinicians also should deter­

66 Chapter 4 after about 3 days, and gradually subsides over the opioid withdrawal syndrome, after which a period of 3 weeks or longer. Physiological, dose reductions can be made gradually. genetic, and psychological factors can signifi­ cantly affect intoxication and withdrawal sever­ Medical complications associated with opioid ity. Figure 4­4 summarizes many of the com­ withdrawal can develop and should be quick­ mon signs and symptoms of opioid intoxication ly identified and treated. Unlike alcohol and and withdrawal. sedative withdrawal, uncomplicated opioid withdrawal is not life­threatening. Rarely, The clinician uses intoxication and withdraw­ severe gastrointestinal symptoms produced by al measures as guides to avoid under­ or over­ opioid withdrawal, such as vomiting or diar­ medicating patients during medically super­ rhea, can lead to dehydration or electrolyte vised detoxification; the number and intensity imbalance. Most individuals can be treated of signs determine the severity of opioid with­ with oral fluids, especially fluids containing drawal. It is important to appreciate that electrolytes, and some might require intra­ untreated opioid withdrawal gradually builds venous therapies. In addition, underlying in severity of signs and symptoms and then cardiac illness could be made worse in the diminishes in a self­limited manner. Repeated presence of the autonomic arousal (increased assessments should be made during detoxifi­ blood pressure, increased pulse, sweating) cation to determine whether symptoms are that is characteristic of opioid withdrawal. improving or worsening. Repeated assess­ Fever may be present during opioid with­ ments also should address the effectiveness of drawal and typically will respond to detoxifi­ pharmacological interventions. Detoxification cation. Other causes of fever should be evalu­ strategies should aim to establish control over ated, particularly with intravenous users,

Figure 4­4 Signs and Symptoms of Opioid Intoxication and Withdrawal

Opioid Intoxication Opioid Withdrawal

Signs Signs Bradycardia (slow pulse) Tachycardia (fast pulse) Hypotension (low blood pressure) Hypertension (high blood pressure) Hypothermia (low body temperature) Hyperthermia (high body temperature) Sedation Insomnia Meiosis (pinpoint pupils) Mydriasis (enlarged pupils) Hypokinesis (slowed movement) Hyperreflexia (abnormally heightened reflexes) Slurred speech Diaphoresis (sweating) Head nodding Piloerection (gooseflesh) Increased respiratory rate Symptoms Lacrimation (tearing), yawning Euphoria Rhinorrhea (runny nose) Analgesia (pain­killing effects) Muscle spasms Calmness Symptoms Abdominal cramps, nausea, vomiting, diarrhea Bone and muscle pain Anxiety

Source: Consensus Panelist Charles Dackis, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 67 because HIV infec­ Management of Withdrawal tion, viral hepati­ With Medications Methadone is the tis, abscesses, infected injection The management of opioid withdrawal with sites, and pneumo­ medications is most commonly achieved most frequently nia occur common­ through the use of methadone (in addition to ly in this popula­ adjunctive medications for nausea, vomiting, used agent tion and always diarrhea, and stomach cramps). Federal regu­ require medical lations restrict the use of methadone for opioid approved for attention. Anxiety withdrawal to specially licensed programs, disorders, especial­ except in cases where the patient is hospitalized detoxification by ly those involving for treatment of another acute medical condi­ panic anxiety, also tion. Methadone is the most frequently used the FDA, and a might show agent approved for detoxification by the Food increased intensity and Drug Administration (FDA), and a new new medication, during opioid with­ medication, buprenorphine (discussed below), drawal. Finally, has been approved for use. Methadone can be used for detoxification from heroin and all opi­ buprenorphine, any condition involving pain is oid agonists. likely to worsen has been during opioid with­ Another commonly used agent is clonidine (Gold et al. 1984), an ­adrenergic agonist drawal because of a a that relieves most opioid withdrawal symp­ approved for use. reduced pain toms without producing opioid intoxication or threshold and the drug reward. However, since clonidine detox­ lack of analgesia (pain relief) afford­ ification is less effective against many opioid withdrawal symptoms, adjunctive medicines ed by opioid use. often are necessary to treat insomnia, muscle This phenomenon is particularly common pain, bone pain, and headache. Adjunctive with dental pain and chronic back pain. agents should not be used in the place of an adequate detoxification dosage. Additional Management of Withdrawal opioid agonists could be used theoretically for Without Medications detoxification but would have to be adminis­ tered “off label,” because the FDA has It is not recommended that clinicians attempt approved only methadone for this purpose. to manage significant opioid withdrawal symp­ Off­label use (prescribing an agent approved toms (causing discomfort and lasting several for another condition) could be difficult to hours) without the effective detoxification justify, given the efficacy of methadone in agents discussed below. Even mild levels of opi­ reversing opioid withdrawal. oid use commonly produce uncomfortable lev­ els of withdrawal symptomatology. Detoxification is indicated for treatment­seek­ Management of this syndrome without medica­ ing persons who display signs and symptoms tions can produce needless suffering in a popu­ sufficient to warrant treatment with medica­ lation that tends to have limited tolerance for tions and for whom maintenance is declined physical pain. or for some reason is not indicated or practi­ cal. In addition, individuals dependent on opioids sometimes are hospitalized for other health problems and may require hospital­ based detoxification even though they are not

68 Chapter 4 seeking substance abuse treatment. Such and endocrinologic defects caused by long­term patients also can be maintained on methadone heroin addiction. This is one of many impor­ during the course of hospitalization for any tant reasons to consider conversion to mainte­ condition other than opioid addiction. The nance during most methadone detoxification hospital does not have to be a registered opi­ admissions. oid treatment program, as long as the patient was admitted for a detoxification treatment Once the dose requirement for methadone has for some substance other than opioids. On been established, methadone can be given the other hand, some persons may not have once daily and generally tapered over 3 to 5 used sufficient amounts of opioids to develop days in 5 to 10mg daily reductions. The initial withdrawal symptoms, and for others suffi­ dose requirement is determined by estimating cient time may have elapsed since their last the amount of opioid use and gauging the dose to extinguish withdrawal and eliminate patient’s response to administered the need for detoxification. methadone. Clinicians should take care not to underdose patients with methadone; adequate dosage is vitally important. Patients some­ Methadone times exaggerate their daily consumption to This section discusses methadone as an agent receive greater dosages of methadone. For for detoxification. For detailed information this reason, history is no substitute for a on methadone maintenance, readers are physical examination that screens for signs of referred to TIP 43 Medication­Assisted opioid withdrawal. Treating clinicians should Treatment for Opioid Addiction in Opioid not only be familiar with the intoxication and Treatment Programs (CSAT 2005d). While withdrawal signs that are set forth in Figure methadone is one of the more common medi­ 4­4 (p. 67), but also should be skilled in dis­ cations for opioid detoxification, its use is cerning these features of opioid withdrawal. highly regulated and it can only be prescribed Avoidance of overmedicating is crucial during for withdrawal by a doctor at a Substance methadone detoxification because excessive Abuse and Mental Health Services doses of this agent can produce overdose, Administration (SAMHSA)­certified whereas opioid withdrawal does not constitute methadone clinic or if the patient is being a medical danger in otherwise healthy adults. hospitalized for another medical condition. For more information on methadone and (Detoxification programs may become certi­ other medications used to treat opioid addic­ Medication­Assisted fied to prescribe methadone by undergoing tion, see TIP 43, Treatment for Opioid Addiction in Opioid the process described in TIP 43.) Federal reg­ Treatment Programs d ulations allow for the use of methadone in (CSAT 2005 ). both a short­term detoxification treatment of Patients with significant opioid dependence less than 30 days and a long­term treatment may require a starting dose of 30 to 40mg per of 30 to 180 days. The regulations also specify day; this dose range should be adequate for that if a patient has failed two detoxification even the most severe withdrawal. If the attempts in a 12­month period he or she must degree of dependence is unclear, withdrawal be evaluated for a different course of treat­ signs and symptoms can be reassessed 1 to 2 ment (e.g., ongoing opioid substitution hours after giving a dose of 10mg of therapy). methadone. The practice of giving a dose of Methadone is a long­acting agonist at the :­opi­ methadone and later assessing its effect (also oid receptor site that, in effect, displaces hero­ termed a challenge dose) is an important in (or other abused opioids) and restabilizes the intervention of detoxification. Sedation or site, thereby reversing opioid withdrawal symp­ intoxication signs after a methadone challenge toms. If maintained for long enough, this stabi­ dose indicate a lower starting dose. Similarly, lizing effect can even reverse the immunologic intoxication at any point of the detoxification

Physical Detoxification Services for Withdrawal From Specific Substances 69 signals the need to hold or more rapidly wean muscle aches, and drug craving. Completion (reduce to a zero dose) the methadone. Care rates for opioid detoxification using clonidine should be taken to avoid giving methadone to have been low (ranging from 20 to 40 per­ newly admitted patients with signs of opioid cent); those patients who complete the proce­ intoxication, since overdose could result. dure are more likely to be dependent on opi­ Note that methadone stabilization is the treat­ oids other than heroin, have private health ment of choice for patients who are pregnant insurance, and report lower levels of subjec­ and opioid dependent. tive withdrawal symptoms than those who do not complete (Strobbe et al. 2003). Clonidine (Catapres) An appropriate protocol for clonidine is Clonidine was originally marketed and 0.1mg administered orally as a test dose. A approved for the treatment of high blood pres­ dose of 0.2mg might be used initially for sure but also has been used for opioid detoxifi­ patients with severe signs of opioid withdraw­ cation since 1978. While clonidine is not FDA al or for those patients weighing more than approved for treatment of opioid withdrawal, it 200 pounds. The sublingual (under the is widely used “off label” for this purpose tongue) route of administration also may be (Alling 1992) because the research literature used. Clinicians should check the patient’s substantiates its effectiveness for this condition. blood pressure prior to clonidine administra­ Advantages of clonidine over methadone in the tion and clonidine should be withheld if sys­ treatment of opioid withdrawal are as follows: tolic blood pressure is lower than 90 or dias­ tolic blood pressure is below 60. These •Clonidine does not produce opioid intoxica­ parameters can be relaxed to 80/50 in some tion and is not reinforcing. cases if the patient continues to complain of •The FDA does not classify clonidine as having withdrawal and is not experiencing symptoms abuse potential. Yet some abuse has been of orthostatic hypotension (a sudden drop in reported. (See p. 107 under the section on blood pressure caused by standing). pregnant women and opioids.) Clonidine (0.1 to 0.2mg orally) can then be •Since clonidine does not interact with the given every 4 to 6 hours on an as­needed :­opioid receptor, detoxification occurs basis. Clonidine detoxification is best con­ without opioids. ducted in an inpatient setting, as vital signs and side effects can be monitored more close­ •No special licensing is required for the dis­ ly in this environment. In cases of severe pensing of this medication. withdrawal, a standing dose (given at regular One disadvantage to methadone detoxification intervals rather than purely “as needed”) of with naltrexone (an opioid antagonist), com­ clonidine might be advantageous (Alling pared with clonidine, is that naltrexone, when 1992). The daily clonidine requirement is it is prescribed for abstinence, can precipitate established by tabulating the total amount opioid withdrawal if given too soon after the administered in the first 24 hours, and divid­ last methadone dose. This problem does not ing this into a three or four times per day exist with clonidine, making this agent particu­ dosing schedule. Total clonidine should not larly beneficial in a drug­free treatment pro­ exceed 1.2mg the first 24 hours and 2.0mg gram or a therapeutic community. after that, with doses being held in accor­ dance with parameters noted above. The Nevertheless, patients addicted to opioids standing dose is then weaned over several generally prefer methadone over clonidine days. Clonidine must be tapered to avoid detoxification. Although clonidine alleviates rebound hypertensions. some symptoms of opioid withdrawal, it usu­ ally is relatively ineffective for insomnia, The clonidine transdermal (administered through the skin) patch, FDA approved in

70 Chapter 4 1986 for the treatment of hypertension (high Buprenorphine is available in oral form as blood pressure), also is used in opioid detoxi­ Subutex, which contains only buprenorphine, fication. However, the safety of the patch for and is meant for patients who are starting treatment of opioid withdrawal has not been treatment for drug dependence. Another sufficiently studied in controlled clinical tri­ form, Suboxone, contains buprenorphine and als. The transdermal route of administration naloxone and is intended for persons depen­ has the disadvantage of continued clonidine dent on opioids who have already started and action even after the patch has been removed. are continuing medication therapy. Blood pressure effects of clonidine can there­ Buprenorphine has great affinity for the fore be prolonged, leading to undesirable and :­opioid receptor, in persistent reductions of blood pressure. For spite of being only a this reason, it has been recommended that the partial agonist, and patch be used only if the patient’s blood pres­ can displace other One advantage of sure is monitored regularly (Alling 1992). opioids such as hero­ in. This feature gives buprenorphine is The clonidine patch is available in three buprenorphine the sizes that deliver a total daily oral equivalent ability to precipitate 2 that it can be clonidine dose of 0.2mg (3.5 cm ), 0.4mg (7.0 opioid withdrawal cm2), or 0.6mg (10.5 cm2). The patch supplies when administered to dispensed at a clonidine for up to 7 days and one patch patients who have application usually is sufficient. The conve­ recently used heroin nience of one application allows the clinician (Kosten and physician’s office, to avoid the disruption that multiple dosing McCance­Katz 1995). might have during rehabilitative program­ unlike methadone, ming. In particular, patients can focus on An advantage to rehabilitative treatment without being dis­ buprenorphine is its which can be tracted by the need to ask repeatedly for oral safety. Because of clonidine doses. Vital signs should be moni­ the partial agonist dispensed only at tored at least four times daily to assess persis­ action, buprenor­ tent signs and symptoms of withdrawal or phine has a “ceiling undesirable effects of clonidine on blood pres­ effect” with regard to designated treat­ sure. overdose potential (Walsh et al. 1994). ment centers. That is, unlike Buprenorphine methadone, which Buprenorphine, a partial a­opioid agonist that produces increasing is FDA approved in an injectable form respiratory suppression with increasing dose, (Buprenex) for the treatment of pain, has respiratory effects of buprenorphine tend to recently been approved as a detoxification level off due to its partial agonist action. agent and for opioid maintenance treatment as Another advantage of buprenorphine is that an alternative to methadone maintenance. A it can be dispensed at a physician’s office, number of clinical trials have reported it to be unlike methadone, which can be dispensed effective for heroin detoxification (Becker et al. only at designated treatment centers. This 2001; Bickel et al. 1988; Diamant et al. 1998), makes access to this medication for opioid and the medication should play an important dependence much more convenient for both role in gradually removing patients from patient and clinician. See TIP 40, Clinical methadone maintenance (Amass et al. 2004; Guidelines for the Use of Buprenorphine in Banys et al. 1994; Johnson et al. 2000). the Treatment of Opioid Addiction (CSAT 2004a).

Physical Detoxification Services for Withdrawal From Specific Substances 71 Unlike methadone, buprenorphine may be described above for heroin. The methadone prescribed by physicians who are not con­ dose should be tapered gradually by 5 to nected with a certified opioid treatment pro­ 10mg/week until a daily dose of 30 to 40mg has gram. However, there is a still a specific been attained. At that time, detoxification with training and certifi­ either clonidine or smaller doses of methadone cation process can be instituted. The use of clonidine has the Inpatient physicians must advantage of brevity as a complete clonidine undergo in order to detoxification usually can be conducted within prescribe the medi­ 2 to 3 weeks (Gold et al. 1984). treatment can cation. Information on the legal aspects Once the daily dose requirement has been provide additional of prescribing established by using the principles outlined buprenorphine and above, the patient can be placed on a stand­ support, medical rules for carrying ing dose of clonidine. The dose required usu­ out detoxification in ally is in the range of 0.2mg, three to four supervision, and the physician’s times daily, although titration (adjustment of office can be found dosage in light of drug response) is necessary rehabilitative at http:// based on the information gathered during the www.buprenor­ clinical examination. Additional doses as needed (sometimes abbreviated “PRN”) of treatment that phine.samhsa.gov/. Information given 0.2mg clonidine also can be given and blood pressure parameters must be followed prior serve as at the site includes the following on the to the administration of standing and PRN Drug Addiction doses to avoid orthostatic hypotension. The disincentives to Treatment Act initial standing dose can be reduced to 0.1mg, (DATA) of 2000: given three to four times daily, after one week relapse. “[DATA 2000] of detoxification, with PRN doses of 0.1mg expands the clinical available. After a period of 1 week on this context of medica­ reduced dosage, clonidine is given for an tion­assisted opioid addiction treatment by additional week only if needed. Because cloni­ allowing qualified physicians to dispense or dine does not reverse all opioid withdrawal prescribe specifically approved Schedule III, symptoms, especially insomnia, adjunctive IV, and V narcotic medications for the treat­ medications for symptom relief of insomnia, ment of opioid addiction in treatment settings nausea, diarrhea, etc. usually are required. other than the traditional Opioid Treatment Clonidine detoxification is best conducted on Program (i.e., methadone clinic). In addition, an inpatient basis to ensure appropriate vital DATA 2000 reduces the regulatory burden on sign monitoring. Inpatient treatment also physicians who choose to practice opioid addic­ reduces the impulse to relapse, especially if tion therapy by permitting qualified physicians the detoxification is difficult. to apply for and receive waivers of the special Methadone detoxification can be continued registration requirements defined in the once a daily dose of 30 to 40mg is achieved, as Controlled Substances Act” (SAMHSA 2002). described above. The dose can be reduced to 20mg per day by a reduction of 5 to Terminating Methadone 10mg/week. Once the patient is on 20mg/day, methadone can be reduced by 1 to 2mg daily, Maintenance Treatment depending on clinical measures of withdraw­ Individuals seeking the discontinuation of al. As with clonidine detoxification, the final methadone maintenance require a much more 2 to 3 weeks of methadone detoxification is lengthy detoxification process than that associated with recidivism (relapsing).

72 Chapter 4 Inpatient treatment, if available, can provide and shortened during the 1980s (Charney et additional support, medical supervision, and al. 1982, 1986; Kleber et al. 1987; Riordan rehabilitative treatment that serve as disin­ and Kleber 1980; Vining et al. 1988) so that a centives to relapse. blocking dose of naltrexone—at least 25mg— usually was used by the second or third day of treatment. The rate­limiting factor of this Rapid and Ultrarapid rapid clonidine­naltrexone method is its Detoxification capacity to adequately relieve the precipitat­ Although there are few data showing that the ed withdrawal symptoms in the conscious rapid or ultrarapid methods of opioid detoxifi­ patient. Golden and Sakhrani (2004) found cation show a positive correlation with the like­ that 25 percent of the 20 patients they studied lihood of a patient’s being abstinent a few who were undergoing rapid detoxification months later, efforts persist to make the detoxi­ using clonidine and naltrexone developed fication process shorter and easier. This stems delirium and had to discontinue the proce­ in part from the desire of the person addicted dure after the first day, and another patient to opioids for a rapid, painless procedure, and dropped out before completion. in part from an attempt to coax more such per­ The 1990s witnessed a variety of attempts to sons into treatment (fewer than one in five peo­ overcome this barrier by using general anes­ ple with substance use disorders in the United thesia or heavy sedation. Although the ultra­ States are in treatment at any time) (Office of rapid procedure under anesthesia has National Drug Control Policy 2002). Another received wide publicity, controlled studies contributing factor is the American culture’s that would make it possible to evaluate the search for rapidity in most endeavors. Finally, risk/benefit ratio are absent. The procedure the desire for rapid opioid detoxification is a is still unproven and controversial. For a remnant of the belief system of a century ago, brief review of studies done in this area, see when detoxification often was erroneously Stine and colleagues (2003). equated with cure. Rapid methods of detoxification have at their Patient Care and Comfort core the use of narcotic antagonists; for exam­ ple, naloxone, naltrexone, or nalmefene, to Opioid detoxification, when properly conduct­ precipitate narcotic withdrawal by displacing ed, usually can be concluded without signifi­ exogenous opioids (those not produced by the cant patient discomfort. Aside from the com­ body itself) from the receptor sites. The ensu­ passionate goal of preventing unnecessary suf­ ing severe symptoms then are managed by a fering, appropriate opioid detoxification variety of medications and techniques. This strengthens the therapeutic alliance between procedure was tried in the mid­1970s (Blachly the patient and clinician and prevents patients et al. 1975; Resnick et al. 1977), using naloxone from leaving treatment prematurely. combined with benzodiazepines or propranolol Discomfort also can indicate that too low a dose to ameliorate symptoms, but relief was insuffi­ of the detoxification agent is being adminis­ cient for the technique to be considered useful. tered. Mere symptomatic treatment is not a substitute for reversing opioid withdrawal With the discovery of clonidine as a nonopi­ and care should be taken to avoid masking oid that could successfully treat much of the symptoms that would better respond to withdrawal syndrome (Gold et al. 1978), the detoxification. method became more successful, but was still problematic. Using combinations of clonidine, Nevertheless, patients receiving adequate naltrexone, benzodiazepines, and other detoxification doses still may complain of adjunct medications, the method was refined symptoms that can be treated with adjunctive

Physical Detoxification Services for Withdrawal From Specific Substances 73 medications. Insomnia can be treated with Benzodiazepines diphenhydramine (Benadryl) 50 to 100mg, trazodone (Desyrel) 75 to 200mg, or hydrox­ and Other Sedative­ yzine (Vistaril) 25 to 50mg at bedtime. Benzodiazepines should be avoided unless Hypnotics required for concomitant alcohol or sedative detoxification. Headache, muscle aches, and Intoxication and Withdrawal bone pain can be managed with acetamin­ Symptoms Associated With ophen (e.g., Tylenol), aspirin, or ibuprofen Benzodiazepines and Other (e.g., Motrin) as needed. Abdominal cramps are rare when the detoxification dose is suffi­ Sedative­Hypnotics cient but can be ameliorated with dicyclomine Patients intoxicated with sedative­hypnotics (e.g., Bentyl) 10 to 20mg every 6 hours. appear similar to individuals intoxicated with Mylanta or Maalox can be administered for alcohol. Slurred speech, ataxia, and poor phys­ epigastric complaints and bismuth subcar­ ical coordination are prominent. If benzodi­ bonate (e.g., Pepto­Bismol) 30 cc can be given azepines are used alone, breath and blood alco­ every 2 to 3 hours for diarrhea. Constipation, hol levels should be zero. It should be remem­ a frequent complaint during methadone main­ bered that benzodiazepines, when ingested tenance, usually can be managed with milk of alone, intentionally, or accidentally in over­ magnesia at 30 cc daily. dose, rarely lead to death by themselves. Unfortunately, most individuals who ingest Opioid dependence, particularly intravenous benzodiazepines also may be using alcohol, heroin dependence, is associated with a num­ other sedative­hypnotics, or other drugs of ber of medical conditions. For this reason, a abuse, which in combination with benzodi­ complete physical examination, review of sys­ azepines could be fatal if not managed appro­ tems, and laboratory evaluation (when indi­ priately. cated) should be conducted. The patient should be screened for tuberculosis as well as Management of benzodiazepines and other for commonly encountered medical complica­ sedative­hypnotics in overdose is in part sup­ tions. These include HIV/AIDS, viral hepati­ ported following principles of ACLS with par­ tis (especially B and C), other sexually trans­ ticular attention to ventilation. Additionally, mitted diseases, and opportunistic infections. removal of the benzodiazepine from the gas­ Injection sites should be examined for infec­ trointestinal tract using lavage and a cathar­ tion or abscess and patients should be tic is generally carried out, particularly if the queried about night sweats, chills, nutritional overdose is recent. Flumazenil (Romazicon) is intake, diarrhea and gastrointestinal distress, a competitive antagonist that acts at the ben­ fever, and cough. History or evidence of trau­ zodiazepine receptor. It can reverse the seda­ ma also should be elicited as part of a com­ tive and overdose effects of benzodiazepines prehensive assessment upon which a full but not of alcohol or other sedative­hyp­ treatment plan will be based. In general, notics. The medication is administered via IV patients should be ambulatory and able to by slow push (2 to 3 minutes) and dosage participate in rehabilitative activities during varies, depending on whether one is treating detoxification. However, during the first 24 sedation reversal or overdose coma­reversal. hours they may require bed rest or reduced Flumazenil is only effective in benzodiazepine activity. overdose and is not an effective antidote against other drugs. Clinicians should be aware that in chronic benzodiazepine users who are physically dependent, flumazenil may induce seizures, high blood pressure,

74 Chapter 4 and delirium. So patients who are comatose diazepine are at risk for falls and myocardial from benzodiazepines and are benzodiazepine infarctions. Delirium without marked auto­ dependent may move quickly from coma to nomic hyperactivity (no elevations of pulse, acute benzodiazepine withdrawal symptoms blood pressure, or temperature) also may be when flumazenil is administered. seen in the elderly. The management of benzo­ diazepine withdrawal is not recommended Assessing the potential or actual severity of a without medical supervision. All benzodi­ benzodiazepine and other sedative­hypnotic azepines should be tapered rather than stopped abstinence syndrome is based primarily on abruptly, regardless of dose or duration of clinical information obtained from the patient, use—unless it is a significant others, and physical assessment. matter of use for only Confirmation of length of benzodiazepine treat­ a few days (Ashton ment with significant others, local pharmacies, 2002). Patients and treating physicians is useful. Specific name of medication, dose, and duration of therapy intoxicated with are vital. The presence or absence of alcohol Management use is also important to know, as with the use of of other sedative­hypnotics, such as medications sedative­hypnotics for sleep. The existence of co­occurring psychi­ Withdrawal atric disorders such as panic disorder also are With appear similar to important factors and should be investigated. Medications Cigarette smoking tends to induce the individuals There are a limited metabolism of some benzodiazepines and this number of controlled can be a factor in scheduling a taper. Physical trials that can pro­ intoxicated with assessment, with particular attention to mental vide guidance regard­ status, and neurologic exams are important. ing the management alcohol. Slurred Determination of vital signs also provides guid­ of benzodiazepine ance. A urine drug screen may confirm the and other sedative­ speech, ataxia, presence of benzodiazepines but otherwise will hypnotic withdrawal. not be particularly helpful. Although sedative­ For reviews, see hypnotic withdrawal scales have been used in and poor physical Rickels and col­ research studies, they are not widely available leagues (1999) and for clinical practice. coordination are Eickelberg and Mayo­ Medical complications of withdrawal from ben­ Smith (1998). One prominent. zodiazepines include problems similar to those strategy that is appro­ seen in alcohol withdrawal. Seizures are partic­ priate is to begin with ularly worrisome and may occur without being a slow taper of the preceded by other evidence of withdrawal. As benzodiazepine that the patient already is tak­ in alcohol withdrawal, seizures and delirium ing. This taper may be conducted over several represent the most extreme pathology seen. weeks or perhaps even months. This may be Anecdotal reports appearing in the literature effective in cases of long­acting benzodiazepines also have described distortions in taste, smell, but often is not effective in detoxification from and other perceptions. Since many individuals short half­life benzodiazepines. Sometimes who take benzodiazepines have underlying switching to another benzodiazepine in a anxiety disorders, it often is difficult during patient who has had serious loss of control and periods of withdrawal to determine whether abuse problems with his primary agent is ther­ symptomatology is related to withdrawal or the apeutic. Another strategy is to switch the emergence of panic attack symptoms. Elderly patient to another benzodiazepine with a long patients who are being withdrawn from benzo­ half­life. Frequently chlorodiazepoxide and

Physical Detoxification Services for Withdrawal From Specific Substances 75 clonazepam are recommended. Figures 4­5 and that, in more severe withdrawal syndromes, 4­6 (p. 78) give the equivalent doses of these they do not decrease symptoms. Imipramine medicines along with numerous other sedative­ can lower the seizure threshold and therefore hypnotics and benzodiazepines. is not recommended. The use of anticonvul­ sants is probably best reserved as an adjunc­ Another alternative is phenobarbital substitu­ tive medicine to the long­acting benzodi­ tion. For patients who have used high doses of azepine or phenobarbital. The use of bus­ benzodiazepines for an extended period of pirone for benzodiazepine detoxification is time, hospitalization is always prudent. ineffective and should not be considered. For Outpatient detoxification should be reserved patients with major autonomic symptoms dur­ for patients whose doses of benzodiazepines ing withdrawal that cannot be controlled by were mainly in therapeutic ranges, who do not the primary treating agent, consideration of have polysubstance dependence, and who are the use of a low dose of clonidine or propra­ reliable and have reliable significant others to nolol may be helpful. aid in monitoring and supervising their progress. In the outpatient setting, patients and Preparing patients and starting detoxification families need to be informed that even with during a period of low external stressors, with sound withdrawal treatment, seizures and patient commitment to tapering, and a plan to delirium are possible. The individual should be manage underlying anxiety disorders, also are instructed not to drive or operate dangerous important in detoxification. A flexible detoxi­ machinery during treatment and perhaps for fication schedule is advised. During periods several weeks thereafter. Recurring assessment of increased withdrawal symptoms, dosage will be necessary, particularly around times of should be stabilized or even increased for a dosage reductions. Pregnant patients will need period of days. Frequent in­person or phone to be detoxified slowly and in consultation with contact with the patient is vital. Patients an obstetrician. being detoxified in the outpatient setting may need to be seen several times per week, espe­ A variety of cognitive and behavioral tech­ cially at times of dosage reductions. niques have been proposed to assist in the pres­ ence of a medication taper. These techniques alter negative cognitions regarding medication Stimulants cessation, provide patient education, and pro­ Cocaine and amphetamines (such as metham­ vide alternative cognitive and behavioral tech­ phetamine) are the most frequently abused cen­ niques for anxiety reduction and sleep tral nervous system stimulants. These agents enhancement during detoxification (Spiegel are intensely rewarding and are self­adminis­ 1999). tered by laboratory animals to the point of Anticonvulsants such as carbamazepine and death. Individuals dependent on stimulants valproate, as well as sedating antidepressants experience profound loss of control over stimu­ such as trazodone and imipramine, have been lant intake, presumably in response to the advocated for use in withdrawal (Dickinson et stimulation and disruption of endogenous (orig­ al. 2003). Rickels and colleagues (1999) assert inating internally) reward centers (Dackis and that these drugs have some beneficial effect in O’Brien 2001). They often use stimulants in a the management of relatively low­dose benzo­ binge pattern that is followed by periods of diazepine discontinuation in their ability to withdrawal. It is not clear whether craving reduce patients’ subjective complaints, but occurs predominantly during stimulant with­

76 Chapter 4 Figure 4­5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents

Generic name Trade name Therapeutic dose Dose equal to Phenobarbital range (mg/day) 30mg of pheno­ conversion barbital for with­ constant drawal (mg)**

Benzodiazepines

alprazolam Xanax 0.75–6 1 30

chlordiazepoxide Librium 15–100 25 1.2

clonazepam Klonopin 0.5–4 2 15

clorazepate Tranxene 15–60 7.5 4

diazepam Valium 4–40 10 3

estazolam ProSom 1–2 1 30

flumazenil Mazicon *** *** ***

flurazepam Dalmane 15–30* 15 2

halazepam Paxipam 60–160 40 0.75

lorazepam Ativan 1–16 2 15

midazolam Versed *** *** ***

oxazepam Serax 10–120 10 3

prazepam Centrax 20–60 10 3

quazepam Doral 15* 15 2

temazepam Restoril 15–30* 15 2

triazolam Halcyon 0.125–0.50* 0.25 120

* Usual hypnotic dose. ** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high­dose withdrawal signs and symptoms. *** Not applicable.

Source: American Psychiatric Association (APA) 1990; Wesson and Smith 1985.

Physical Detoxification Services for Withdrawal From Specific Substances 77 Figure 4­6 Other Sedative­Hypnotics and Their Phenobarbital Withdrawal Equivalents

Generic name Trade Common Dose equal Phenobarbital Conversion name(s) therapeutic to 30mg of for with­ constants indication therapeutic drawal (mg)** dose range (mg/day)

Barbiturates amobarbital Amytal sedative 50–150 100 0.33 butabarbital Butisol sedative 45–120 100 0.33 butalbital Fiorinal, sedative/ 100–300 100 0.33 Sedapap analgesic* pentobarbital Nembutal hypnotic 50–100 100 0.33 secobarbital Seconal hypnotic 50–100 100 0.33

Others buspirone Buspar sedative 15–60 *** *** chloral hydrate Noctec, hypnotic 250–1,000 500 0.06 Somnos ethchlorvynol Placidyl hypnotic 500–1,000 500 0.06 glutethimide Doriden hypnotic 250–500 250 0.12 meprobamate Miltown, sedative 1,200–1,600 1,200 0.025 Equanil, Equagesic methylprylon Noludar hypnotic 200–400 200 0.15

* Butalbital usually is available in combination with opioid or non­opioid analgesics. ** Phenobarbital withdrawal conversion equivalence is not the same as therapeutic dose equivalency. Withdrawal equivalence is the amount of the drug that 30mg of phenobarbital will substitute for and prevent serious high­dose withdrawal signs and symptoms. *** Not cross­tolerant with barbiturates.

Source: APA 1990; Wesson and Smith 1985.

78 Chapter 4 drawal or after these symptoms have largely or amphetamine withdrawal and, in part, a disappeared. While the processes that govern reaction to individuals’ acute realization of the addiction to cocaine and amphetamines are devastating psychosocial consequences after a believed to be similar, recent animal research binge ends. While both cocaine and suggests that there are also subtle differences in amphetamine users may experience depression the ways in which these two types of drugs cre­ during withdrawal, the period of depression ate sensitization (and perhaps addiction) in reg­ experienced by amphetamine users is more ular users (Li et al. 2005). prolonged and may be more intense. Amphetamine users, in particular, should be monitored closely during detoxification for Stimulant Withdrawal signs of suicidality and treated for depression if Symptoms appropriate. Stimulants are associated with withdrawal Although the literature on cocaine withdrawal symptoms that differ markedly from those seen is controversial, reasonable consensus supports with opioid, alcohol, and sedative dependence the constellation of symptoms depicted in (see Figure 4­7). While most clinicians believe Figure 4­7 (Coffey et al. 2000; Cottler et al. that alcohol and heroin withdrawal should be 1993). These symptoms often disappear after treated aggressively with detoxification, there several days of stimulant abstinence but can has been little emphasis on treating symptoms persist for 3 to 4 weeks (Coffey et al. 2000). In of stimulant withdrawal. Consequently, no addition, since individuals addicted to stimu­ medications have been developed for this pur­ lants often fail to achieve abstinence, withdraw­ pose. This situation is understandable because al symptoms can be a persistent component of stimulant withdrawal usually does not involve active addiction. In addition, individuals medical danger or intense patient discomfort. addicted to stimulants may experience impair­ However, if stimulant withdrawal predicts poor ment in hedonic function (ability to experience outcome, it may be a reasonable target for clin­ pleasure) that has been ascribed to stimulant­ ical interventions. induced disruptions of endogenous reward cen­ An often overlooked but potentially lethal ters (Dackis and O’Brien 2002). Research on “medical danger” during stimulant withdrawal animals has found that exposure to high doses is the risk of a profound dysphoria (depres­ of methamphetamine results in changes to both sion, negative thoughts and feelings) that may the dopaminergic and serotonergic systems of include suicidal ideas or attempts. This may the brain (Nordahl et al. 2005) and dopamine be, in part, a physiological response to cocaine abnormalities among animals and humans who had been ingesting cocaine (Schuckit 2000).

Figure 4­7 Stimulant Withdrawal Symptoms

•Depresion •Poor concentration •Hypersomnia (or insomnia) •Psychomotor retardation •Fatigue •Increased appetite •Anxiety •Paranoia •Irritability •Drug craving

Source: Consensus Panelist Robert Malcolm, M.D.

Physical Detoxification Services for Withdrawal From Specific Substances 79 Researchers have also observed abnormalities electrocardiogram (between the q wave and the in regions of the brain that govern attention t wave), while QTc is the relative (or “correct­ and memory in animals that were regularly ed”) QT interval. Some conditions and many administered methamphetamine (Nordahl et al. drugs (LAAM, other opioids, and even antibi­ 2005). otics) can cause the interval to lengthen and this can result in cardiac rhythm disturbances. Although cocaine withdrawal has traditionally Anterior chest pain or cardiac symptoms been viewed as relatively mild (Satel et al. should therefore be fully evaluated in these 1991; Weddington et al. 1990), evidence sug­ individuals. Seizures also may be a complica­ gests that individuals dependent on cocaine tion of stimulant abuse and can occur during with severe stimulant withdrawal are more like­ detoxification. Persistent headaches could rep­ ly to have a poor clinical outcome (Kampman resent a subdural, subarachnoid, or intracere­ et al. 2001a). The level of withdrawal symp­ bral bleed (bleeding in or around the brain) toms, therefore, may be clinically significant and should be appropriately evaluated. It also and should be monitored and recorded for should be emphasized that people who abuse future treatment (Kampman et al. 2001b). stimulants usually become addicted to other Kampman reported significantly higher substances, such as alcohol, sedatives, or opi­ dropout rates in individuals dependent on oids, and therefore can experience any of the cocaine who scored high on the Cocaine complications ascribed to detoxification from Selective Severity Assessment (CSSA), a reli­ these substances. Covert (secretive) use of able and valid structured interview designed to other substances should be suspected and capture cocaine withdrawal symptoms assessed with urine toxicology. (Kampman et al. 1998). Patients with high scores on the CSSA were five times more likely to leave treatment and four times more likely to Management of Withdrawal resume cocaine use than those with low scores Without Medications (Mulvaney et al. 1999). The CSSA is an easily administered 18­item questionnaire. Each item The most effective means of treating stimulant is a 7­point rating scale, so that a person can withdrawal involves establishing a period of score a number of points on any given ques­ abstinence from these agents. Access to brief tion. Scores in excess of 22 indicate the pres­ hospitalization, a level of care previously avail­ ence of significant cocaine withdrawal. See able for those who abuse stimulants, has been appendix C for more information on the CSSA. largely eliminated by managed care initiatives. Given the poor prognosis associated with In its place, intensive outpatient treatment can cocaine withdrawal, it is reasonable that more assist the patient to cease use long enough for clinical attention be directed toward this phe­ withdrawal symptoms to abate entirely. nomenon. Rehabilitative approaches to achieve stimulant abstinence have been reviewed elsewhere (Dackis and O’Brien 2001). The avoidance of Medical Complications of cue­induced craving is particularly important Stimulant Withdrawal in these individuals, especially in light of research that shows limbic activation (activity As previously noted, stimulant withdrawal is in a certain part of the brain) in response to not usually associated with medical complica­ cue­induced craving (Childress et al. 1999). It tions. However, patients with recent cocaine also is important that individuals dependent on use can experience persistent cardiac complica­ stimulants abstain from other addictive sub­ tions, including prolonged QTc interval and stances. vulnerability for arrhythmia and myocardial infarction (Chakko and Myerburg 1995). QT is an interval of time that can be measured on an

80 Chapter 4 Management of Withdrawal or hydroxyzine (Vistaril) 25 to 50mg at bed­ With Medications time. Benzodiazepines should be avoided unless required for concomitant alcohol or sedative There are no medications with proven efficacy detoxification. As stimulant withdrawal symp­ to treat stimulant withdrawal. However, toms wane, patients are best treated with an researchers have investigated some medications active rehabilitative approach that combines for cocaine detoxification. Amantadine may entry into substance abuse treatment with sup­ help reduce cocaine use in patients with more port, education, and changes in lifestyle. severe withdrawal symptoms (Kampman et al. 2000). Modafinil, an antinarcolepsy agent with stimulant­like action, is currently under inves­ Other Immediate Concerns tigation by one research group as a cocaine Central nervous system stimulants exert most detoxification agent (Dackis and O’Brien of their toxic effects through vasoconstriction 2002). One small study in Thailand found the (constriction of the blood vessels). antidepressant mirtazapine (Remeron) was Consequently, a number of medical conditions effective at reducing a number of the symptoms can arise from associated with amphetamine withdrawal ischemia (lack of (Kongsakon et al. 2005). None of these medica­ proper blood supply) Intensive tions, however, are approved for use in treating or infarction (death stimulant withdrawal and further research is of tissue as the result outpatient needed. Gorelick and colleagues (2004) review of lack of blood sup­ the full range of clinical literature on pharma­ ply) as a result of cological intervention for cocaine addiction. stimulant use. treatment can Myocardial (heart muscle) infarction assist the patient Patient Care and Comfort and stroke are widely Since stimulant withdrawal is not associated recognized complica­ to cease use long with severe physical symptoms, adjunctive tions of stimulant use. medications are seldom required. These However, other prob­ enough for patients often are sleep deprived and might be lems such as sponta­ unable to benefit from therapeutic activities neous abortion, bowel withdrawal during the first 24 to 36 hours of abstinence. necrosis (tissue They often are hungry and in need of large death), and renal symptoms to abate meal portions initially as their food intake may (kidney) infarction have been inadequate during active addiction. also have been Stimulant users also may be irritable and care reported from entirely. should be taken to avoid needless confrontation cocaine­induced vaso­ during the initial withdrawal phase. Headaches constriction. Cardiac often are reported and can be treated symp­ arrhythmias also are common. Other medical tomatically. Persistent headaches should be problems that are associated with stimulant evaluated, as cocaine can produce cerebrovas­ dependence include dental disease, neuropsy­ cular disease. Similarly, chest pain of possible chiatric abnormalities, and movement distur­ cardiac origin should be evaluated medically bances/disorders. with electrocardiography, cardiac enzymes, and appropriate medical attention. On occa­ Antidepressants, such as selective serotonin sion, patients undergoing withdrawal from reuptake inhibitors, can be prescribed for the cocaine or amphetamines report insomnia and depression that often accompanies metham­ may benefit from diphenhydramine (Benadryl) phetamine or other amphetamine withdrawal. 50 to 100mg, trazodone (Desyrel) 75 to 200mg,

Physical Detoxification Services for Withdrawal From Specific Substances 81 Inhalants/Solvents There are no specific assessment instruments available to measure inhalant withdrawal symptoms. A patient who presents with a his­ Withdrawal Symptoms tory of inhalant use and symptoms of seda­ Associated With tive­like withdrawal should alert the clinician Inhalants/Solvents to the possibility of inhalant withdrawal. These patients require a complete history and The term “inhalants” is used to describe a physical exam. Additionally, a blood alcohol large and varied group of psychoactive sub­ level and urine drug screen are helpful in the stances that all share the common characteris­ cases of suspected polydrug abuse. tic of being inhaled for their effects. They are commonly found in household, industrial, and medical products. These drugs are used pri­ Medical Complications of marily by adolescents, although some, especial­ Withdrawal From ly the nitrates, are used by adults as well Inhalants/Solvents (NIDA 2000). Figure 4­8 presents some of the more commonly abused inhalants. There are a large number of medical complica­ tions associated with inhalant abuse and intoxi­ Dependence on inhalants and subsequent cation. Many of these complications are not the withdrawal symptoms are both relatively result of withdrawal but may still be seen when uncommon phenomena (Balster 2003). There the patient presents to the clinician. Most is no specific or characteristic withdrawal inhalants produce some neurotoxicity with cog­ syndrome that would include all drugs in the nitive, motor, and sensory involvement. inhalant class. Intoxication with the solvents, Additionally, damage to internal organs includ­ aerosols, and gases often produces a syn­ ing the heart, lungs, kidneys, liver, pancreas, drome most like that of alcohol intoxication and bone marrow has been reported. but lasting only 15 to 45 minutes (Miller and Gold 1990). Rarely, symptoms similar to sedative withdrawal have been described, Management of Withdrawal including “fine tremors, irritability, anxiety, Without Medications insomnia, tingling sensations, seizures and It is crucial to provide the patient with an envi­ muscle cramps” (Miller and Gold 1990, p. ronment of safety that removes him from access 87). Toluene withdrawal has been reported to to inhalants. This can pose a challenge due to cause delirium tremens (Miller and Gold the almost universal availability of these drugs 1990). Longtime users also may exhibit weak­ in society. Many of the medical consequences of ness, weight loss, inattentive behavior, and inhalant usage will remit once the patient depression (NIDA 2005). It has been reported achieves abstinence (Balster 2003). The patient that withdrawal symptoms can occur with as should be monitored for withdrawal symptoms little as 3 months of regular usage (Ron 1986). and changes in mental status. When present, the withdrawal typically lasts 2 to 5 days (Evans and Raistrick 1987). Most patients presenting for treatment of inhalant dependence will be adolescents. In addition to their short­term intoxicating Ideally, they should be entered into an age­ affects, nitrates are used to enhance sexual appropriate treatment program that meets pleasure by vasodilation (dilation of blood their medical and psychosocial needs. vessels) that produces a rush and sensation of Supportive care, including helping them to get warmth. There is no withdrawal syndrome enough sleep and a well­balanced diet, usually that has been associated with nitrate abuse. will be sufficient to get patients safely through withdrawal (Frances and Miller 1998).

82 Chapter 4 Figure 4­8 Commonly Abused Inhalants/Solvents Type Example Chemicals in Inhalant/Solvent

Adhesives Airplane glue Toluene, ethyl acetate Other glues Hexane, toluene, methyl chloride, acetone, methyl ethyl ketone, methyl butyl ketone Special cements Trichloroethylene, tetrachloroethylene Aerosols Spray paint Butane, propane (U.S.), fluorocarbons, toluene, hydro­ carbons, “Texas shoe shine” (a spray containing toluene) Hair spray Butane, propane (U.S.), chlorofluorocarbons (CFCs) Deodorant; air freshener Butane, propane (U.S.), CFCs Analgesic spray CFCs Asthma spray CFCs Fabric spray Butane, trichloroethane PC cleaner Dimethyl ether, hydrofluorocarbons Anesthetics Gaseous Nitrous oxide Liquid Halothane, enflurane Local Ethyl chloride Cleaning agents Dry cleaning Tetrachloroethylene, trichloroethane Spot remover Xylene, petroleum distillates, chlorohydrocarbons

Degreaser Tetrachloroethylene, trichloroethane, trichloroethylene

Management of Withdrawal has been established, although some clinicians have found phenobarbital useful (CSAT With Medications 1995d). The usefulness of benzodiazepines is Patients presenting with only inhalant with­ unknown but would seem a reasonable alter­ drawal are unusual. Clinicians should prompt­ native given our current understanding of ly ascertain if the patient has been abusing any inhalant withdrawal (Brouette and Anton other substances and proceed with appropriate 2001). No other medications have been rou­ detoxification as clinically indicated. When a tinely used for inhalant withdrawal. patient presents with (1) a history of extensive inhalant usage, (2) a sedative­like withdrawal syndrome, and (3) no significant history or lab­ Patient Care and Comfort oratory data that supports other substances, For patients who have only been abusing then the clinician can assume that the patient is inhalants, treatment of insomnia during with­ in inhalant withdrawal. drawal is not usually necessary. Sedative sub­ stitution during the period of detoxification As noted before, withdrawal from inhalants is may allow the patient to sleep. However, a similar to withdrawal from sedative­hyp­ period of postdetoxification insomnia should notics. No systematic detoxification protocol be expected and usually can be treated by the

Physical Detoxification Services for Withdrawal From Specific Substances 83 Figure 4­8 (continued) Commonly Abused Inhalants/Solvents Solvents and gases Nail polish remover Acetone, ethyl acetate

Paint remover Toluene, methylene chloride, methanol acetone, ethyl acetate Paint thinner Petroleum distillates, esters, acetone

Correction fluid and thinner Trichloroethylene, trichloroethane

Fuel gas Butane, isopropane

Lighter Butane, isopropane

Fire extinguisher Bromochlorodifluoromethane

Food products Whipped cream Nitrous oxide

Whippets Nitrous oxide

“Room odorizers” Locker Room, Rush, Isoamyl, isobutyl, isopropyl or butyl nitrate (now legal), Poppers cyclohexyl Source: Balster 2003.

recommendation of good sleep hygiene prac­ Nicotine tices such as avoiding caffeine, daytime nap­ ping, and overstimulation in the evening. In 2004, approximately 44.5 million adults were cigarette smokers (23.4 percent were If the patient is able to refrain from inhalant men and 18.5 percent were women) (CDC (and other substance) use and has no serious 2005a). Nicotine addiction in the form of psychiatric or medical consequences, then cigarette smoking accounts for more deaths outpatient treatment should be the first each year than AIDS, alcohol, cocaine, hero­ option. Inpatient or residential treatment in, homicide, suicide, motor vehicle crashes, should be used for those patients who cannot and fires combined (U.S. Department of achieve abstinence or have serious co­occur­ Health and Human Services [U.S. HHS] ring medical or psychiatric disorders. 2000b). Between 1995 and 1999, there were Hospitalized patients will need a thorough 490,000 smoking­related premature deaths history and physical exam. Therapy to annually, and smoking cost the country at address denial, addiction, and pertinent psy­ least $157 billion yearly in health­related eco­ chosocial issues should be initiated as soon as nomic losses. This amounts to approximately possible during the hospitalization. $7.18 per pack of cigarettes (Fellows et al. Supportive care and abstinence will resolve 2002), a truly staggering figure. most medical problems associated with chron­ ic inhalant usage (Balster 2003). Smokers are at increased risk for several medical problems, including myocardial infarction, coronary artery disease, hyperten­ sion, stroke, peripheral vascular disease,

84 Chapter 4 chronic obstructive lung disease, chronic drink, and others have shown that continued bronchitis, and several types of cancer (lung, nicotine dependence may be a relapse trigger stomach, head and neck, and bladder). Other for resumption of drinking (Stuyt 1997). The problems associated with nicotine addiction concern that smoking cessation may precipi­ include gastro­esophageal reflux disease and tate relapse to other substances of abuse has gastric ulcerations, cataracts, and premature not been supported in the literature (Hughes wrinkling of the skin. There also appears to 1995). be an antiestrogen effect (suppression of an important hormone) that may lead to early Treatment programs that have attempted to development of osteoporosis in women treat nicotine dependence in conjunction with (Okuyemi et al. 2000). other drugs of addiction have met with limit­ ed success (Bobo and Davis 1993; Burling et In 1988, the U.S. Surgeon General’s Report al. 1991; Hurt et al. 1994) and have generat­ concluded that nicotine is the principal addic­ ed increased interest in smoking cessation as tive agent in tobacco. Nicotine binds to nico­ a part of a patient’s overall substance abuse tinic acetylcholine receptors in the brain and treatment (Sees and Clark 1993). One study has the direct ability to stimulate the release reported that forcing unmotivated patients of dopamine in the nucleus accumbens area. (or patients who did not consider smoking a The nucleus accumbens has long been consid­ problem) to quit was countertherapeutic ered the “reward center” in the brain. This (Trudeau et al. 1995). increase in dopamine is similar to what occurs when patients use stimulants and is felt to be Moreover, it has traditionally been accepted an essential element in the reward process of that nicotine detoxification concurrent with addiction (Glover and Glover 2001). detoxification from other substances makes the undertaking more difficult. Several fac­ As many as 90 percent of patients entering tors are involved including the following: (1) treatment for substance abuse are current patient ambivalence and/or lack of interest in nicotine users (Perine and Schare 1999). smoking cessation; (2) physician ambivalence There has long been controversy in the field about the importance of smoking cessation of addiction medicine as to how best to handle early in treatment; (3) staff’s use of nicotine; the problem of nicotine dependence in (4) staff’s ambivalence about the importance patients seeking treatment for other types of of nicotine cessation early in treatment; (5) substance abuse. Traditionally, it has been easy availability of cigarettes from peers, argued that patients would find that trying to family, visitors, staff, and at 12­Step meet­ stop smoking while also contending with other ings; (6) lack of sufficient training and exper­ (more pressing) addiction problems would be tise on the part of physicians and staff in too difficult and distracting in early absti­ managing nicotine withdrawal; and (7) staff nence. However, others argue that nicotine resistance to patient smoking cessation dependence is a lethal disease and that physi­ because withdrawal symptoms include irri­ cians have the responsibility to intervene in tability, anxiety, and depression, all of which this addiction with the same aggressiveness can make patients more difficult to manage. they show toward other addictive substances. This pro­intervention position has received increasing attention from clinicians, inasmuch Withdrawal Symptoms as it is now understood that alcohol consump­ Associated With Nicotine tion is associated with increased nicotine The Diagnostic and Statistical Manual of usage (Henningfield et al. 1984). Gulliver and Mental Disorders, 4th edition, text revision colleagues (1995) have demonstrated that the (DSM­IV­TR) (APA 2000) notes that typically, urge to smoke is correlated with the urge to a person in nicotine withdrawal will have four

Physical Detoxification Services for Withdrawal From Specific Substances 85 or more of the signs presented in Figure 4­9, 4­10) has been reduced to six questions though some clinicians believe that three or (Giovino et al. 1995; Heatherton et al. 1991). more is sufficient to make the diagnosis of Scores greater than seven are consistent with nicotine withdrawal. Furthermore, it should nicotine dependence. be noted that symptoms vary in duration and intensity, with decreased heart rate and light­ While both the FTQ and FTND are very use­ headedness resolving in 48 hours, while ful for estimating a patient’s physical depen­ increased appetite may remain present for dence on nicotine, there is still a need to weeks to months (Glover and Glover 2001). assess more accurately the degree to which Smokers who have severe craving during smoking behavior plays a role in maintaining withdrawal are less likely to be successful in addiction. The Glover­Nilsson Smoking their attempt at quitting (Hughes and Behavioral Questionnaire (GN­SBQ) is an 11­ Hatsukami 1992). Depression during with­ question, self­administered test that evaluates drawal also has been linked to relapse to the impact of behaviors and rituals associated smoking (Covey et al. 1993). with smoking (see Figure 4­11, p. 88). It was designed to assist clinicians in identifying and quantifying behavioral aspects of smoking Assessing Severity that play a role in maintaining nicotine Since 1978, the standard instrument used to dependence, which can then help the clinician measure physical dependence on nicotine has develop a cessation strategy that takes into been the eight­item Fagerstrom Tolerance account both physical dependence and behav­ Questionnaire (FTQ) (Fagerstrom 1978). A ioral dependence (Glover et al. 2002). later revision known as the Fagerstrom Test for Nicotine Dependence (FTND) (see Figure

Figure 4­9 DSM­IV­TR on Nicotine Withdrawal

A. Daily use of nicotine for at least several weeks. B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by 4 or more of the following signs: 1. Dysphoric or depressed mood 2. Insomnia 3. Irritability, frustration, or anger 4. Anxiety 5. Difficulty concentrating 6. Restlessness 7. Decreased heart rate 8. Increased appetite or weight gain C. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Source: APA 2000, pp. 244–245.

86 Chapter 4 Figure 4­10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence

Questions Answers Points

1. How soon after you wake up do you smoke your Within 5 minutes 3 first cigarette? 6–30 minutes 2 31–60 minutes 1 After 60 minutes 0

2. Do you find it difficult to refrain from smoking in Yes 1 places where it is forbidden (e.g., in church, at the No 0 library, in the cinema, etc.)?

3. Which cigarette would you hate most to give up? The first thing in the morning 1 All others 0

4. How many cigarettes/day do you smoke? 10 or less 0 11–20 1 21–30 2 31 or more 3

5. Do you smoke more frequently during the first Yes 1 hours of waking than during the rest of the day? No 2

6. Do you smoke if you are so ill that you are in bed Yes 1 most of the day? No 0

Source: APA 1996.

To better understand a patient’s level of nico­ tine replacement therapy and patients often tine dependence, providers can assess bio­ find it a helpful motivator in their attempt to chemical markers including nicotine, coti­ maintain abstinence (Benowitz 1983). nine, and carbon monoxide. Nicotine and its metabolite cotinine can be measured in urine, blood, or saliva. Cotinine continues to be pre­ Medical Complications of sent in bodily fluids for up to 7 days after ces­ Withdrawal From Nicotine sation. Clinicians should use caution when There are no major medical complications pre­ interpreting the meaning of nicotine and coti­ cipitated by nicotine withdrawal itself. nine assays, as they are not specific to tobac­ However, patients frequently experience co­derived nicotine and may indicate the uncomfortable withdrawal symptoms starting patient’s compliance with nicotine replace­ within a few hours of cessation. In addition to ment therapy rather than smoking. the symptoms previously noted, patients may Carbon monoxide is easily measured in complain of increased coughing, a desire for expired breath and can show whether the sweets, and difficulty concentrating (Hughes patient has been smoking within a few hours and Hatsukami 1992). Clinicians should be prior to the test. It can be used to monitor aware that withdrawal symptoms can masquer­ smoking cessation for patients receiving nico­

Physical Detoxification Services for Withdrawal From Specific Substances 87 Figure 4­11 The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ)

Please indicate your choice by circling the number that best reflects your choice. 0 = Not at all; 1 = Somewhat; 2 = Moderately so; 3 = Very much so; 4 = Extremely so

How much do you value the following (Specific to Questions 1–2)? 1. My cigarette habit is very important to me. 0 1 2 3 4

2. I handle and manipulate my cigarette as part of the ritual of smoking. 0 1 2 3 4

Please indicate your choice by circling the number that best reflects your choice. (Specific to Questions 3–11). 0 = never; 1 = seldom; 2 = sometimes; 3 = often; 4 = Always

3. Do you place something in your mouth to distract you from smoking? 0 1 2 3 4

4. Do you reward yourself with a cigarette after accomplishing a task? 0 1 2 3 4

5. If you find yourself without cigarettes, will you have difficulties in concentrating before attempting a task? 0 1 2 3 4

6. If you are not allowed to smoke in certain places, do you then play with your cigarette pack or a cigarette? 0 1 2 3 4

7. Do certain environmental cues trigger your smoking (e.g., favorite chair, sofa, room, car, or drinking alcohol)? 0 1 2 3 4

8. Do you find yourself lighting up a cigarette routinely (without craving)? 0 1 2 3 4

9. Do you find yourself placing an unlit cigarette or other objects (pen, toothpick, chewing gum, etc.) in your mouth and sucking to get relief from stress, tension or frustration, etc.? 0 1 2 3 4

10. Does part of your enjoyment of smoking come from the steps (ritual) you take when lighting up? 0 1 2 3 4

11. When you are alone in a restaurant, bus terminal, party, etc., do you feel safe, secure, or more confident if you are holding a cigarette? 0 1 2 3 4

TOTAL______Scoring for Behavioral Dependence <12 Mild 12–22 Moderate 23–33 Strong >33 Very Strong

Source: Glover et al. 2002

88 Chapter 4 ade as other psychiatric conditions, especially lent pharmaceutical guide. Figure anxiety and depression (see Figure 4­12). 4­13 (p. 90) shows the effects of abstinence from smoking on blood levels of a number of Smoking cessation also may affect the medications. metabolism of other drugs primarily through the Cytochrome P 450 (CYP450) system. This system is one of many hepatic liver enzyme sys­ Management of Withdrawal tems that is responsible for the metabolic Without Medications breakdown of various drugs into inactive com­ pound products. Different drugs and com­ About one third of current smokers attempt pounds have varying affinities for the CYP450 to quit smoking each year and more than 90 system. The higher the affinity, the faster the percent of these try to do so without any for­ breakdown of the drug or compound in the mal nicotine cessation treatment. Most smok­ body. Some compounds can slow the ers will make several attempts on their own to metabolism or breakdown of other drugs with a quit and ultimately, only about 50 percent are b lower affinity, leading to a buildup of that drug successful over a lifetime (U.S. HHS 2000 ). or compound in the body. While some smokers are able to quit on their own, others may require intervention in the During detoxification from nicotine, some form of behavioral treatment and/or pharma­ medications will have their metabolism cotherapy. altered, including theophylline, caffeine, tacrine, imipramine, haloperidol, penta­ There are insufficient data available to deter­ zocine, propranolol, flecainide, and estradiol; mine who will benefit most from a particular in general, these effects are short­lived and type of treatment. Some patients may prefer seldom drastic. Nicotine also reduces beta to stop smoking without the use of medica­ blockers’ ability to lower blood pressure and tion. An elevated score on the GN­SBQ would heart rate and decreases the amount of seda­ indicate a strong behavioral component to tion from benzodiazepines as well as de­ smoking that might guide the clinician in rec­ creases the amount of pain relief provided by ommending behavioral treatment as a prima­ some opioids, most likely because of its stimu­ ry intervention. Patients who also have ele­ lant effects (Zevin and Benowitz 1999). A vated FTQ scores may benefit by a combina­ complete discussion of nicotine’s effects on tion of behavioral and pharmaceutical inter­ medications is beyond the scope of this TIP vention. and physicians are encouraged to consult the Physicians’ Desk Reference (2004) or equiva­

Figure 4­12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With Other Psychiatric Conditions

Anxiety Depression Increased REM (rapid eye movement) sleep Insomnia Irritability Restlessness Weight gain

Source: APA 1996.

Physical Detoxification Services for Withdrawal From Specific Substances 89 Figure 4­13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications

Abstinence Increases Blood Abstinence Does Not Increase Effect of Abstinence on Blood Levels Blood Levels Levels Is Unclear

Clomipramine Amitriptyline Alprazolam Clozapine Chlordiazepoxide Chlorpromazine Desipramine Ethanol Diazepam Desmethyldiazepam Lorazepam Doxepin Midazolam Fluphenazine Triazolam Haloperidol Imipramine Oxazepam Nortriptyline Propranolol

Source: APA 1996.

The U.S. Public Health Service’s Treating interventions alone have not been very suc­ Tobacco Use and Dependence: Clinical cessful at helping people achieve abstinence Practice Guideline is a comprehensive review from tobacco. The Guideline suggests, howev­ of the smoking cessation literature (Fiore et er, that self­help can be a useful adjunct to al. 2000a). It discusses a range of nonphar­ other forms of treatment (Fiore et al. 2000a). macological interventions for the management of withdrawal from nicotine; these can be sep­ One type of self­help intervention that shows arated into two basic categories: self­help some promise is the use of computer­generat­ interventions and behavioral interventions ed personalized written feedback for patients. (Anderson and Wetter 1997). The computer makes recommendations based on an individual’s response to standardized questions about her smoking (Etter and Self­help interventions Perneger 2001; Shiffman et al. 2000). Many tobacco users prefer to attempt to quit without any assistance from professionals. A Behavioral interventions number of self­help products are available that can assist them in their cessation The U.S. Public Health Service study noted attempts. These include a wide array of pam­ that when physicians took as little as 3 min­ phlets, manuals, video­ and audiotapes (e.g., utes to advise their patients to stop smoking, from the American Lung Association and the long­term quit rates were modestly improved National Cancer Institute), 12­Step self­help from 7.9 percent to 10.2 percent (Fiore et al. a support groups, and telephone helplines. The 2000 ). Westmaas and colleagues note that U.S. Public Health Service’s Guideline, which “simple, clear advice from a physician can be analyzed all types of self­help interventions considered an easy, cost­effective intervention together, found that the self­help approach to that not only moves smokers closer to the cessation yielded results only slightly better decision to quit, but also may motivate some than no intervention at all. To date, self­help smokers to make an actual attempt”

90 Chapter 4 (Westmaas et al. 2000, p. 58). The greater the effective but not routinely recommended amount of time in face­to­face interventions, (Fiore et al. 2000a). the higher the success rate for patients, but interventions as short as 3 minutes have been found to be effective (Fiore et al. 2000a). A Management of Withdrawal counseling session of longer than 10 minutes With Medications produced a cessation rate of 20.1 percent A U.S. Public Health Service panel recom­ compared to a rate of 10.9 percent for no mends that all primary care physicians pro­ treatment. The guideline also indicated that if vide a five­step intervention, known as the “5 cessation information is given by multiple A’s,” to all tobacco users. The panel recom­ types of providers (e.g., physician, psycholo­ mends that all smokers who want to quit gist, dentist, nurse, and pharmacist) it can should be offered active medication that has have a dramatic effect on cessation rates, been approved for assisting in smoking cessa­ increasing the rate to 23 percent compared to tion unless there is a medical contraindication 10.8 percent for patients who had no (Fiore et al. 2000a). Figure 4­14 provides a provider contact. summary of the “5 A’s” for brief intervention. A review of behavioral intervention studies concluded that both supportive care by a Nicotine Replacement clinician and the ability of patients to develop problemsolving and coping skills improved Therapy (NRT) success rates for smoking cessation (Anderson Nicotine polacrilex gum was approved by the and Wetter 1997). Other components such as FDA in 1984. In the 1990s other NRTs received cigarette fading (gradually decreasing the FDA approval, including the nicotine transder­ number of cigarettes smoked over a period of mal patch, the nicotine nasal spray, and the time), establishing a quit date, enhanced envi­ nicotine inhaler. Nicotine gum and nicotine ronmental support, improved diet and transdermal patch are now available over the increased exercise, relaxation training, and counter. After the acute withdrawal period, contingency contracting were not associated patients are then weaned off the medication with improved outcome. Aversive condition­ until they become nicotine free. All NRTs are ing, such as rapid smoking techniques, is

Figure 4­14 The “5 A’s” for Brief Intervention

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 quit attempt. For the patient willing to make a quit attempt, use counseling and pharmacother­ apy to help him or her quit.

Arrange followup. Schedule followup contact, preferably within the first week after the quit date.

Source: Fiore et al. 2000a, p. 26.

Physical Detoxification Services for Withdrawal From Specific Substances 91 effective, with 1­year quit rates between 11 and Bupropion SR 34 percent (Okuyemi et al. 2000). Bupropion SR (Sustained Release) was initially There has been some concern about the manufactured under the name Wellbutrin as a addictive potential of NRTs, and it has been treatment for major depressive disorder. In reported that 5 to 20 percent of patients using 1997, the FDA approved bupropion SR for nicotine polacrilex gum continue to use it for smoking cessation, and it has been marketed more than 1 year (Hughes 1989). There was under the name Zyban. Bupropion is a novel also initial concern that the nicotine nasal antidepressant that is involved primarily with spray, with its rapid onset of action and high dopamine but also affects adrenergic mecha­ plasma concentrations, might become a drug nisms in the central nervous system. Its exact of abuse. This has not been reported in the mechanism of action is unknown, but it is not a literature, and it nicotine substitute or replacement like the could be speculated NRTs. The recommended dose is 150mg daily that this is because for 3 days and then 150mg twice daily for 7 to of the nasal spray’s 12 weeks. Typically patients set their quit date relatively uncom­ 1 to 2 weeks from the time they start the medi­ Patients should be fortable side effects cation in order to get the drug to therapeutic that cause many levels. This is an ideal time for the patient to encouraged to use patients to dislike focus on making behavioral changes and enlist­ the product (Schuh ing social support to augment his quit attempt. combined NRT et al. 1997). In gen­ Bupropion SR has proven useful in smoking eral, withdrawal cessation with a 12­month abstinence rate of treatments if they symptoms from 35.5 percent compared to a placebo at 15.6 NRTs are mild com­ percent and the nicotine patch at 16.4 percent are unable to quit pared to those that (Westmaas et al. 2000). The most commonly occur in smoking reported side effects include dry mouth and using a single type cessation, and con­ insomnia. Bupropion SR should not be used in tinued use of these patients with a history of seizures, heavy alco­ hol use, head trauma, or with anorexia or of first line products may be the result of patients’ bulimia. fear of returning to pharmacotherapy. active smoking (APA 1996). For Other nonnicotine those patients who pharmacotherapy continue to use Covey and colleagues examined nonnicotine NRTs, providers pharmaceutical products that have been evalu­ should balance the patient’s continued depen­ ated in controlled trials of smoking cessation dence on nicotine with the considerable (Covey et al. 2000). These drugs include the health benefit of decreasing active tobacco following: usage. It is clear that constituents of tobacco •The alpha­2 agonist antihypertensive, other than nicotine are responsible for caus­ clonidine ing cancer. No ill effects have been attributed •The tricyclic antidepressant, nortriptyline to long­term use of nicotine replacement ther­ apy (Benowitz and Gourlay 1997). •The monoamine oxidase inhibitor (MAOI) antidepressant, moclobemide •The serotonin 5­HT1A agonist anxiolytic, buspirone

92 Chapter 4 •The antihypertensive CNS nicotinic receptor els, several clinical trials have evaluated the blocker, mecamylamine effectiveness of combining available products. •Oral dextrose tablets The simultaneous use of nicotine gum and the nicotine patch has been evaluated in several Although none of these agents has been studies. Short­term gains in cessation were seen approved by the FDA for smoking cessation, with the combination compared to either medi­ clonidine, nortriptyline, and moclobemide have cation alone, but no long­term benefits in absti­ all been found to be effective treatments (Covey nence were demonstrated (Anderson and et al. 2000). Clonidine may be a helpful Wetter 1997). Blondal and colleagues (1999) adjunct to nicotine replacement during acute compared the combination of nicotine nasal nicotine withdrawal. Doses of 0.05mg to 0.1mg spray and the nicotine patch to the patch alone three times a day can be tried as tolerated and found that at 3 months 37 percent of the (sedation and low blood pressure are con­ patients were smoke free (compared to 25 per­ cerns), and the medication needs to be tapered cent for the patch alone). An open­label study when discontinued to avoid rebound hyperten­ of the combined use of nicotine inhaler and the sion. nicotine patch found a 12­week cessation rate of 30 percent and good tolerability for the com­ Treating The Public Health Service’s bination (Westman et al. 2000). Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al. 2000a) has So­called “combination NRT” involves com­ classified nortriptyline and clonidine as sec­ bining different types of nicotine replacement ond­line treatments. Clonidine is an antihy­ products, such as the patch and gum, on the pertensive and may be appropriate for premise that doing so will boost nicotine patients addicted to certain types of drugs but blood levels. Further rationale for this prac­ not appropriate for others. The antidepres­ tice is that a “passive” nicotine delivery sys­ sant selective serotonin reuptake inhibitor tem (i.e., patch) produces relatively steady (SSRI) fluoxetine has been tested in a number levels of nicotine in the body that prevent the of multisite trials (Cook et al. 2004; Hitsman user from going below a threshold minimum et al. 1999; Niaura et al. 2002) and found to while “active” NRTs (i.e., gum, inhaler, have a small benefit at best, although for spray, sublingual tablet, etc.) permit the user patients who experience mild depressive to respond to situational cravings with ad libi­ states it may be a worthwhile adjunctive tum dosing on an acute basis. Several clinical treatment. The usefulness of other SSRIs for trials have evaluated the effectiveness of com­ smoking cessation is unknown, but studies bining available NRT products (for a review have generally been unfavorable. More infor­ see Silagy et al. 2000). After reviewing avail­ mation on smoking cessation for people with able data, the Guideline panel (Fiore et al. co­occurring substance use and other mental 2000a) felt that there was moderately strong disorders can be found in appendix D of TIP evidence to conclude that “Combining the 42, Substance Abuse Treatment for Persons nicotine patch with a self­administered form With Co­Occurring Disorders (CSAT 2005c). of nicotine replacement therapy (either the nicotine gum or nicotine nasal spray) is more efficacious than a single form of nicotine Combination drug therapy replacement, and patients should be encour­ Combining NRT products aged to use such combined treatments if they NRT products typically provide less than half are unable to quit using a single type of first­ a the nicotine plasma levels that cigarette users line pharmacotherapy” (Fiore et al. 2000 , p. achieve through smoking (Benowitz et al. 1997; 77). Dale et al. 1995; Gupta et al. 1995; Lawson et al. 1998). To attempt to increase nicotine lev­

Physical Detoxification Services for Withdrawal From Specific Substances 93 NRT using high­dose nicotine and emotional support to patients attempting to quit. Discussing nicotine withdrawal symp­ patch therapy toms can often help allay patient concerns. The highest dose of nicotine available by patch is 22mg. Several studies have evaluated Fear of weight gain is a barrier for many who whether higher doses of nicotine (up to 44mg) want to quit smoking (French et al. 1995). improve abstinence rates. The effect of this This is an especially important issue for strategy has been small and the routine use of women and may deter their attempts to stop higher dose patches is not recommended smoking (Gritz et al. 1989). Though the (Hughes et al. 1999; Killen et al. 1999). health gains of stopping smoking clearly out­ weigh the health risks of weight gain, this argument does little to assuage patients’ Combining nicotine patch fears. Dieting during smoking cessation is not and bupropion SR recommended in general and has been shown to increase the likelihood of smoking relapse In a double­blind, placebo­controlled study, (Hall et al. 1992). Physicians should, howev­ the combination of bupropion SR and the nico­ er, recommend both exercise and proper tine transdermal patch showed higher absti­ nutrition for patients attempting to stop nence rates at 12 months (35.5 percent) com­ smoking. Patients should be informed that pared to bupropion SR alone (30.3 percent), alcohol use also is considered a risk factor for nicotine patch alone (16.4 percent), or placebo relapse to smoking by most clinicians patch and pill group (15.6 percent) (Jorenby et (Shiffman 1982), and patients who can al. 1999). This combination was well tolerated. abstain from drinking during the withdrawal Clinicians who use this combination should period should do so. first start the patient on bupropion SR 150mg for 3 days and then increase the dosage to Patients generally will find a smoke­free envi­ 150mg twice daily for 1 to 2 weeks prior to the ronment helpful during quit attempts. If the day of smoking cessation. On the “quit day,” patient lives in a household where others nicotine patch therapy should be initiated and smoke, household members and friends can the combination treatment continued for 3 to 6 help by not smoking in front of the patient months (Okuyemi et al. 2000). and limiting the number of smoking cues in their residence. Patient Care and Comfort Patients with more severe nicotine depen­ Most smokers attempt cessation on an outpa­ dence may benefit from enrollment in a spe­ tient basis and without any assistance from cialized smoking cessation program. They professionals. However, if a patient decides might also benefit from more intensive medi­ that she or he wants help with smoking cessa­ cal management using several drugs (NRT + tion, it is important for the clinician to present anticraving), medication for longer periods of a supportive and nonjudgmental attitude and time, closer followup, and longer enrollment develop a therapeutic alliance with the patient. in treatment. There are a number of cessation It must be emphasized that nicotine depen­ programs available from organizations such dence is a chronic relapsing disorder and that as the American Lung Association patients often make several attempts at quitting (http://www.lungusa.org) and the American before succeeding. Cancer Society (http://www.cancer.org). Some community and local organizations also spon­ Most smokers who want treatment will seek sor smoking cessation programs. For the most help from their primary care physician. The severely dependent smokers, there are a lim­ physician has the responsibility of providing ited number of residential facilities that treat pharmaceutical treatment, education about nicotine dependence on an inpatient basis common problems associated with cessation, (Hurt et al. 1992). Providers of detoxification

94 Chapter 4 services should be familiar with the programs no immediate medication during the detoxifi­ available in their communities in order to cation period and usually are self­limiting. make referrals. However, the clinician should be aware of the potential for more persistent problems. Screening the patient for suicidal ideation or Marijuana and Other other mental health Drugs Containing THC problems is warrant­ ed. Some reviews Most experts now Marijuana and hashish are the two sub­ have advocated the stances containing THC (delta­9­tetrahydro­ use of buspirone as believe that a cannabinol) commonly used today. The field an alternative to of addiction medicine has given considerable benzodiazepines for THC­specific with­ attention to the question of whether there is a the management of specific withdrawal syndrome associated with persistent general­ drawal syndrome cessation from prolonged THC use. In the ized anxiety (Gatch past, many have stated that there is no acute and Lal 1998). Other does occur in some abstinence syndrome that develops in people common problems who abruptly discontinue THC (CSAT encountered during 1995d). More recently this has been called withdrawal can be patients who are into question and most experts now believe managed with nonad­ that a THC­specific withdrawal syndrome dictive, supportive heavy users, does occur in some patients who are heavy medications. For users (Budney et al. 2001), though cannabis patients with more though cannabis withdrawal is not yet included in the APA’s persistent difficulty Diagnostic and Statistical Manual of Mental sleeping, clinical withdrawal is not Disorders. experience suggests that Trazodone may The THC abstinence syndrome usually starts yet included in the be useful. Trazodone within 24 hours of cessation. The amount of can lead to low blood THC that one needs to ingest in order to APA’s Diagnostic pressure upon stand­ experience withdrawal is unknown. It can be ing, dizziness, and assumed, however, that heavier consumption and Statistical may increase falls, is more likely to be associated with withdraw­ particularly in indi­ al symptoms. The most frequently seen symp­ Manual of viduals over age 60. toms of THC withdrawal are anxiety, restless­ Benzodiazepines and ness and irritability, sleep disturbance, and other addictive medi­ Mental Disorders. change in appetite (usually anorexia). Other cations should be symptoms of withdrawal are less frequently avoided. seen and appear to include tremor, diaphore­ sis (sweating), tachycardia (elevated heart The patient should be encouraged to maintain rate), and GI disturbances, including nausea, abstinence from THC as well as other addic­ vomiting, and diarrhea. Cognitive difficulties tive substances. Some patients will require a including depression also have been reported substance­free, supportive environment to and may persist but usually improve with achieve and maintain abstinence. Clinicians time. There are no medical complications of should educate all patients about the effects withdrawal from THC, and medication is gen­ of withdrawal, validate their complaints, and erally not required to manage withdrawal. reassure them that their symptoms will likely improve with time. Symptomatic relief may be Clinicians may see a variety of the symptoms provided in order to increase the patient’s mentioned above, but these generally require comfort.

Physical Detoxification Services for Withdrawal From Specific Substances 95 There are no clinical assessment instruments use. However, neither cessation nor disclo­ available that measure THC withdrawal. sure of anabolic steroid use can be assumed Both animal and human studies indicate that when treating these individuals. a withdrawal syndrome starts within 24 hours of cessation and may last for up to a week. Withdrawal Symptoms Associated With Steroids Anabolic Steroids Anabolic steroids can be associated with with­ Anabolic steroids, as differentiated from cor­ drawal symptoms emerging after their abrupt ticosteroids and female gonadotropic hor­ discontinuation. Withdrawal symptoms mones, are androgens (male hormones) and include (in descending order of prevalence) subject to abuse as a means of increasing craving for more steroids, fatigue, depres­ muscle mass. These sion, restlessness, anorexia (loss of appetite), agents also can pro­ insomnia, reduced libido (sex drive), Interventions duce aggressive, headaches, and nausea (Lukas 1998). It is not manic­like behavior known how commonly this syndrome occurs, directed toward that may include but steroid withdrawal appears more likely in delusions (Lukas heavy users. The clinician’s index of suspi­ cessation should 1998). Males cion should be raised when evaluating indi­ involved in profes­ viduals who are predisposed to steroid misuse involve patient sional sports, and who exhibit these symptoms. Also indica­ weight lifting, body tive of possible steroid abuse are certain education regarding building, or other physiological signs of androgen exposure, pursuits that value including hair loss, acne, dysuria (difficult or the dangers and muscular mass are painful urination), small testicles, edema of more likely to use the extremities, and rapid weight gain. medical complica­ these substances Females can develop decreased breast size, than are women, acne, virilism (clitoral enlargement, excessive tions of anabolic although use in and abnormal bodily hair growth, male pat­ women has been tern baldness) and amenorrhea (suppression steroids, their reported. of menstruation). Males who abuse steroids Adolescents use have been reported to possess a distorted behavioral effects, anabolic steroids to body image and may inaccurately view them­ improve their selves as small and weak (Pope et al. 1993). and a thorough appearance and may have increased evaluation of the access to these com­ Medical Complications of pounds (Yesalis et Steroid Withdrawal al. 1993). The large patient’s rationale Due to anabolic steroids’ long duration of numbers of anabol­ action, side effects that might emerge cannot ic steroid prepara­ for misuse. be quickly reversed by the discontinuation of tions that have these substances. Therefore, related side medical and veteri­ effects might require medical management nary uses are pri­ beyond the simple recommendation that marily obtained illegally through diversion. steroids immediately be discontinued. High doses of anabolic steroids can be medi­ Persistent side effects include urinary tract cally dangerous but side effects, usually infections, bladder irritability, skin blistering involving endocrine, liver, central nervous (at the injection site), erythema (abnormal system, and cardiac function, tend to be skin redness) when given as a skin patch, and reversible upon cessation of anabolic steroid

96 Chapter 4 priapism (prolonged erections lasting hours). Patient Care and Comfort The latter condition involves a painful penile Patient comfort during steroid withdrawal can erection and constitutes an emergency that be achieved by addressing side effects, if pre­ requires specialized medical attention. Edema sent, that are discussed above. Counseling also (swelling) of the hands or feet, commonly seen is a useful intervention and specialized psychi­ with anabolic steroids, can be treated with atric interventions may be necessary. If the diuretics (medications that increase urine flow). Elevated liver function tests and jaun­ individual also is using other substances of abuse, referral to drug or alcohol rehabilitative dice usually resolve with cessation of anabolic steroid administration, although hepatic car­ treatment should be made. cinoma (cancer of the liver) has been report­ ed. Other side effects such as headache, nau­ sea, vomiting, acne, insomnia, and lethargy Club Drugs are time­limited and resolve after steroid ces­ Club drugs represent diverse classes of drugs sation. Behavioral disturbances, such as psy­ that include sedative­hypnotic type agents as chosis or severe aggressiveness, should be well as stimulant/hallucinogens. Club drugs are treated symptomatically with appropriate illicit drugs used in the setting of nightclubs, psychopharmacological interventions. In dance clubs, parties, and “raves.” Raves are extreme cases of psychotic or manic presenta­ overnight dance parties, usually with several tions, emergency psychiatric hospitalization hundred people in attendance. might be necessary to address dangerousness Abuse of these drugs by adolescents and to self or others. young adults has risen greatly in recent years. All healthcare professionals need familiarity Management of Steroid with their short­ and long­term effects. Withdrawal Although withdrawal syndromes have been reported with some of these drugs, this is not There is no recommended detoxification pro­ the most common clinical problem. tocol for anabolic steroids. The key medical Intoxication and severe intoxication with goal is that of persuading the patient to cease overdose are more frequent problems. With steroid misuse. This intervention should be some of these compounds, there appears to be followed by evaluating and treating any side the potential for neurotoxicity (destructive effects (discussed above) that might be pre­ effects on the nervous system) and persistent sent. Interventions directed toward cessation psychiatric and neurologic syndromes. At the should involve patient education regarding present time, much of the available informa­ the dangers and medical complications of tion regarding club drugs comes from surveys anabolic steroids, their behavioral effects, and anecdotal case reports. Human laborato­ and a thorough evaluation of the patient’s ry studies and rigorously controlled clinical rationale for misuse. A family meeting often is trials are not common. helpful if agreed upon by the patient. Unfortunately, education alone often is insuf­ One difficulty in assessing the effects of intox­ ficient. Patients with distorted body images ication, overdose, withdrawal, and long­term might be especially difficult to dissuade from health consequences of club drugs is that in steroid misuse, and referral to psychotherapy general, there are no baseline evaluations of by a qualified clinician trained in the treat­ individuals before they used club drugs. Also, ment of body image disorder should be con­ these individuals abuse more than one sub­ sidered. Similarly, patients who derive signifi­ stance. Some of these patients may have had cant muscle gain from anabolic steroids might moderate to severe psychopathology (includ­ be resistant to cessation and may conceal con­ ing psychosis) prior to their introduction to tinued steroid use. club drugs. In the past, some club drugs were

Physical Detoxification Services for Withdrawal From Specific Substances 97 referred to as “designer drugs” because of Withdrawal syndromes have not been report­ their production in a laboratory rather than ed with hallucinogens; however, considerable being processed from plant products. attention has been paid to residual effects such as delayed perceptual illusions with anx­ iety, “flashbacks,” residual psychotic symp­ Hallucinogens toms, and long­term cognitive impairment. Hallucinogens are a broad group of sub­ Controversies around these issues are not stances that can produce sensory abnormali­ important in the clinical setting. The impor­ ties and hallucinations. Most hallucinogens tant thing is to determine whether residual have some adrenergic effects as well. symptoms are present and provide an appro­ Hallucinogens also are referred to as priate environment and appropriate care for psychedelics and psychomimetics. The more the individual who has them. Generally, staff traditional hallucinogens such as lysergic acid of emergency rooms, clinics that treat people diethylamide (LSD) are considered primarily who abuse substances, and social detoxifica­ serotonergic­acting agents. Some of the other tion centers have individuals who are very compounds include phenylethylamines which familiar with “talking down” individuals with have hallucinogenic properties but act like bad hallucinogenic trips. amphetamines as well. These drugs include mescaline and MDMA (3,4­methylenedioxy­N­ Acute intoxication and bad trips usually can methylamphetamine). Other drugs include be managed with placement of the individual MDA (3,4­methylenedioxyamphetamine) and in a quiet, nonstimulating environment with DOM (dimethyloxymethylamphetamine). (See immediate and direct supervision so that the section on ecstasy below.) Other hallucinogens patient does not cause harm to herself or to are acetylcholine antagonists. These include others. Occasionally, a low dose of a short­ or belladonna, drugs such as benzotrophine intermediate­acting benzodiazepine may be used to treat parkinsonian symptoms, and useful to control anxiety and promote seda­ many common over­the­counter antihis­ tion. Individuals with chronic depressive­like tamines. reactions may require antidepressant thera­ py. Individuals with residual psychotic symp­ Hallucinogen intoxication often begins with toms are likely to require antipsychotic medi­ autonomic effects, sometimes nausea and cations. On rare occasions, the use of a low vomiting, and mild increases of heart rate, dose, high­potency antipsychotic medication body temperature, and slight elevations of may be required orally or parenterally (any systolic blood pressure. Dizziness and dilated method other than the digestive tract, e.g., pupils may occur. The prominent effects dur­ intravenously, subcutaneously, or intramus­ ing intoxication are sensory distortions with cularly). Assessment of residual psychiatric illusions and hallucinations. Visual distor­ and cognitive symptoms should be made prior tions are more common than auditory or tac­ to treatment referral. tile ones. So­called “bad trips” may involve anxiety including panic attacks, paranoid reactions, anger, violence, and impulsivity. Gamma­hydroxybutyrate Either due to delusions or misperceptions, (GHB) individuals may feel they can fly or have spe­ GHB use has increasingly been reported in cial powers, and thus injure themselves in night clubs and at raves by adolescents and falls or other accidents. Suicide attempts also young adult populations. GHB is a compound can occur during “bad trips” and possible that is produced in the central nervous sys­ suicidal ideation should be carefully evaluat­ tem, and it acts as an inhibiting neurotrans­ ed, even though it may be quite transient. mitter similar to GABA (Shannon and Quang 2000). In pharmacologic (medication­propor­

98 Chapter 4 tioned) doses, GHB serves as a sedative­hyp­ using the substance regularly over a 2­year notic medication. GHB intoxication may look period, and Rosenberg and colleagues (2003) like alcohol or sedative­hypnotic intoxication. note that in severe cases GHB withdrawal may be life­threatening. Although GHB is illegal, psychotropic com­ pounds similar to GHB such as gamma­ Milder cases of GHB withdrawal syndrome hydroxy lactone (GBL) and 1,4­butanediol may be managed with benzodiazepines such (1,4­BD) are widely available chemical com­ as lorazepam and supportive care. However, pounds and may be obtained through catalogs in more severe cases high doses of intra­ and the Internet. These compounds produce venous benzodi­ effects similar to those of GHB. At the pre­ azepines (e.g., sent, overdose syndromes are more likely to lorazepam) or barbi­ Withdrawal be seen than withdrawal syndromes. turates (e.g., pheno­ Overdose syndromes may require airway and barbital, pentobar­ syndromes have not respiratory management. GHB has been stud­ bital) may be ied in Europe (Addolorato et al. 1999a) in a required (Miotto been reported with randomized, single­blind study comparing it and Roth 2001; to diazepam as a treatment for alcohol with­ Rosenberg et al. hallucinogens; drawal. GHB was as effective as diazepam in 2003). Patients suppressing alcohol withdrawal symptoms experiencing GHB however, consider­ and was said to be quicker in reducing anxi­ withdrawal are like­ ety and agitation with less sedation than ly to have a high tol­ able attention has diazepam. Because of its history of abuse in erance for the seda­ the United States, it is unlikely to be viewed tive effects of benzo­ been paid to as a therapeutic agent any time in the near diazepines and future. require large and residual effects such frequent doses to Miotto and Roth (2001) describe a GHB with­ manage the with­ as delayed drawal syndrome, noting that it shares fea­ drawal (Miotto and tures of both alcohol and benzodiazepine Roth 2001); in cases perceptual illusions withdrawal. They have found this syndrome where high doses of most pronounced in patients who have taken lorazepam prove with anxiety, GHB around­the­clock, at 2­ to 4­hour inter­ ineffective, pento­ vals. The GHB withdrawal syndrome has the barbital may be “flashbacks,” prolonged duration of symptoms found in effective (Sivilotti et benzodiazepine withdrawal and features al. 2001). Clonidine residual psychotic delirium tremens that appear early (often may be used to treat within an hour) with peak manifestations episodes of tachy­ symptoms, and occurring within 24 hours; the delirium may cardia (rapid heart last up to 14 days. Confusion, psychosis, and rate) (Miotto and long­term cognitive delirium are the most prominent features of Roth 2001). GHB withdrawal, and the autonomic effects impairment. (i.e., tremor, diaphoresis [sweating], hyper­ tension, and temperature changes) are less Ecstasy severe than found in alcohol withdrawal. MDMA (3, 4­methylenedioxy­metham­ They note that brief periods of significant phetamine) commonly known as ecstasy, was tachycardia (rapid heart rate) begin early in synthesized around the turn of the century and GHB withdrawal. Garvey and Fitzmaurice patented by Merck Pharmaceuticals in 1914 (2004) also report seizure activity in a case of (Christophersen 2000; Parrot et al. 2000). GHB withdrawal in a male who had been These drugs are phenel­ethylene stimulants

Physical Detoxification Services for Withdrawal From Specific Substances 99 with various substitution groups off the ben­ tured illicitly as oral drugs of abuse. PCP fre­ zene ring that give the medications hallucino­ quently is sold as LSD. genic properties. There are a number of relat­ ed compounds that are designated by their ini­ Some studies have found that ketamine and tials (MDMA, MDA, MDEA, DOM, 2­CB, and PCP act specifically at the MDMA/glutamate DOT). Clinicians are likely to have to manage receptor as noncompetitive MDMA receptor the complications of intoxication and overdose antagonists. Research in animals indicates but not withdrawal. that both drugs are reinforcing, in that ani­ mals will press a bar to obtain doses of either Patients using MDMA or related compounds drug. Furthermore, in these same animal frequently are hyperactive and hyperverbal, models, abstinence syndromes have been reporting heightened tactile and visual sensa­ observed. Withdrawal symptoms in humans tions. They frequently will use camphor on have included depression, drug craving, the skin in facial masks, gloves, and other increased appetite, and hypersomnolence clothing to heighten their tactile sensations. (excessive sleep). Sometimes light sticks are used to heighten visual experiences at raves. Hyperthermia, In the clinical setting, syndromes of acute dehydration, water intoxication with low sodi­ intoxication with hallucinations, delusions, um, rhabdomyolysis (severe muscular injury agitation, and violence are the most pressing and breakdown of muscle fibers), renal fail­ problems. A human laboratory study (Lahti ure, cardiac arrhythmia, and coma have been et al. 2001) conducted a comparison of reported. ketamine and placebo in normal volunteers never exposed to ketamine and to people with MDMA has been proven to be toxic to sero­ schizophrenia with a previous history of tonergic neurons in several animal studies. ketamine use. In both groups, ketamine pro­ Heavy ecstasy users can have paranoid think­ duced a dose­related, but brief, increase in ing, psychotic symptoms, obsessional think­ psychotic symptoms. The magnitude of ing, and anxiety (Parrott et al. 2000). ketamine­induced positive psychotic symp­ Impaired cognitive performance in heavy toms was similar for both groups, although ecstasy users also has been identified the schizophrenia group had higher baseline (Gouzoulis­Mayfrank et al. 2000). Ecstasy scores. users performed more poorly than control groups in complex attention, memory, and Although originally MDMA receptor antago­ learning tasks. The duration or permanence nists were felt to have neuroprotective effects of such effects has not yet been well studied. (preventing damage to brain cells) and have been explored as post­stroke medications, there is some evidence now that ketamine and Ketamine and PCP PCP may in fact have some neurotoxic (Phencyclidine) effects. Studies (e.g., Curran and Monaghan 2001) have found greater memory impairment Ketamine and PCP (phencyclidine) were both among chronic ketamine users than infre­ developed in the 1950s as anesthetic agents for quent ketamine users. Acute human laborato­ humans. Phencyclidine was briefly marketed ry studies by this group indicate persistent for human anesthetic use but taken off the memory impairment with ketamine exposure. market because of an unusual high incidence of This same study did not find persistent psy­ psychotic symptoms. PCP remains in legitimate chotic features beyond acute use. use for veterinarian anesthesia for large ani­ mals as does ketamine for small animals. In the clinical setting, ketamine and PCP use Although both drugs were originally developed require management for the agitation and for intravenous use, they are now manufac­ psychotic features produced during acute use. Occasionally, patients will have such large

100 Chapter 4 overdoses, intentionally or accidentally, that In an evaluation of admissions to publicly they will require airway management and funded detoxification programs in ventilatory support for some hours. The Massachusetts between 1984 and 1996, behavioral management of the agitation and McCarty and colleagues (2000) found a steady violence that may be seen is best managed in increase in the number of patients using both a controlled environment with limited stimuli alcohol and other substances in the month and very close supervision. Occasionally, oral prior to admission. In 1988, 26 percent of or parenteral uses of sedating medications admissions reported using two or more sub­ such as benzodiazepines will be required. In stances in the previous month; by 1996 that extreme cases, restraints may be required for number had nearly protection of the patient and staff. doubled to 50 per­ cent (McCarty et al. Following acute management, assessment of 2000). There is no One of the most persistent mood and cognitive effects must be reason to believe that made prior to any treatment attempts. The this trend has not significant changes persistence of psychotic symptoms may repre­ appeared elsewhere sent an underlying psychiatric disorder that in this country. As in detoxification may require medication treatment. There are Miller and colleagues no studies to guide the treatment of ketamine a (1990 ) note, “For services in recent or PCP detoxification. The need to manage the contemporary withdrawal symptoms from these drugs is drug addict, multiple unlikely, but if it should arise, benzodi­ drug use and addic­ years has been the azepines should be administered. tion that includes alcohol is the rule” increase in the Other (p. 597). number of Rohypnol is a benzodiazepine that is sold In the Massachusetts under trade names in Europe and Mexico as a evaluation, which patients requiring sedative­hypnotic. Rohypnol is occasionally did not include mari­ used as a club drug and at dance clubs. In the juana or nonopioid last decade it began to be smuggled into the prescription medica­ detoxification United States and was commonly used among tion use, the most homeless youth involved in the sex industry. commonly seen com­ from more than Rohypnol has a reputation as a “date rape” bination of sub­ drug because it can produce powerful amnestic stances was alcohol one substance. and hypnotic effects, as well as coma. For fur­ and cocaine. Thirty ther details on benzodiazepines, see the benzo­ percent of patients diazepine section regarding intoxication and admitted for detoxifi­ potential withdrawal reactions. cation in 1996 reported using this combina­ tion; 12 percent used alcohol, cocaine, and heroin together; 10 percent combined alcohol Management of and cocaine; and 7 percent combined heroin and cocaine (McCarty et al. 2000). Other Polydrug Abuse: An studies, evaluating patient populations at Integrated Approach inpatient treatment centers, found that One of the most significant changes in detoxi­ between 70 and 90 percent of patients who fication services in recent years has been the reported cocaine abuse also abused alcohol. increase in the number of patients requiring Rates of alcohol dependence among detoxification from more than one substance. methadone patients and patients dependent on heroin were between 50 and 75 percent,

Physical Detoxification Services for Withdrawal From Specific Substances 101 An Example of Potential Problems: Detoxification for Polydrug Abuse

Mr. L is a 43­year­old male with a 25­year heroin dependence. He is well known to the detoxification center, having been through the program there (which consisted primarily of support and hydration) on many occasions over the years. Though he looked more gaunt and, not surprisingly, a bit more ill each time he arrived, his course usually was about the same: 2 or 3 days of serious stomach cramps, nausea, and diar­ rhea, then a few days of feeling poorly, and then a return to the community. This time, however, was differ­ ent. He looked “sicker” than usual. Mr. L usually was a compliant patient; now he was hostile and belliger­ ent. He seemed to be talking to himself and did not seem as alert as he should have been. The staff asked him several times if he had used anything else and each time he denied it. His drug of choice was always heroin—he drank alcohol once in a while, and occasionally smoked marijuana when he could not get any­ thing else. On the third day of detoxification, Mr. L seemed acutely more ill. On his way to the bathroom he was observed staggering, and as he reached for the door he fell, striking his head, and suffered a grand mal seizure. At the local hospital, a toxicological screen showed the presence of PCP, high levels of barbiturates, opioids, and trace amounts of benzodiazepines

and 80 to 90 percent who were being treated Prioritizing Substances of for cannabis abuse also reported alcohol abuse (Miller et al. 1990a). Abuse While substances of abuse may have complex Clinicians need to be constantly aware that a interactions, it is not always possible to deter­ patient may be abusing multiple substances. mine how those interactions will affect with­ Even if a patient admits the abuse of one sub­ drawal. Therefore, it is generally best practice stance he may not admit to using others. to prioritize the substances an individual has Patients may not see that other substances been dependent on and treat them sequentially are a problem, they may be worried about the according to the severity of the withdrawal pro­ legal consequences of use, or they sometimes duced by the substance. The substances with may not even be aware of what substances the most serious withdrawal syndromes, those they have been using. For these reasons, clin­ where the withdrawal syndrome can be fatal, icians should not rely on patients’ self­reports are alcohol and the sedative­hypnotics. When to determine which substances are being detoxifying a patient who has been dependent used. Interviews with family, friends, or oth­ upon multiple substances, the sedative­hyp­ ers who know the patient may be helpful, but notics must be addressed first. these also are insufficient. The consensus panel strongly recommends that all patients Oral methadone, LAAM, or buprenorphine receive an immediate urine drug screening should be used to stabilize withdrawal from upon admission to a detoxification program to opioids while tapering the dose of the seda­ determine the types of substances being tive­hypnotic or anxiolytic (anti­anxiety medi­ abused. It is not necessarily true that the per­ cation) by 10 percent each day. After the son is drug free simply because a drug is not patient has been tapered off of the sedative­ detected on a drug screen. It is possible that hypnotic or anxiolytic, withdrawal from the the toxicology is not able to detect the class or substitute opioid can begin (Wilkins et al. type of drug. Staff should be aware of what 1998). Some patients can successfully be the program/detoxification center/hospital detoxified from both sedative­hypnotics and tests for, what is not tested for, what cannot opioids simultaneously, but this requires a be tested for or found, and the limitations of great deal of medical and nursing attention. “dip” tests. Most patients will benefit from opioid mainte­

102 Chapter 4 nance for an extended period of time follow­ screening, even a hand­held screening, can be ing the completion of sedative withdrawal. an expensive item for what often is a very limit­ ed budget. Besides, in this case, the patient was If the patient has been abusing multiple seda­ believed to be a known quantity—someone who tive­hypnotic substances or a sedative­hypnotic only used heroin. and alcohol, withdrawal should be handled in the same way as withdrawal from one such sub­ This scenario is not uncommon. It is likely that stance. The patient should be administered a the patient himself was unaware of what was in regularly decreasing dosage of sedative­hypnot­ his body. One of the more frightening facts con­ ic, usually a benzodiazepine that the clinician is cerning the purchase of illicit drugs is the lack comfortable with and accustomed to using. The of knowledge of what is in them. To make buy­ dosage should be decreased according to the ers believe that they are buying a higher­quali­ patient’s physiologic response. Providers also ty product than they are, drugs often are cut may administer an anticonvulsant such as car­ with adulterants (inferior ingredients) that can bamazepine (Tegretol XR), even in the absence produce effects similar to the drug they think of epilepsy or withdrawal seizures, to help they are buying. In this case, Mr. L may have ensure patient safety (Wilkins et al. 1998). been buying barbiturates and benzodiazepines Phenobarbital also may be used for detoxifying in his heroin for some time without knowing it, patients who have been abusing both alcohol a fact that could have had deadly conse­ and benzodiazepines. When the dose of alcohol quences. Both are sedating and could have and sedative­hypnotics that a patient is taking given him some of the comfortable sedation and is not known, tolerance testing as previously euphoria he was seeking from his drug of described can be helpful in determining the choice. Unfortunately, however, where opioid dose of phenobarbital. withdrawal is not life­threatening, withdrawal from barbiturates can be. Furthermore, he When treating patients detoxifying from sub­ could have gotten PCP in the marijuana he stances other than sedative­hypnotics, manage­ occasionally used, again without knowing it. ment of opioid detoxification should be the next priority. Generally, other substances of abuse, including stimulants, marijuana, hallucinogen­ Alternative ics (LSD and similar drugs), and inhalants, will not require specific treatment in patients who Approaches are being detoxified from sedative­hypnotics Alternative methods that have been studied sci­ and/or opioids. entifically do not claim to be stand­alone with­ drawal methods, nor stand­alone treatment Patients may abuse a wide range of substances modalities. Alternative approaches are in various combinations, and the clinician must designed to be used in a comprehensive, inte­ be vigilant in assessing and treating withdrawal grated substance abuse treatment system that from multiple substances. The case study above promotes health and well­being, provides pal­ illustrates some of the serious problems the liative symptom relief, and improves treatment clinician faces in evaluating and treating retention. Therefore, because isolation of any patients withdrawing from multiple substances. of these approaches as an independent variable In the private sector, where money for toxico­ in rigorous controlled studies is difficult, if not logical screening is readily available, the first impossible, there are no conclusive data on the question many would ask concerning the case effectiveness of alternative methods of Mr. L. is, “Why wasn’t the drug screen done (Trachtenberg 2000). sooner?” However, those working in public Auricular (ear) acupuncture has been used facilities will recognize that such screenings throughout the world, beginning in Hong Kong, often are unavailable or available only after an as an adjunctive treatment during opioid extended turnaround time. Toxicological

Physical Detoxification Services for Withdrawal From Specific Substances 103 detoxification for about 30 years. Its use in the choosing outpatient programs with acupunc­ United States originated in California ture were less likely to relapse in the 6 (Seymour and Smith 1987) and New York months following discharge than were patients (Mitchell 1995) but has not been subjected to who had chosen residential programs rigorous controlled research. One report (Shwartz et al. 1999). (Washburn et al. 1993) noted that patients dependent on heroin with mild habits appeared Ear acupuncture detoxification, which was to benefit more than those with severe with­ originally developed as an alternative treat­ drawal symptoms, which acupuncture did not ment for opioid agonist pharmacotherapy, is alleviate. The 1997 National Institute of Health now augmenting pharmacotherapy treatment Consensus Statement on acupuncture stated for patients with coexisting cocaine problems that acupuncture treatment for addiction could (Avants et al. 2000). The advocates of be part of a comprehensive management pro­ acupuncture have joined with the advocates gram. The National Acupuncture of opioid agonist pharmacotherapy to create a Detoxification Association has developed holistic synthesis. Each has contributed to the acupuncture protocols involving ear acupunc­ success of the other, both clinically and in ture in group settings that originated at Lincoln public perception. Hospital in the Bronx and are used by over 400 Care must be taken to ensure sterile acupunc­ drug treatment programs and 40 percent of ture needles in the heroin­dependent popula­ drug courts. SAMHSA’s National Survey of tion, given the high incidence of HIV infec­ Substance Abuse Treatment Services (NSSATS) tion, viral hepatitis, and other infections. found that 5.4 percent of the 13,720 facilities Acupuncture is not recommended as a stand­ polled in 2001 offered acupuncture as a service alone treatment for opioid withdrawal. (Office of Applied Studies 2002b). Other alternative management approaches Acupuncture is one of the more widely used that are not supported by controlled studies alternative therapies within the context of include neuroelectric therapy (the adminis­ addictions treatment. It has been used as an tration of electric current through the skin) adjunct to conventional treatment because it and herbal therapy. In fact, the former has seems to reduce the craving for a variety of been shown to be no better than placebo in a substances of abuse and appears to con­ controlled study (Gariti et al. 1992). The use tribute to improved treatment retention rates. of herbs for healing purposes dates back to In particular, acupuncture has been viewed the dawn of civilization, while the use of as an effective adjunct to treatment for alco­ herbs in the treatment of substance abuse has hol and cocaine disorders, and it also has been documented since 1981 in methadone played an important role in opioid treatment programs, free clinics, therapeutic communi­ (i.e., methadone maintenance). It is used as ties, outpatient programs, and hospitals an adjunct during maintenance, such as when (Nebelkopf 1981). Herbal remedies are used tapering methadone doses. The ritualistic in substance abuse detoxification and treat­ aspect of the practice of acupuncture as part ment in a number of cultures around the of a comprehensive treatment program pro­ world. However, in no scientific studies have vides a stable, comfortable, and consistent herbs been isolated as a discrete variable to environment in which the client can actively test their efficacy. Much research is currently participate. As a result, acupuncture being conducted on the effectiveness of herbal enhances the client’s sense of engagement in medicine on a wide variety of physical the treatment process. This may, in part, conditions. account for reported improvements in treat­ ment retention (Boucher et al. 2003). A 1999 CSAT­funded study showed that patients

104 Chapter 4 Considerations for strong linkages to agencies that provide the above­mentioned services and should set up Specific Populations systems to ensure that pregnant women can All individuals undergoing detoxification are access the additional services they need. especially vulnerable. Patients who experience Pregnant women who present for detoxification negative attitudes from staff may experience will benefit from a comprehensive medical further loss of self­esteem, may leave detoxifi­ examination that includes a careful obstetrical cation prematurely, or may experience other component. Since it is estimated that approxi­ psychologically damaging feelings. Negative mately 44 to 70 percent of women who abuse experiences can undermine the recovery pro­ substances have a his­ cess. It is important to recognize that individu­ tory of physical, emo­ als do not fit into just one population category. tional, and sexual Pregnant women A person will be a member of several popula­ abuse (Moylan et al. tions (e.g., a Latina woman who is pregnant, 2001; Stevens et al. who present for bisexual, and has psychiatric diagnoses of post­ 1997), care should be traumatic stress disorder and major depres­ given to the comfort sion) and may benefit from a number of the of the patients during detoxification will considerations discussed below. It also should the examination. One be noted that the information in the specific of the major internal benefit from a populations sections should not be used to cate­ barriers that prevents gorize individuals or leave the reader with the pregnant women from comprehensive impression that the information below will fit seeking treatment is all individuals who are members of a group. the shame and stigma medical examina­ attached to substance Pregnant Women use, especially during tion that includes pregnancy. Any nega­ While in detoxification, pregnant women tive experience a careful should receive comprehensive medical care, encountered during especially since this may be the first time they detoxification can have sought any type of care or treatment. lead these women to obstetrical Ideally, programs detoxifying pregnant women leave treatment and from alcohol and illicit drugs should include not return. component. the following services: •Detoxification on demand Detoxification during pregnancy poses a •Woman­centered medical services special risk in that •Transportation services to and from detoxifi­ care should be taken cation (as well as to substance abuse treat­ to ensure the health and safety of both the ment afterward) mother and fetus. From a clinical standpoint, •Childcare services before giving any medications to pregnant •Counseling and case management services women it is of vital importance that they understand the risks and benefits of taking •Access to drug­free, safe, affordable housing these medications and sign informed consent •Help with legal, nutritional, and other social forms verifying that they have received and service needs understand the information provided to them. Since pregnant women often present to treat­ While it is recognized that provision of all of ment in mid­ to late­second trimester and poly­ these services is an ideal to be striven for, at a drug use is the norm rather than the exception minimum detoxification programs must have (Jones et al. 1999), it is important first to

Physical Detoxification Services for Withdrawal From Specific Substances 105 screen these women for dependence on the two naltrexone, naloxone, or nalmefene adminis­ classes of substances that can produce a life­ tration during pregnancy. Although propra­ threatening withdrawal: alcohol and sedative­ nolol (Inderal), labetalol (Trandate), and hypnotics. Pregnant women should be made metoprolol (Lopressor) are the beta blockers aware of all wraparound services that will of choice for treating hypertension (high assist them in dealing with newborn issues, blood pressure) during pregnancy including food, shelter, medical clinics for inoc­ (McElhatton 2001), the impact of using them ulations, as well as programs that will help with for alcohol detoxification during pregnancy is developmental or physical issues that the unclear. The use of SSRIs, a class of antide­ neonate (newborn baby) may experience as a pressant medication, is safer for the mother result of substance and fetus than are tricyclic antidepressants exposure. (Garbis and McElhatton 2001). Fluoxetine (Prozac) is the most studied SSRI in pregnan­ A National cy and no increased incidence in malforma­ Alcohol tions was noted, nor were there neurodevel­ Institutes of When pregnant opmental effects observed in preschool­age women are detoxi­ children (Garbis and McElhatton 2001). Health consensus fied from alcohol, However, possible neonatal withdrawal signs benzodiazepine have been observed. Given that the greatest panel tapers appear to be amount of data are available for fluoxetine, the current practice this is the recommended SSRI for use during recommended of choice. The cur­ pregnancy (Garbis and McElhatton 2001). rent state of knowl­ The use of anticonvulsants, such as valproic methadone edge suggests that benzodiazepine acid, is associated with several disfiguring therapy in general malformations. If this type of medication maintenance as does not have as must be used during pregnancy, the woman much of a terato­ must be told that there is substantial risk of the standard of genic (producing a malformations (Robert et al. 2001). deformed baby) risk Barbiturate use during pregnancy has been care for pregnant as do other anticon­ studied to some extent, and phenobarbital is vulsants as long as used therapeutically during pregnancy, but women with they are given over the risk of any anticonvulsive medication a short time period. should be discussed with the patient (Robert et al. 2001). There also are reports of a with­ opioid It appears that short­acting benzo­ drawal syndrome in the neonate following prenatal exposure to phenobarbital (Kuhnz et dependence. diazepines, like the ones described to al. 1988). treat alcohol with­ drawal above, can Opioids be used in low doses for acute uses such as detoxification, even in the first trimester While it is not recommended that pregnant (Robert et al. 2001). Long­acting benzodi­ women who are maintained on methadone azepines should be avoided—their use during undergo detoxification, if these women the third trimester or near delivery can result require detoxification, the safest time to in a withdrawal syndrome in the baby (Garbis detoxify them is during the second trimester. and McElhatton 2001). For further information, consult the forth­ coming TIP Substance Abuse Treatment: Although no teratogenic effects have been Addressing the Specific Needs of Women observed, little is known about the effects of (SAMHSA in development e) and TIP 43

106 Chapter 4 Medication­Assisted Treatment for Opioid but may be associated with a withdrawal syn­ Addiction in Opioid Treatment Programs drome in the neonate (Jones and Johnson (CSAT 2005d). In contrast, it is possible to 2001). detoxify women dependent on heroin who are abusing illicit opioids by using a methadone A National Institutes of Health consensus taper. panel recommended methadone maintenance as the standard of care for pregnant women Before starting a detoxification, women with opioid dependence. Methadone currently should weigh the risks and benefits of detoxi­ is the only medication recommended for med­ fication, since many women eventually ication­assisted treatment for pregnant relapse to drug use and thus place themselves women. Clinical trials are being conducted to and their fetuses at risk for adverse conse­ determine the efficacy and safety of quences (Jones et al. 2001b). During pregnan­ buprenorphine with pregnant women but it cy, the protein binding of many drugs, includ­ has not yet been approved for use with this ing methadone and diazepam (a benzodi­ population. Two early studies on treatment of azepine), is decreased (e.g., Adams and pregnant women with opioid dependence with Wacher 1968; Dean et al. 1980; Ganrot 1972) buprenorphine showed promising results with the greatest decrease noted during the (Fischer et al. 2000; Johnson et al. 2001). third trimester (Perucca and Crema 1982). Comer and Annitto (2004) conclude, from This decreased binding may be due to the their review of the research literature, that decreased levels of albumin reported during buprenorphine should be used more aggres­ pregnancy (Yoshikawa et al. 1984). From a sively to detoxify pregnant women who want clinical standpoint, it may be that pregnant to be opioid­free at delivery. women could be at risk for developing greater toxicity and side effects, yet at the same time Because of the potential for premature labor an increase in metabolism of the drug may and delivery and risks of morbidity and mor­ result (such as found with methadone). This tality to the fetus related to withdrawal from may result in reduced therapeutic effect from opioids, it is recommended that a pregnant the drug, since many women require an woman who is dependent on opioids be main­ increase in their dose of methadone during tained during pregnancy (Kaltenbach et al. the last trimester (Pond et al. 1985). 1998). Other reasons to stabilize a pregnant woman on methadone rather than attempt Other medications used to treat the withdraw­ withdrawal are the risks of relapse, conse­ al signs and symptoms include clonidine. quences associated with HIV and use of multi­ Clonidine is used as a second­line drug to ple needles, and the potential lack of prenatal treat hypertension (high blood pressure) dur­ care. ing pregnancy and appears to lack teratogenic effects (McElhatton 2001). It has reportedly The Federal government mandates that pre­ been abused by pregnant women. Some preg­ natal care be available for pregnant women nant women take clonidine with their on methadone. It is the responsibility of treat­ methadone because it is hard to detect in ment providers to arrange this care. More urine and it increases the high they get from than ever, there is need for collaboration methadone. However, little is known about its involving obstetric, pediatric, and substance effects on the baby following therapeutic abuse treatment caregivers. Comprehensive doses given in a detoxification context or care for the pregnant woman who is opioid doses taken in higher than therapeutic dependent must include a combination of amounts (Anderson et al. 1997a). methadone maintenance, prenatal care, and Buprenorphine has been examined in preg­ substance abuse treatment. nancy and appears to lack teratogenic effects

Physical Detoxification Services for Withdrawal From Specific Substances 107 Pregnant women should be maintained on an Specific Needs of Women (SAMHSA in devel­ adequate (i.e., therapeutic) methadone dose. opment e). There is a documented withdrawal An effective dose prevents the onset of with­ syndrome in neonates who have been prena­ drawal for 24 hours, reduces or eliminates tally exposed to benzodiazepines (Sutton and drug craving, and blocks the euphoric effects Hinderliter 1990), and this syndrome may be of other narcotics. An effective dose usually is delayed in onset more than that associated in the range of 50–150mg (Drozdick et al. with other drugs. 2002). Dosage must be individually deter­ mined, and some pregnant women may be able to be successfully maintained on less Stimulants than 50mg while others may require much The principles of detoxification from stimulants higher doses than 150mg. The dose often such as cocaine are the same for pregnant and needs to be increased as a woman progresses nonpregnant women. Since there is no current through gestation, due to increases in blood pharmacotherapy to use in tapering individuals volume and metabolic changes specific to from stimulant use, the use of any medications pregnancy (Drozdick et al. 2002; Finnegan to treat medical complications that might arise and Wapner 1988). from the withdrawal should only be done after discussion with the patient of the risks and ben­ Generally, dosing of methadone is for a 24­ efits of each medication. hour period. However, because of metabolic changes during pregnancy it might not be pos­ sible to adequately manage a pregnant woman Solvents during a 24­hour period on a single dose. The principles of detoxification from solvents Split dosing, particularly during the third are the same for pregnant and nonpregnant trimester of pregnancy, may stabilize the women. It should be noted that based on a woman’s blood methadone levels and effec­ review of case reports, there is a complex tively treat withdrawal symptoms and crav­ array of characteristics that appear to be sim­ ing. ilar to fetal alcohol effects. Fetal Alcohol Breastfeeding is not contraindicated for Syndrome (FAS) is characterized by growth women who are on methadone. Very little deficiency (born small for gestational age; methadone comes through breast milk; the failure to grow at a normal rate), particular American Academy of Pediatrics (AAP) facial features (e.g., eyes are too close togeth­ Committee on Drugs lists methadone as a er, ears are set low on the head), and CNS “maternal medication usually compatible with dysfunctions (mental retardation, microen­ breastfeeding” (AAP 2001, pp. 780–781). cephaly [small brain size]) and brain malfor­ mations (Costa et al. 2002). Thus fetal devel­ opment in pregnant women who have a histo­ Benzodiazepines ry of solvent abuse should be evaluated and The principles of detoxification from benzodi­ carefully monitored (Jones and Balster 1998). azepines are the same for pregnant and non­ pregnant patients. It is important to taper the Nicotine dose of benzodiazepine slowly in order not to induce fetal withdrawal or other adverse con­ There is extensive documentation that smoking sequences in the fetus or mother. during pregnancy causes numerous adverse Detoxification is most likely safest during the fetal consequences (see Schaefer 2001). second trimester in order to avoid sponta­ Cigarette smoking during pregnancy is the neous abortion or premature labor. For more largest modifiable risk for pregnancy­related information, see the forthcoming TIP morbidity and mortality in the United States Substance Abuse Treatment: Addressing the (Dempsey and Benowitz 2001). While women

108 Chapter 4 are undergoing detoxification, they should be Marijuana, anabolic steroids, offered education about the risk of cigarette smoking during pregnancy and, ideally, pre­ and club drugs vented from smoking. This is especially impor­ The principles of detoxification from these tant since cigarette smoking is strongly associat­ drugs is the same for pregnant and nonpreg­ ed with decreased birth weight, which is a pre­ nant women. The use of anabolic steroids dur­ dictor of developmental problems in newborns ing pregnancy is rare; however, these can be (Ernst et al. 2002). If women are unable to stop catastrophic to a pregnancy, and if use is smoking using behavioral interventions, nico­ found, a detailed ultrasound examination is tine replacement products may be used; how­ recommended to determine the morphological ever, the woman should fully understand the (physical or structural) development of the possible risks and benefits of these pharma­ fetus (Scialli 2001). cotherapies (Jones and Johnson 2001). Although the class of It also is important to point out to patients club drugs is rela­ While women are that there are data to suggest that women may tively new there have derive less benefit from NRT than do men been a few reports undergoing and that they may derive greater benefit from (McElhatton et al. some non­NRT medications (e.g., bupropion), 1999) suggesting that detoxification, thus producing quit rates in women compara­ there is an increased ble with those in men (Perkins 2001). risk of congenital they should be However, the data regarding the use of malformation in bupropion during pregnancy are limited. neonates prenatally offered education exposed to ecstasy. Examinations of the acute effects of NRT in Other club drugs about the risk of pregnant women reveal that nicotine has min­ such as fluni­ imal impact on the maternal and fetal cardio­ trazepam (Rohypnol) vascular systems. NRT may well be viewed as may have effects sim­ cigarette smoking the lesser of two evils, inasmuch as smoking ilar to those of some cigarettes delivers, in addition to nicotine, benzodiazepines; during pregnancy thousands of chemicals. Among these are however, this is spec­ many that also are viewed as developmental ulative. For compre­ and, ideally, toxins (e.g., carbon monoxide and lead). It is hensive information doubtful that the reproductive toxicity of on the treatment of prevented from cigarette smoking is primarily related to nico­ this specific popula­ tine. Thus, if NRT is to be used during preg­ tion, see the forth­ smoking. nancy, the dose of nicotine in NRT should be coming TIP similar to the dose of nicotine that the preg­ Substance Abuse nant woman received from her ad lib (when­ Treatment: ever desired) smoking. Although intermittent­ Addressing the Specific Needs of Women use formulations of NRT (e.g., chewing gum) (SAMHSA in development e). have been recommended over continuous­use formulations (e.g., transdermal patch) due to reductions in the total dose of nicotine deliv­ Older Adults ered to the fetus (Dempsey and Benowitz It has been recommended that, when treating 2001), it is unknown what the impact of inter­ older adults, there should be a policy of using mittent acute doses followed by withdrawal of age­specific group treatment that is both sup­ nicotine has on the fetus. portive and nonconfrontational (Royer et al. 2000; West and Graham 1999). Older adults may be dealing with depression, loneliness,

Physical Detoxification Services for Withdrawal From Specific Substances 109 and loss of career or a loved one. Thus, as a People With Disabilities or Co­ standard policy, older adults should be screened for depression and grief or loss­ Occurring Conditions related issues. Similar to the situation with In any patient population, the clinician other specific populations, the detoxification should expect to encounter persons with dis­ setting should ideally have in place a policy abilities including co­occurring medical or that mandates, at a minimum, well­estab­ mental disorders. These patients often will lished linkage with general medical services require special assistance to overcome both and specialized services for the aging, because physical and psychological barriers in under­ of their increased vulnerability to physical going detoxification and treatment, including ailments. Establishing policies that create an their own psychological barriers that must be environment that is positive and does not tol­ overcome, as well as those attitudinal and erate “ageism”—a general tendency to react communication barriers that often prevent negatively toward elderly adults—is impor­ complete and clear understanding between tant for the optimal treatment of older indi­ patient and clinician or clinician and institu­ viduals. tion. Effective communication is essential for effective services. Accommodations must take Alcohol and other drug­related disorders in into consideration the expressed preference of elderly individuals often are more severe than the individual with a disability. Substance those of younger individuals and they are at abuse treatment programs need to be in com­ increased risk for co­occurring medical disor­ pliance with two Federal laws regarding this ders. It is the medical complications rather matter: the 1992 Amendments to the than age itself for which detoxification in a Rehabilitation Act of 1973 and the Americans medical setting is needed. The elderly may with Disabilities Act [ADA] of 1990. have slower metabolism of medications mak­ According to the ADA, programs must ing dosage adjustments necessary in some remove or compensate for physical or archi­ cases. The elderly also may be at greater risk tectural barriers to existing facilities when for drug interactions, since they may be accommodation is readily achievable, mean­ receiving medications to treat other problems. ing “easily accomplishable and able to be car­ A complete and careful assessment with ongo­ ried out without much difficulty or expense” ing monitoring should be done to examine the (P.L. 101­336 § 301). Providers should exam­ existence of diseases such as, but not limited ine their programs and modify them to elimi­ to, heart disease, respiratory disease, dia­ nate four fundamental groups of barriers to betes, and dementia. Potential for falls also treatment for people with disabilities and/or should be evaluated in the context of pre­ co­occurring disorders: (1) attitudinal barri­ scribed medications. The previously present­ ers; (2) discriminatory policies, practices, and ed protocols for detoxification from alcohol, procedures; (3) communications barriers; and opioids, benzodiazepines, stimulants, sol­ (4) architectural barriers. Federal, State, and vents, nicotine, marijuana, anabolic steroids, other sources of assistance might be available and club drugs (anabolic steroids and club to fund ADA­related improvements. See TIP drug abuse are rare in this population) 29, Substance Use Disorder Treatment for appear to be applicable to the elderly popula­ People With Physical and Cognitive tion as long as sensitivity to the withdrawal Disabilities (CSAT 1998g) for further infor­ medication is considered. TIP 26, Substance mation. Abuse Among Older Adults (CSAT 1998f), provides comprehensive information on the The following passage clarifies terms and treatment of this population. addresses the basic issues presented by patients with disabilities and/or co­occurring disorders. Diseases, disorders, and injuries,

110 Chapter 4 whether congenital or acquired, can have ties (WHO 1980). This complex system has diverse effects on organs and body systems. been simplified here into four main cate­ Conditions (and diseases) such as multiple gories: sclerosis, traumatic brain injury, spinal cord Physical injury, diabetes, and cerebral palsy can lead 1. impairments are caused by con­ to impairments, such as impaired cognitive genital or acquired diseases and disorders ability, paralysis, blindness, or muscular dys­ or by injury or trauma. For example, function. These impairments in turn cause spinal cord injury is a disorder that can disabilities, which limit an individual’s ability cause paralysis, an impairment. Sensory to function in various areas of life, such as 2. impairments include blindness learning, reading, and mobility. While dis­ and deafness, which may be caused by eases, impairments, and disabilities are dis­ congenital disorders, diseases such as tinct categories, they often are used inter­ encephalopathy or meningitis, or trauma changeably. These essential terms are defined to the sensory organs or the brain. Cognitive in Figure 4 ­15. 3. impairments are disruptions of thinking skills, such as inattention, memo­ The field of disability services has developed ry problems, perceptual problems, disrup­ its own terminology to discuss physical, senso­ tions in communication, spatial disorienta­ ry, and cognitive disabilities (see definitions tion, problems with sequencing (the ability below), and many treatment providers of peo­ to follow a set of steps in order to accom­ ple with substance use disorders will not be plish a task), misperception of time, and familiar with these terms as the profession perseveration (constant repetition of defines them. WHO has devised a method for meaningless or inappropriate words or the classification of impairments and disabili­ phrases).

Figure 4­15 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 func­ tions. Disability: Any restriction or lack (resulting from an impairment) of the ability to perform an activity in the manner or within the range considered normal for a human being. A disability is always perceived in the context of certain societal expectations, and it is only within that context that the disadvantages resulting from a disability can be properly evaluated. Functional capacities: The degree of ability possessed by an individual to meet or perform the behav­ iors, tasks, and roles expected in a social environment. Functional limitations: The inability to perform certain behaviors, fulfill certain tasks, or meet certain social roles as a consequence of a disability. Those limitations can be anatomical (e.g., amputation), physiological (e.g., diabetes), cognitive (e.g., traumatic brain injury), sensory (e.g., blindness, deaf­ ness), or affective (e.g., depression) in origin and nature. They represent substandard performance on the part of the individual in meeting life activities and reflect the interaction between the person and the environment. (A list of the areas of functional capacity and disabilities most often assessed is in Figure 4­16, p112.)

Sources: Livneh and Male 1993; Stedman 1990; World Health Organization (WHO) 1980.

Physical Detoxification Services for Withdrawal From Specific Substances 111 Figure 4­16 Impairment and Disability Chart

Impairment Category Common Disabilities

Physical Spina bifida Spinal cord injury Amputation Diabetes Chronic fatigue syndrome Carpal tunnel Arthritis

Sensory Blindness Hearing impairment Deafness Deaf­blindness Visual impairment

Cognitive Learning disabilities Traumatic brain injury Mental retardation Attention deficit disorder

Affective Depression Bipolar disorder Schizophrenia Eating disorder Anxiety disorder Posttraumatic stress disorder

Source: CSAT 1998e.

4. Affective impairments are disruptions in abilities and co­occurring medical and/or psy­ the way emotions are processed and chiatric conditions. The failure to recognize expressed. For the purposes of this discus­ these problems in patients can result in poor sion, affective impairments are considered outcomes (Cook et al. 1992). Additionally, to include problems caused by both affec­ intoxicated individuals with co­occurring tive and mood disorders, such as major depressive disorders are at high risk for sui­ depression and mania. These impairments cide attempts. Of course, an individual include the symptoms of mental disorders, patient may present with two or more disabil­ such as disorganized speech and behavior, ities and/or co­occurring disorders. Clinicians markedly depressed mood, and anhedonia treating people with co­occurring substance (joylessness). use and mental disorders should consult TIP 42, Substance Abuse Treatment for Persons One of the most important practices that With Co­Occurring Disorders (CSAT 2005b). should be in place as a standard in any detox­ ification setting is routine screening for dis­

112 Chapter 4 All programs should make a good faith effort al. Physical therapy and exercise, chiroprac­ to provide equal access in as comprehensive a tic care, biofeedback, hypnotism, and thera­ manner as possible for all patients. Individual peutic heat or cold are some other approach­ unique needs should be taken into account es to caring for persons with physical prob­ when providing services. For example, lems. Most of these alternative treatments patients with physical, sensory, or cognitive have limited or no research support of their disabilities may need help with self­care (e.g., efficacy; yet some clinicians believe they eating, grooming), moving (e.g., using stairs, work. Thus, consultation with experts on walking), communication (e.g., reading, their use is necessary before starting a person speaking), learning, social skills, and execu­ with chronic pain on these remedies. tive functions (e.g., planning and organiza­ tion, decisionmaking). Unresponsiveness to An alternative model supports the idea that instructions, lack of participation in discus­ patients should be treated simultaneously in sions and activities, forgetfulness, or confu­ substance abuse treatment, mental/physical sion by an individual with cognitive disabili­ health, and detoxification settings, yet treat­ ties should not be viewed as a lack of motiva­ ments may occur in separate facilities and be tion, resistance, or denial. Programs may conducted by separate staff. The consequent need to develop the expertise or engage an task for all is to be supportive and knowl­ expert on cognitive disabilities to determine edgeable about each other’s interventions. the limitations resulting from the substance The severity of the addiction and abuse and those resulting from the disability. medical/psychiatric problems at the time of Both require patience in the response. detoxification entry should determine which Information presented to the person with a acute services the patient receives first. cognitive disability should include different Naturally, a person’s medical and psychiatric and complementary media; for example, visu­ disabilities must be accounted for in the al and tactile materials can reinforce the preparation of any treatment plan. In some usual verbal interaction. cases, substance abuse treatment cannot begin until issues relating to medical and psy­ Programs also may need to alter their policies chiatric disabilities are settled. regarding the use of drugs prescribed for pain control, since most medications of this class There are a number of resources for clini­ are drugs with a high abuse potential. A num­ cians to employ, including experts in the field ber of patients with substance use disorders of disability services. Figure 4­17 (p. 114) dis­ also live with chronic pain. Living in a drug­ cusses ways of locating expert help for treat­ free state may not be desirable if it is associ­ ing patients with disabilities and/or co­occur­ ated with unrelieved pain, which can be quite ring disorders. disabling. The clinician should explore with Finally, integrated treatment combines sub­ patients what pain management options have stance abuse treatment, treatment for co­ been tried in the past, and which management occurring disorders, and detoxification services medications are being used currently. into one program. For more complete informa­ Patients should be encouraged to discuss tion on the treatment of many of these disor­ their feelings about pain and how it affects ders, see chapter 5. their daily life, and especially to what extent it curtails or prevents their participation in the activities of daily living. African Americans There are a number of alternative treatments For African Americans, entrance into detoxifi­ for chronic pain. Acupuncture is already in cation has been associated with enrolling in fur­ use in some treatment programs for detoxifi­ ther treatment, reductions in HIV/AIDS risk cation to help relieve symptoms of withdraw­ behaviors, and linkages with social and health­

Physical Detoxification Services for Withdrawal From Specific Substances 113 Figure 4­17 Locating Expert Assistance

“Experts” in disability services can be located in several ways, depending upon the nature of the patient’s disability and the local resources available. Patients who understand their disability may in fact be the best “experts” on their condition and specific needs; however, it is not uncommon that persons requiring treat­ ment for substance use disorders will not understand basic aspects of their situation or condition. In such cases, immediate family members or close friends may be important sources of information and guidance. The treatment team also should consider contacting other sources: •A disability­specific service organization (e.g., United Cerebral Palsy, organizations for the blind or deaf such as the National Association of the Deaf and American Deafness and Rehabilitation Association, the Association for Retarded Citizens) •Social workers •Case managers •Rehabilitation specialists •Psychologists •Nurses or physicians associated with a social service agency providing disability services for the individual patient in question (e.g., vocational rehabilitation, family services for people who are deaf and hard of hearing, the Department of Veterans Affairs’ physical rehabilitation unit, community case management services) •Other organizations recognized by the disability community (e.g., Centers for Independent Living, gover­ nors’ committees for persons with disabilities, Paralyzed Veterans of America, local or State consumer coalitions for persons with disabilities)

Source: CSAT 1998e.

care services (Lundgren et al. 1999). African mind the standard of respecting the client as Americans are at greater risk than other popu­ an equal partner in treatment. For further lations for the co­occurrence of diabetes and information on this subject (as well as infor­ hypertension (high blood pressure) that can mation on working with members of other predispose them to a risk of stroke. This cultural/ethnic groups), see the forthcoming should be taken into account when placing and TIP Improving Cultural Competence in monitoring them on withdrawal medications. Substance Abuse Treatment (SAMHSA in development a). In treating African­American patients, treat­ ment efficacy and therapist efficacy may be The previously discussed protocols for detoxi­ associated with the therapist’s understanding fication from all substance of abuse appear of how race plays a role in recovery adequate for the detoxification of African (Luborsky et al. 1988; Pena et al. 2000). In Americans. However, there are a few further addition, when working with counselors from aspects to consider: other cultures, African Americans may dis­ •If treating African Americans with beta play mistrust and a reluctance to show any blockers, propranolol is less effective in weakness. To overcome this mistrust and to treating African Americans than Caucasians build rapport, especially when the clinician is (Pi and Gray 1999). discussing the detoxification process, it is par­ •African Americans are more likely (15 to 25 ticularly important for the clinician to keep in percent) to have less of the enzyme activity

114 Chapter 4 needed to eliminate diazepam than others, so quate for the detoxification of Asians and it may have a longer half­life in African Pacific Islanders. During the detoxification Americans than it does in other ethnic groups process, there are a number of issues to con­ (Pi and Gray 1999). sider: •Since co­occurring disorders such as depres­ •If possible and appropriate, incorporate tra­ sion frequently are seen in people with sub­ ditional healing methods (e.g., meditation stance use disorders, it is important to know and religious exercises). These can help that African Americans may require lower reduce stress and anxiety and promote recov­ doses and may be at greater risk of develop­ ery (Chang 2000). While there is a large ing toxic side effects when prescribed antide­ immigrant population among many Asian­ pressants, since they are likely to metabolize American groups, it is erroneous to assume tricyclic antidepressants and SSRIs less effi­ that all are foreign born. Variation in prac­ ciently than Caucasians (Pi and Gray 1999). tice of traditional healing methods is consid­ •Although the clearance of nicotine is similar erable and consistent with generational dif­ for African Americans and Caucasians, the ferences. When considering detoxification, clearance of cotinine, a metabolite of nico­ recognize the importance of bicultural prac­ tine, is slower in African Americans, which tices, values, and beliefs that might influence may cause different smoking patterns than responsiveness to treatment. found in Caucasians (Ahijevych 1998). •When discussing detoxification medications, discuss with patients their feelings about tak­ Asians and Pacific Islanders ing “Western” medications for detoxification. In some Southeast Asian cultures, Western This group is the most diverse in nations of medications are believed to be too strong for origin and has widely differing languages, the Asian person. It is important to assess a beliefs, practices, dress, and values. Often person’s feelings about these since the patient the only common thread among these people may not wish to disagree with the clinician is their geographic origin (Chang 2000). yet may be noncompliant in taking the medi­ Although this group appears to have lower cations. Compliance with detoxification medi­ rates of alcohol and illicit drug use, these cation may be better achieved if doses are problems should not be overlooked; members reduced or regimens shortened, yet this of this group may not seek treatment until the should only be attempted if it is in the best problems are quite severe. Successful treat­ interest of the patient. ment involves the family and important val­ ues include balance, harmony, wisdom, and •Racial differences in alcohol sensitivity modesty. Thus, it may be important to talk to among Asians and Caucasians have long been the family about the process of detoxification recognized, with more than 80 percent of and dispel their fears and concerns as well as some Asians compared to 10 percent of the patient’s. Caucasians being sensitive to alcohol (i.e., having a flushing reaction) (Wolff 1972, Asians and Pacific Islanders tend to be con­ 1973). This is the result of genetic differences cerned about the clinician’s credibility and in alcohol metabolizing enzymes. trustworthiness. Generally speaking, male­ Approximately 50 percent of Asians lack the ness, mature age, the projection of self­confi­ enzyme ALDH2, found in the liver, that helps dence, possession of sound cultural compe­ the body get rid of alcohol (Hsu et al. 1985; tence skills, good educational background, Yoshida et al. 1985). One reason for lower and level of experience are of importance. In drinking rates among Asians may be the addition, a concrete logical approach to the flushing reaction in the face and body follow­ problem at hand is valued (Brems 1998). The ing alcohol ingestion and an increase in skin previously discussed protocols for detoxifica­ temperature. Other uncomfortable signs and tion from all substances of abuse appear ade­ symptoms associated with the negative reac­

Physical Detoxification Services for Withdrawal From Specific Substances 115 tion to alcohol ingestion can include nausea, American Indians dizziness, headache, fast heartbeat, and anx­ There are currently more than 500 federally iety (Caetano et al. 1998). recognized American­Indian tribes, and there •Five studies have shown that the metabolism is among them great variability in appear­ of codeine is slower in Chinese people than ance, dress, values, religious beliefs, prac­ in Caucasians. Chinese patients seem to tices, and traditions. More than 200 different require lower doses of codeine, since the languages are spoken by American­Indian slower metabolism leads to a higher concen­ tribes. Alcohol use varies widely among tribes tration of codeine in the blood (Smith and (Mancall 1995). Of all ethnic and racial Lin 1996). groups, American Indians have the greatest •If treated with beta blockers, Asians require rates of alcohol and illicit drug use (Office of much lower doses than Caucasians, since Applied Studies 2002a). they are very sensitive to this medication’s blood pressure and heart rate effects (Pi An early study of treatment utilization by and Gray 1999). American Indians found that there was a sig­ nificant association between involvement in •Asians as a group have a higher number of society and treatment outcomes. Those individuals than other ethnic groups who involved in either the traditional Indian soci­ are poor metabolizers of diazepam. This ety or both the traditional Indian society and may result in the need for lower doses, Caucasian society had more than a 70 percent since they report greater sedative effects success rate, whereas those involved in nei­ with a typical dose (Lesser et al. 1997). It ther society had a 23 percent success rate also may be that a lower body fat, which is (Ferguson 1976). At a 10­year followup, those typical of Asian­American individuals, can who had reported greater Indian culture affil­ lead to differences in the pharmacokinetics iation and more severe liver dysfunction at of lipophilic drugs (Lesser et al. 1997). baseline had better alcohol treatment out­ •In treatment for co­occurring depression comes (Westermeyer and Neider 1984). and a substance use disorder, Asians appear to metabolize clomipramine more When engaging an American Indian in the slowly than Caucasians (Pi and Gray 1999). process of detoxification, moving through the In contrast, Asians may metabolize process too quickly or abruptly can be per­ phenelzine faster, resulting in the need for a ceived as showing a lack of caring and is con­ higher dose relative to that which would be sidered contrary to trust building (Brems appropriate for Caucasians (Pi and Gray 1998). The pace of conversation is important; 1999). a slower pace is more agreeable than a rapid •Chinese Americans tend to metabolize nico­ conversation. Moreover, a confrontational approach also is not advised with this popula­ tine 35 percent more slowly than tion (Abbott 1998). American Indians may Hispanics/Latinos and Caucasians. Thus, want a close and involved relationship with they may need to smoke less frequently and their therapists and often want the clinician take in less nicotine to achieve the same to be a friend or relative (Brems 1998). The nicotine levels as do Hispanics/Latinos and trust often is built by idle small talk to a level Caucasians. This may have implications for the dosing of NRTs (Benowitz et al. 2002). of shared understanding. Use of fables and illustrative stories to express ideas can be •Smoking rates among male Asian extremely helpful. According to the forthcom­ Americans, especially immigrant males, are ing TIP Improving Cultural Competence in exceedingly high and masked by the lower Substance Abuse Treatment (SAMHSA in rates among Asian­American females. development a), avoidance of eye contact also is traditional. The Talking Circle is a native

116 Chapter 4 tradition that can be helpful in the treatment Spanish or Portuguese does not guarantee process (Canino et al. 1987; Coyhis 2000). cultural sensitivity or competence. For The previously discussed protocols for detoxi­ instance, it is important that the treatment fication from all substances of abuse appear staff understand the role of the family. The adequate for the detoxification of American functional family can be extended and should Indians. The following are some issues to con­ take into account people who have day­to­day sider during detoxification. contact with and a role in the family •Fetal Alcohol Syndrome is 33 times higher in (Markarian and Franklin 1998). this population than the national average Hispanics/Latinos are likely to view drug (SAMHSA in development a). This may be dependency as moral failing or personal important for pregnant women coming to weakness. Traditional healing such as folk detoxification and also may be important if remedies and folk the adult has FAS. healers may provide benefit. The previ­ •Indian women who drink have a six­fold Hispanics/Latinos ously discussed pro­ increase in cirrhosis of the liver relative to tocols for detoxifica­ Caucasian women (Heath 1989). are now the tion from alcohol, •Although some American Indians have opioids, benzodi­ largest ethnic reported a flushing response to alcohol, it azepines, stimulants, appears that the flushing reaction in solvents, nicotine, minority group in American Indians is milder and less adverse marijuana, anabolic than that experienced by Asians (Gill et al. steroids, and club 1999). drugs appear ade­ America. •If Alcoholics Anonymous or other 12­Step quate for the detoxi­ programs are to be introduced, framing the fication of Assessment of the steps in terms of a circle rather than a ladder Hispanics/Latinos. may be better received, since the circle is patient’s level of important concept in Indian culture (SAMHSA in development a). Gays and acculturation can •If possible and appropriate, other traditional Lesbians methods that can help recovery are sweat Approximately 5 to be helpful in lodges, vision quests, smudging ceremonies, 33 percent of all les­ sacred dances, and four circles (Abbott bian and gay individ­ understanding 1998). uals are estimated to substance abuse •Overall, detoxification for this population is have a substance the same as for other populations, but abuse problem patterns. American Indians are likely to seek treatment (Cochran and Mays later and have more medical complications 2000; Hughes and and poorer nutrition (Abbott 1998). Wilsnack 1997). A contributing factor may be the stress and Hispanics/Latinos anxiety associated with the social stigma attached to homosexuality. Further, alcohol Hispanics/Latinos are now the largest ethnic and drugs may serve as an escape and ease minority group in America. Assessment of the social interactions at social settings such as patient’s level of acculturation can be helpful bars. More information on this subject will be in understanding substance abuse patterns. available in the forthcoming TIP Improving Language is one of the most difficult barriers Cultural Competence in Substance Abuse to treatment entry and success for Treatment (SAMHSA in development a). The Hispanics/Latinos. However, simply knowing previously discussed protocols for detoxifica­

Physical Detoxification Services for Withdrawal From Specific Substances 117 tion appear adequate for gay and lesbian there is liver toxicity or suicidal intent patients. Since numerous misconceptions and (Giannini et al. 1991). The use of club drugs stereotypes exist concerning gay and lesbian is higher in this population than in others. individuals, it is important for the clinician to Screening and Assessing Adolescents assess his beliefs and take care not to impose TIP 31, for Substance Use Disorders d them on the patient. (CSAT 1999 ), and TIP 32, Treatment of Adolescents With There are a number of principles of care for Substance Use Disorders (CSAT 1999f), pro­ treating gay and lesbian individuals, which vide comprehensive information on the treat­ are outlined in A Provider’s Introduction to ment of adolescents. Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001). These principles include: (1) Incarcerated/Detained Persons counselors’ being able to monitor their own Substance use disorders are common among feelings about working with this population of inmate populations. At the time of arrest and patients in order to provide professional, eth­ detention, it has been estimated that 70 to 80 ical, and competent care; (2) helping patients percent of all inmates in local jails and State heal from the negative experiences of homo­ and Federal prisons had regular drug use or phobia and heterosexism; (3) helping patients had committed a drug offense, and 34 to 52 understand their reactions to discrimination percent of these inmates were intoxicated at and prejudice; and (4) helping patients accept the time of their arresting offense (Federal personal power over their own lives by help­ Bureau of Prisons 2000; Mumola 1999). ing them improve their self­images and build Although women comprise a small proportion support networks. of the incarcerated population (12.3 percent in jails and 7.4 percent in State and Federal prisons) than men (Harrison et al. 2004), Adolescents females have a greater prevalence of illicit The previously discussed protocols for detoxifi­ drug use (i.e., 40 percent compared to 32 per­ cation from all substances of abuse appear ade­ cent were under the influence of drugs at the quate for the detoxification of adolescents; time the crime was committed) than do males however, there are several additional aspects to (Greenfeld and Snell 1999). consider: Persons who are incarcerated or detained in •Physical dependence generally is not as holding cells or other locked areas should be severe, and response to detoxification is more screened for physical dependence on alcohol, rapid than in adults. opioids, and benzodiazepines and provided •Retention is a major problem in adolescent with needed detoxification and treatment. treatment (Thurman et al. 1995). Screening should occur over time, since the •Peer relationships play a large role in treat­ onset and intensity of withdrawal is depen­ ment. Among adolescents who do not use dent on the type of drug taken, when the per­ drugs, few of their friends reported use. In son last took the drug, and how long the drug one study, among those who reported specific lasts in the person’s body. The duration of drug use, over 90 percent of their friends detention will affect what detoxification ser­ reported using the same drug (Dinges and vices can be provided, and many facilities will Oetting 1993). not be able to provide detoxification or con­ •It is estimated that 75 percent of those tinuing care services. There are some special reporting steroid use are high school stu­ considerations for the detoxification of this dents, and most of them are male. Detoxifica­ population: tion from steroids does not typically require •Abrupt withdrawal from alcohol can be life­ specific pharmacological intervention unless threatening.

118 Chapter 4 •Abrupt withdrawal from opioids or benzo­ •Many correctional facilities have restric­ diazepines is not life­threatening but can tions on the use of methadone or LAAM and cause severe withdrawal signs and symp­ special provisions for maintaining or taper­ toms and great distress. ing the individual may need to be made. •It should be determined whether depen­ •If medications are provided to medically dence on either opioids or benzodiazepines detoxify inmates, the Federal Bureau of is the result of illicit use and not the result Prisons’ Clinical Practice Guidelines for of taking medications that have been pre­ Detoxification of Chemically Dependent scribed to treat pain or anxiety disorders. Inmates (2000) suggest retaining strict con­ •If medically supervised withdrawal is indi­ trol over access to these medications to pre­ cated, the substitution of a long­acting drug vent diversion or misuse (e.g., eating cloni­ from the same class of substances the dine patches to obtain a state of euphoria). patient is using (e.g., giving methadone to TIP 44, Substance Abuse Treatment for treat heroin dependence) and the gradual Adults in the Criminal Justice System (CSAT tapering of that substance (no faster than 2005b), and TIP 30, Continuity of Offender 10 to 20 percent per day) should be con­ Treatment for Substance Use Disorders From ducted under closely monitored settings. Institution to Community (CSAT 1998b), pro­ •There are cases when individuals main­ vide more detailed information about the tained on opioid agonist medications are treatment of this population. TIP 21, detained or incarcerated. If the incarcera­ Combining Alcohol and Other Drug Abuse tion is 30 days or less, the individual should Treatment With Diversion for Juveniles in be maintained on her usual dosage. If the the Justice System (CSAT 1995b), also pro­ incarceration is longer, the individual may vides information about incarcerated youth. be appropriate for gradual dose tapering. •Persons who transition from a state of opi­ oid dependence to a drug­ or medication­ free state are at greater risk of overdose upon relapse to opioid use.

Physical Detoxification Services for Withdrawal From Specific Substances 119 5 Co­Occurring Medical and Psychiatric Conditions In This Chapter… Patients undergoing detoxification frequently present with medical and psychological conditions that can greatly affect their overall well­ General Principles being and the process of detoxification. These may simply be pre­ of Care for existing medical conditions not related to substance use or the direct Patients With Co­ outcome of the substance abuse. In either case, the detoxification pro­ Occurring Medical cess can negatively affect the co­occurring disorder or vice versa. Conditions Furthermore, people who abuse substances often present with medical conditions in advanced stages or in a medical crisis. Co­occurring Treatment of mental disorders also are likely to be exacerbated by substance abuse. Co­Occurring For more on treating patients with co­occurring psychiatric disorders, Psychiatric the reader should refer to TIP 42, Substance Abuse Treatment for Conditions Persons With Co­Occurring Disorders (Center for Substance Abuse Treatment [CSAT] 2005c). Standard of Care for Co­Occurring This chapter is intended primarily for medical personnel treating Psychiatric patients in detoxification settings, though nonmedical staff may find it Conditions informative as well. This chapter is not meant to take the place of authoritative sources from internal medicine. Rather, it presents a cursory overview of special conditions, modifications in protocols, and the use of detoxification medications in patients with co­occurring conditions or disorders. Overall treatment of specific conditions is not addressed unless modification of such treatment is needed.

121 General Principles of on the overall health of patients, staff mem­ bers are in a position to help patients see the Care for Patients With importance of engaging in treatment for their substance use disorders. Patients should have Co­Occurring Medical appointments for followup care made prior to Conditions detoxification discharge for all chronic medi­ cal conditions, conditions needing further Patients who use substances can present with any of the conditions or combinations of con­ evaluation, and substance abuse treatment. ditions that can be found in the general popu­ This section highlights the conditions most lation. In most cases, the management of the frequently seen in individuals who abuse sub­ medical condition in the patient with a sub­ stances, though it is not inclusive. Disorders stance use disorder diagnosis does not differ of the following systems will be covered: gas­ from that of any other patient. However, the trointestinal (including the gastrointestinal medication used for detoxification and the [GI] tract, liver, and pancreas), cardiovascu­ actual detoxification protocol may need to be lar system, hematologic (blood) abnormali­ modified to minimize potentially harmful ties, pulmonary (lung) diseases, diseases of effects relevant to the co­occurring condition. the central and peripheral nervous system, infectious diseases, and special miscellaneous Detoxification staff providing support should disorders. Where special considerations are be familiar with the signs and symptoms of needed for a patient presenting with a given common co­occurring medical disorders. disorder in a detoxification setting they are Likewise, personnel at medical facilities (i.e., listed following the heading “Special emergency rooms, physicians’ offices) should Considerations.” be aware of the signs of withdrawal and how it affects the treatment of the presenting med­ ical conditions. Gastrointestinal Disorders The setting in which detoxification is carried Frequently, the use of substances can present out should be appropriate for the medical a range of gastrointestinal problems. Cocaine conditions present and should be adequate to use, for example, can result in various gas­ provide the degree of monitoring needed to trointestinal complications, including gastric ensure safety (e.g., oximetry [a measurement ulcerations, retroperitoneal fibrosis, visceral of the amount of oxygen present in the infarction, intestinal ischemia, and gastroin­ blood], greater frequency of taking vital testinal tract perforations (Linder et al. signs, etc.). Acute, life­threatening conditions 2000). Gastrointestinal disorders may affect need to be addressed concurrently with the many different organs and organ systems withdrawal process and intensive care unit (e.g., liver, pancreas), making diagnosis diffi­ monitoring may be indicated. cult. Since symptoms can be vague and patients are not always able to articulate the Clinicians should keep in mind that consulta­ specific problem, diagnosis can be difficult. tion with specialists in infectious diseases, For a simple rule of thumb, urgent attention cardiology, pulmonary medicine, hematology, is needed if the patient is diagnosed with any neurology, and surgery may be warranted. of the following: Whenever possible, consent should be sought •Appendicitis to involve the patient’s primary healthcare provider in the coordination of care. •Abdominal aortic aneurysm Attending medical staff should be aware that •Perforated peptic ulcer co­occurring medical conditions present an •Boerhaave’s Syndrome (spontaneous opportunity to engage patients. By focusing esophageal rupture) on the adverse effects of the substance abuse •Obstructed or strangulated bowel

122 Chapter 5 •Ischemic bowel disease (a condition that may decrease lower esophageal sphincter pres­ results from inadequate blood supply to the sure and aggravate reflux (Dell’Italia 1994). intestines) •Abcess of the pancreas or liver Mallory–Weiss Syndrome •Ruptured spleen or other trauma to the Mallory–Weiss Syndrome is caused by torn abdominal area mucosa of the esophagus at the gastro­ Other possible diagnoses of abdominal pain esophageal junction due to protracted or vio­ include: lent vomiting. Mallory–Weiss Syndrome is the etiology of 5 to 15 percent of all upper GI •Hepatitis bleeds (Schuylze­Delrieu and Summers 1994). •Peptic ulcer (nonperforating) •Peritonitis Boerhaave’s •Acute pancreatitis syndrome •Pelvic inflammatory disease Boerhaave’s syn­ •Endometriosis drome is manifested Co­occurring •Nephrolithiasis (kidney stones) by rupture of the •Inflammatory bowel disease esophagus. Patients medical conditions •Ovarian cysts presenting with this condition complain of Clinicians should also be aware of some decep­ acute epigastric pain present an tive causes of abdominal pain: (83 percent of •Myocardial infarction patients), vomiting opportunity to (79 percent), and •Pulmonary emboli shortness of breath engage patients in •Herpes zoster (shingles) (39 percent) as the •Acute pylonephritis (kidney infection) predominant, nonspe­ treatment for cific symptoms. This Specific co­occurring gastrointestinal disorders lack of specificity can their substance requiring special attention in patients undergo­ delay making the cor­ ing detoxification are discussed below. rect diagnosis (Brauer et al. 1997). use disorders. Reflux esophagitis Tachycardia, cyanosis, and subcu­ Reflux esophagitis can be a result of alcohol’s taneous emphysema effect on the lower esophageal sphincter (i.e., also can be seen. If relaxation) and a decrease in peristalsis of the this condition is left distal esophagus, allowing gastric contents to untreated, the prognosis is severe. come into contact with the lower esophagus. Typical symptoms include burning in the epi­ gastric or retrosternal area (commonly called Gastritis “heartburn” or “indigestion”). Esophageal Gastritis is described as the disruption of the bleeding can result from reflux esophagitis and gastric mucus lining that allows gastric acid to esophageal varices (resulting from portal contact the mucosa with resultant inflammation hypertension). and possible bleeding. The patient presents with nausea, vomiting, and abdominal pain Special considerations (Ivey 1981). Alcohol increases gastric acid Several drugs used in typical protocols, such as secretion and reduces the mucosal cell barrier, beta blockers and calcium channel blockers,

Co­Occurring Medical and Psychiatric Conditions 123 allowing back­diffusion of the gastric acid into ered as an appropriate agent, as it can be the mucosa. This frequently causes an occur­ administered intravenously or intramuscular­ rence of erosive gastritis in the individual with ly. Opioids may have to be used to control an alcohol use disorder (Fenster 1982). pain. Special considerations Aspirin and nonsteroidal medications should be Liver disorders avoided in the withdrawal protocols. Liver disease can range from fairly benign fatty liver, which presents usually as an asymptomatic enlargement of the liver associ­ Pancreatitis ated with mild elevation of the serum liver Pancreatitis can be enzymes, to a broad spectrum of viral infec­ caused by many fac­ tions and the toxic consequences of alcohol Detoxification tors, although stud­ and other drug use. The end point of liver ies suggest that alco­ disease is liver necrosis or failure. Midway in staff providing hol may be a factor the progression of liver disease is acute alco­ in anywhere from 5 holic hepatitis. The presentation is one of support should be to 90 percent of all liver tenderness, jaundice, fever, ascites, and cases (Apte et al. an enlarged liver. The patient is quite sick 1997), with some and frequently has nausea and vomiting. familiar with the experts suggesting about 60 percent of Special considerations signs and all cases result from Alcoholic hepatitis usually needs acute medi­ excessive alcohol cal treatment to prevent electrolyte imbalance symptoms of com­ consumption and dehydration. Protocols may have to be (Yakshe 2004). The adapted if the patient cannot take oral mon co­occurring acute condition pre­ agents. sents with abdomi­ medical conditions. nal pain, which is described as sharp, Portal hypertension burning, and con­ Portal hypertension is a frequent conse­ stant and is located quence of liver disease. If elevation of the in the epigastric portal pressure goes untreated, esophageal area of the varices develop and hemorrhage can ensue. abdomen with radiation to the back. Treatment of acute hemorrhage includes Presenting symptoms and signs can include endoscopic sclerotherapy or ligation. Initial abdominal tenderness, decreased bowel therapy should include prompt and adequate sounds, low­grade fever, tachycardia, nausea, intravascular volume replacement, correction and vomiting. Pancreatitis can proceed to a of severe anemia and coagulopathies, and chronic condition where pancreatic calcifica­ adequate airway management. tion, diabetes mellitus, malabsorption, and chronic abdominal pain occur. Special considerations Propranolol or isosorbide therapy is effective Special considerations in the prophylaxis of variceal bleeding There may be a need to forbid oral intake of (Trevillyan and Carroll 1997), though beta food and medications, necessitating a change blockers can interfere with measuring the of route of administration of both food and true heart rate that determines the content of medications to intravenous forms. In alcohol many detoxification protocols. If bleeding is withdrawal protocols, Ativan might be consid­

124 Chapter 5 present, changeover to intravenous medica­ Cardiovascular Disorders tion protocols is recommended, as the patient The presentation of chest pain or discomfort will not be able to take oral medications. remains one of the most difficult differential diagnoses to sort through, as disorders of sev­ Cirrhosis eral systems can cause this single complaint. Inability to correctly diagnose this symptom Cirrhosis, or the formation of fibrous tissue can be brought about by the patient’s inabili­ in the liver, leads to a state of increased resis­ ty to be interviewed and give succinct symp­ tance in the hepatic venous circulation. The toms (the intoxicated or severely withdrawing inability of blood to flow freely gives rise to patient), a sociocultural or educational level portal hypertension with ensuing esophageal that does not allow for the verbal nuances varices, splenomegaly, ascites, dilatation of necessary to making a diagnosis, or fabrica­ superficial veins, peripheral edema, and hem­ tion of symptoms by a patient seeking to orrhoids. obtain pain medications or other drugs. Liver necrosis can be seen in patients who use A normal resting electrocardiogram does not inhalants, particularly chronic use of benzene rule out the presence of organic heart disease and carbon tetrachloride. African Americans and the presence of nonspecific changes does and Hispanics/Latinos have higher mortality not necessarily mean that heart disease is pre­ rates from cirrhosis of the liver resulting from sent. Final diagnoses can range from reflux to alcohol abuse than do Caucasians and Asians myocardial infarction brought about by and Pacific Islanders (Sutocky et al. 1993). underlying ischemic heart disease or the use Liver function test abnormality and jaundice of cocaine. Frequently, lung diseases can have can occur in individuals who use anabolic as their presenting symptom chest discomfort. steroids, but this usually resolves on cessation The consensus panel believes that this condi­ of the drugs. Studies in the elderly show that tion should never be overlooked or minimized 1­year mortality was 50 percent among and it is imperative that an especially prompt patients over age 60 with cirrhosis, versus 7 diagnosis be made and treatment be under­ percent for those under age 60 (Potter and taken to ensure patient safety. James 1987). Great care needs to be used when giving diuretics to elderly patients with Underlying cardiac illness could be worsened cirrhosis, since their total body water may by the presence of autonomic arousal (elevat­ already be decreased, making them more sus­ ed blood pressure, increased pulse and sweat­ ceptible to fluid and electrolyte depletion ing) as seen in alcohol, sedative, and opioid (Scott 1989). withdrawal. Thus prompt attention to these findings and aggressive withdrawal treatment Alcohol­related hepatic injury is seen in a is indicated. Special considerations for the higher proportion of women due to a possible treatment of specific cardiac conditions are potentiation (strengthening) of this effect by outlined below. estrogen (Brady and Randall 1999).

Special considerations Hypertension For the treatment of alcohol withdrawal, lorazepam (Ativan) is well tolerated in Hypertension frequently is seen in the detoxi­ patients with severe liver disease (D’Onofrio fication patient. Evaluation should include a et al. 1999) as is oxazepam (Serax), with its complete history to determine if the elevated short half­life of 6 to 8 hours and simple blood pressure predated the present with­ metabolism with no metabolites. drawal status. Consideration should be given to include serum electrolytes, urinalysis, BUN/creatinine, and an EKG in the detoxifi­

Co­Occurring Medical and Psychiatric Conditions 125 cation unit’s initial workup. More elaborate Ischemic heart disease workup can be carried out after completion Ischemic heart disease presents as chest pain of detoxification. or pressure, palpitations, dizziness, and/or Propranolol (Inderal), labetalol (Trandate) shortness of breath and requires immediate and metoprolol (Lopressor) are the beta attention, which will dictate what setting is blockers of choice for treating hypertension appropriate for the detoxification. during pregnancy (McElhatton 2001), howev­ Cocaine use is associated with various cardio­ er, the impact of using them for alcohol vascular complications including angina pec­ detoxification during pregnancy is unclear. If treating African Americans with beta block­ toris, myocardial infarction, and sudden ers, clinicians should be aware that propra­ death. It is estimated that over half of the 64,000 patients evaluated annually for nolol is less effective in this population than it cocaine­associated chest pain will be admitted is in Caucasians (Pi and Gray 1999). Asians to hospitals for evaluation of myocardial require much lower doses of beta blockers ischemia. Only about 6 percent of patients than Caucasians, inasmuch as they tend to be will demonstrate biochemical evidence of very sensitive to the blood pressure and heart myocardial infarction (Hoffman and rate effects (Pi and Gray 1999). Hollander 1997). The typical patient with Special considerations cocaine­related myocardial infarction is a The presence of a hypertensive history and male in his mid­30s with a history of chronic poorly controlled blood pressures may have tobacco and repetitive cocaine use (Hollander an effect on the proper evaluation of with­ 1995). This effect of cocaine appears to be drawal as the examiner would have difficulty increased because the drug causes an increase determining whether the elevated blood pres­ in myocardial oxygen demand and thus a sure was due to withdrawal or to the underly­ decrease in oxygen supply. These two factors, ing hypertensive history. Thus modifications which are caused by vasospasm and vasocon­ of the usual parameters and scheduling of striction of the coronary arteries, may lead to detoxification medications should be consid­ cardiovascular disorders. ered. In any event, severe elevation of blood Patients with recent cocaine use can experi­ pressure should be treated concurrently with, ence persistent cardiac complications such as at minimum, salt restriction and rest. If the prolonged QT interval and vulnerability for blood pressure is still elevated in several days arrhythmia and myocardial infarction despite a reduction in other withdrawal (Chakko and Myerburg 1995). (QT is the Q to parameters and symptoms, then medication is T interval measured on EKGs. If the interval warranted. is prolonged, it can lead to cardiac rhythm Beta blockers and clonidine have been used disturbances.) Amphetamines are rarely in the treatment of alcohol withdrawal and reported as the cause of myocardial infarc­ clonidine also has been used in opioid proto­ tion, though a case report shows that a cols. These medications can help control patient subsequently experienced a non–Q­ blood pressure and also work well in the pro­ wave anterior wall infarction associated with tocol. Calcium channel antagonists have also amphetamine use (Waksman et al. 2001). been used to ameliorate some of the symptoms Cocaine use and HIV infection have been of alcohol withdrawal and can be used con­ associated with an increased incidence of car­ currently for blood pressure control. diac dysfunction, but concomitant exposure may cause a synergistic effect (Soodini and Morgan 2001).

126 Chapter 5 Special considerations Arrhythmias Beta­adrenergic blocking agents may exacer­ Arrhythmias (irregular heartbeats) can be bate cocaine­induced coronary arterial vaso­ seen in the presence of ischemia and car­ constriction and thereby increase the myocar­ diomyopathy. Two specific cases of arrhyth­ dial ischemia. Nitroglycerin and verapamil mogenic disorders are “holiday heart,” where reverse cocaine­induced hypertension and the patient who has ingested alcohol presents coronary arterial vasoconstriction and are with supraventricular arrhythmia the medications of choice in the patient who (Greenspon and Schaal 1983), and the indi­ uses cocaine and presents with chest pain vidual who uses cocaine with the stimulant (Pitts et al. 1999). Cocaine may cause platelet leading to significant atrial and ventricular activation leading to acute coronary events— arrhythmias. Consumption of anabolic thus more aggressive antiplatelet therapy may steroids also has be indicated (Callahan et al. 2001). been associated with hypertension, Cocaine use is Cardiomyopathy ischemic heart dis­ ease, cardiomyopa­ Cardiomyopathy is caused by degenerative thy, and arrhythmia associated with changes of the cardiac muscle with enlarge­ (Sullivan et al. ment of the heart (cardiomegaly) and left ven­ 1999). various tricular failure. Alcoholic cardiomyopathy presents with a similar picture as cardiac fail­ Special consider­ cardiovascular ure from other etiologies, with shortness of ations breath on exertion, shortness of breath when Treatment of arrhyth­ complications the patient is lying flat, and edema of the mia in the person who lower extremities. abuses substances is including angina similar to that for the Besides alcohol as the etiology, a dilated car­ patient who does not diomyopathy can be seen with use of the pectoris, abuse substances, inhalant trichlorethylene. Cardiomyopathy in though the setting of the elderly patient with an already underlying detoxification may myocardial ischemic or atherosclerotic heart disease can have to be altered to be quite debilitating. Women have shown allow for cardiac infarction, and alcohol metabolism different from that of men monitoring (teleme­ and distinct pathophysiologic mechanisms, try). sudden death. which frequently lead to a higher sensitivity to alcohol­induced heart damage. The preva­ lence of cardiomyopathy in women is equal to Hematologic that in men, despite cases in which women Disorders have consumed far less ethanol (Fernandez­ Sola and Nicolas­Arfelis 2002). Hematologic (blood) disorders can be seen due to several factors, such as a direct toxic effect Special considerations of the drug on the bone marrow, as seen in Alcoholic cardiomyopathy may respond poor­ alcohol and benzene use, or as a result of mal­ ly to digitalis with increased likelihood of digi­ absorption of essential nutrients (B12, folate), talis toxicity (Zakhari 1991). or as a general poor state of nutrition.

Co­Occurring Medical and Psychiatric Conditions 127 Anemia platelet count (thrombocytopenia), which is due to enlargement of the spleen and abnor­ Anemia can be seen due to folate deficiency, mally high platelet storage. Thrombocyto­ iron deficiency, B12 deficiency, acute blood penia also can be seen in cases of vitamin B12 loss, or more frequently as a combination of and folate deficiency. factors. Folate deficiency can cause a mega­ loblastic anemia, which is diagnosed by The African­American patient with sickle cell macroovalocytes and hypersegmented neu­ disease or trait can be severely affected (inas­ trophils seen on a peripheral blood smear. much as the patient already has an impaired Iron deficiency anemia results from blood loss oxygen delivery system) if other harm threat­ and thus subsequent iron loss. This can be ens the bone marrow. seen in low­level gastrointestinal Special considerations bleeding, after Elevated heart rates can hinder the use of the childbirth, and as a heart rate as a parameter in various detoxifica­ result of menstrual tion protocols. Traumatic brain blood loss. The pre­ sentation of anemia injury (TBI) usually is nonde­ Pulmonary Disorders (Other script with general­ Than Infectious) ized fatigue and should always be Pulmonary disorders are common in people weakness. With who abuse substances, in part because of the severe anemia, considered in high rate of nicotine use in this population shortness of breath (Graham et al. 2003). on exertion and an patients with elevated heart rate can be seen. Aspiration pneumonia neurological Specific to the Alcohol or other drug ingestion may reduce a megaloblastic ane­ patient’s gag reflex, leading to the blockage of impairment. mias (B12 and the airways. Aspiration pneumonia occurs folate deficiency) when oro­pharyngeal secretions and/or gastric one can see neuro­ contents enter into the lower airways. This seri­ logic complications ous condition may require prolonged hospital­ such as peripheral ization. neuropathy.

White blood cell disorders Asthma Asthma, a chronic condition characterized by White blood cell disorders can occur due to exacerbations of bronchial spasm manifested malnutrition and liver disease. Lymphopenia by wheezing, should be differentiated from may be present in the patient with HIV disease. bronchospasm, which is related to inhaled drugs and usually is self­limited. Treatment is Platelet disorders similar to that provided to patients who do not use substances, with the addition of cessa­ Platelet disorders frequently are attributable tion of the substance use. to the direct effect on the bone marrow by the substance being abused or, as seen in alcohol­ The patient with underlying chronic asthma related thrombocytopenia, are due to bone can be severely compromised if the use of a marrow suppression. Splenomegaly caused by smokeable drug causes exacerbation of an portal hypertension also can cause a low already impaired system.

128 Chapter 5 Special considerations ularly in hospitalized patients. Evaluation for Asthma medications can cause a significant infections and the use of oxygen, steroids, increase in heart rate, which can affect the and inhalers is dictated by the clinical pic­ evaluation of withdrawal protocols that use ture. During detoxification, if nicotine use is heart rate as one of the parameters. not allowed, there can be significant effects on drug levels (see chapter 4). Chronic Obstructive Neurologic System Pulmonary Disease The neurologic system of patients with sub­ Chronic obstructive pulmonary disease stance use disorders is affected directly in the (COPD) (emphysema, chronic bronchitis) fre­ toxic effects on cell membranes, effects on quently is due to cigarette use and the result­ neurotransmitters, associated metabolic ing alterations of the pulmonary immune sys­ changes from other underlying disorders, and tem, inflammation, and destruction of lung changes in blood flow. Researchers have parenchyma. Presentation includes shortness found that the majority of those with an alco­ of breath on exertion, a cough producing hol use disorder (75 percent) have some mucous, and wheezing. degree of cognitive impairment (Goldstein African Americans who smoke cigarettes take 1987). Specific disorders found in patients in more nicotine, and therefore more tobacco with substance use disorders can affect the smoke toxins per cigarette, than Caucasians central nervous system and the peripheral (Perez­Stable et al. 1998). system. For example, a broad array of neu­ ropathologic changes are seen in the brains of Daily marijuana smoking has been shown to people who use heroin. The main findings are have adverse effects on lung function includ­ due to infections as a result of endocarditis or ing a productive cough, wheezing, and exces­ HIV infection. Other complications include sive sputum production. However, the habitu­ hypoxic­ischemic changes with cerebral al marijuana­only smoker, in the absence of edema, ischemic neuronal damage thought to alpha­1­antitrypsin deficiency, would have to be due to heroin­induced respiratory depres­ smoke four to five marijuana cigarettes per sion, stroke due to thromboembolism, vas­ day for a span of at least 30 years to develop culitis, septic emboli, and hypotension. overt manifestations of COPD (Van Hoozen Myelopathy occurs as a result of possible iso­ and Cross 1997). lated vascular accident in the spinal cord, and a distinct condition, leukoencephalopa­ Special considerations thy, has been described after the inhalation of During nicotine withdrawal and cessation pre­heated heroin (Buttner et al. 2000). treatment, different levels of nicotine absorp­ tion, as seen in some groups, will affect dosing As a final note, traumatic brain injury (TBI) for nicotine replacement therapies (Perez­ should always be considered in patients pre­ Stable et al. 1998). The patient with COPD, senting with neurological impairment. People especially if elderly, would be sensitive to the who abuse substances are at high risk of falls, sedating effects of many of the detoxification motor vehicle accidents, gang violence, protocol medications, especially the benzodi­ domestic violence, etc., which may result in azepines, which may have to be reduced in head injury (Graham et al. 2003). dosage to avoid respiratory depression and Unrecognized TBI can affect the treatment worsening hypoxemia and hypercarbia outcome. (decrease in oxygen and increase in carbon dioxide). For smokers, always consider the use of the nicotine replacement agents, partic­

Co­Occurring Medical and Psychiatric Conditions 129 Wernicke­Korsakoff’s 50mg every 6 hours for 24 hours) when detox­ Syndrome ifying from alcohol. Wernicke­Korsakoff’s Syndrome is composed Individuals with an alcohol use disorder show of Wernicke’s encephalopathy and an increase in seizures due to withdrawal, Korsakoff’s psychosis. Wernicke’s metabolic insults such as hypoglycemia or encephalopathy is an acute neurological dis­ electrolyte imbalance, or head trauma. In one order with a triad of study, researchers found that of 195 cases of seizures in those with an alcohol use disorder, •Oculomotor dysfunction (bilateral abducens 59 percent were due to alcohol withdrawal, 20 nerve palsy—eye muscle paralysis) percent to head trauma, and 5 percent to vas­ •Ataxia (loss of muscle coordination) cular disorders (Earnest et al. 1988). •Confusion Special considerations Weakness and nystagmus are also seen in this Evaluation of a first seizure should include a syndrome on examination of the eyes. neurological evaluation and evaluation for Wernicke’s encephalopathy is clearly related to head trauma. Metabolic etiologies, such as low thiamine deficiency. magnesium levels, should be considered. Korsakoff’s psychosis is a chronic neurologi­ Mayo­Smith (1997) has shown that benzodi­ cal condition resulting from thiamine defi­ azepines confer protection against alcohol ciency that includes retrograde and antegrade withdrawal seizures and thus patients with amnesia (profound deficit in new learning and previous seizures should be treated early with remote memory) with confabulation (patients this class of medications. The consensus panel make up stories to cover memory gaps). suggests that anti­epileptic drug therapy should be considered in alcohol withdrawal Special considerations patients with multiple past seizures (of any Thiamine initially is given parenterally and cause), a history of recent head injury, past then oral administration is the treatment of meningitis, encephalitis, or a family history of choice. Always give thiamine prior to glucose seizures. administration. Clinicians should be aware that treatment of the first seizure with benzodiazepines does Alcohol and sedative not prevent the likelihood of a second seizure withdrawal seizures (D’Onofrio et al. 1999). Slower medication Alcohol and sedative withdrawal seizures rep­ tapers should be considered when this condi­ resent a significant medical challenge (Ahmed tion co­occurs with detoxification. et al. 2000), since no large clinical studies Lorazepam, which can be used in patients have been conducted to firmly establish the with liver disease, has been suggested as best treatment practices. Up to 90 percent of appropriate, but it and other short­acting alcohol withdrawal seizures occur in the first benzodiazepines may not prevent late­occur­ 48 hours and usually are single and nonfocal. ring withdrawal seizures (Shaw 1995). Repeated episodes of drinking and withdraw­ Dosages of anticonvulsant medications should al are thought to predispose people to be stabilized before sedative­hypnotic with­ seizures due to a kindling phenomenon (Post drawal begins. Adequate treatment with a et al. 1987). Patients with a history of with­ long­acting benzodiazepine is effective in pre­ drawal seizures are at greatest risk and venting withdrawal seizures (Mayo­Smith and should receive prophylactic doses of a long­ Bernard 1995). D’Onofrio and colleagues acting benzodiazepine (e.g., chlordiazepoxide (1999) found that a one­time dose of the rela­

130 Chapter 5 tively shorter acting agent lorazepam also There is a higher than normal incidence of reduced the risk of a subsequent seizure com­ hemorrhagic stroke and other intracranial pared to placebo. However, in D’Onofrio’s bleeding among patients with heavy alcohol study doses were small and the results were use, and a particular association of strokes limited somewhat by use in an emergency within 24 hours of a drinking binge (Altura room setting. 1986). Older, first­generation anticonvulsants have Special considerations limitations in that they have only been stud­ Nifedipine and verapamil have been shown to ied in mild to moderate withdrawal, on rare prevent alcohol­induced vasospasm, which sug­ occasions they can cause serious hepatic and gests a possible therapeutic approach to hyper­ bone marrow toxicities, and they can interact tension and stroke in the patient with heavy with other classes of medication. Newer alcohol use (Altura 1986). drugs, such as gabapentin (Neurontin) and oxcarbazepine (Trileptal), do not appear to have these liabilities, but sufficient studies to Polyneu­ show this have not yet been done. There is lit­ ropathy tle evidence that long­term use of phenytoin is helpful in the patient who does not have an Polyneuropathy fre­ underlying seizure disorder (Kasser et al. quently is seen in 2000). Medications that may lower the seizure nutritional deficien­ Treatment of the threshold, including phenothiazines, such as cies that occur in the prochlorperazine (Compazine), and several patient with chronic first seizure with antidepressants, such as bupropion, should alcohol use. Presenting signs and be used with great caution in the patient with benzodiazepines a seizure history. symptoms include lower extremity The use of anticonvulsants, such as valproic pain, distal motor does not prevent acid and barbiturates, has been studied in loss, numbness or pregnant women. Valproic acid is associated tingling, and loss of the likelihood of a with several malformations in the fetus. The reflexes. use of any anticonvulsant medication should Polyneuropathy can second seizure. be discussed with the pregnant patient and be seen in the risks and benefits explained (Robert et al. inhalation of h­hex­ 2001). ane, methyl­n­butyl ketone, and toluene (Geller 1998). Cerebrovascular accidents Cerebrovascular accident (stroke) can be seen in alcohol and cocaine use, coagulation impair­ Hepatic encephalopathy ment, and severe uncontrolled hypertension. Hepatic encephalopathy is a toxic brain syn­ drome that results from the accumulation of Patients with recent cocaine/amphetamine use unmetabolized nitrogenous waste products in may present with headaches, which could a patient with severe liver dysfunction. represent subarachnoid and/or intracerebral Presenting signs and symptoms include an bleed, and therefore should be appropriately alteration in consciousness and behavior, evaluated (Buxton and McConachie 2000). fluctuating neurologic signs such as a flapping Heavy alcohol consumption increases the risk tremor (asterixis), and an elevated serum for all major types of stroke by a variety of ammonia level. Clinicians should evaluate mechanisms (Hillbom and Numminen 1998).

Co­Occurring Medical and Psychiatric Conditions 131 patients for precipitating causes, which Drug Abuse 2000). Hepatitis B infections are include the following: likely to present more often as a chronic •GI hemorrhage infection than as an acute­stage phenomenon. Testing for chronic hepatitis B and C infec­ •Electrolyte imbalance (metabolic alkalosis) tion is appropriate during the detoxification •Infections period. •Excessive diuresis (dehydration) •Use of sedatives Special considerations •Increase of dietary protein intake Followup for hepatitis B and C should be Those patients who are infected with arranged for after discharge from the detoxi­ Helicobacter pylori may be more prone to fication setting. Vaccination is recommended hepatic encephalopathy (Duseja et al. 2003). for hepatitis A and B in the patient with hep­ atitis C. The vaccination schedule is over a 6­ Special considerations month period, so it needs to be done after the Clinicians should avoid the use of diuretics, detoxification program. If significant liver identify and treat factors that may have pre­ disease is present, use of shorter­acting medi­ cipitated the cation with less liver metabolism should be encephalopathy, considered. For more on infectious disease Immuno­ decrease dietary and substance abuse, see TIP 6, Screening protein intake, and for Infectious Diseases Among Substance Abusers (CSAT 1993c). compromised use Lactulose to decrease nitroge­ nous waste prod­ patients may not Endocarditis ucts via the GI tract. Protocols Endocarditis is caused by the introduction of react to the that use the benzo­ various bacterial species into the vascular diazepines should system when the protective defense mecha­ tuberculin skin be adjusted to use nisms of the skin are bypassed through injec­ those specific medi­ tion. The patient frequently will present with tests. cations that are fever, cardiac murmur, anemia, enlargement hepatically metabo­ of the spleen, petechiae, and peripheral lized minimally or embolic disease. The course can be subtle and not at all. indolent to fulminant, and if untreated can lead to a poor prognosis. In the patient who uses drugs intravenously, the tricuspid valve Infectious Diseases is affected in 70 percent of cases, followed by The viral causes of hepatitis are multiple, effects on the aortic valve and the mitral though the hepatitis B and C viruses are the valve. Seventy­five percent of all cases are predominant causative agents. Hepatitis C caused by Staphylococcus aureus and up to virus infection appears to be the most com­ 15 percent are caused by gram negative aero­ mon form of infectious hepatitis in patients bic bacilli (Aragon and Sande 1994). with substance use disorders. At least 76 per­ Endocarditis always should be suspected in cent of patients who have used injection drugs the febrile patient who uses intravenous for less than 7 years are positive for hepatitis drugs. Patients who use drugs intravenously C, while 25 percent of patients with alcohol are 300 times more likely to die suddenly use disorders and those who do not inject from infectious endocarditis than patients drugs show serologic evidence of infection who use drugs nonintravenously (Burke et al. (Fingerhood et al. 1993; National Institute on 1997). Patients who use cocaine intravenously

132 Chapter 5 may have a higher rate of endocarditis as a infected patient presents with complaints of result of more frequent injections and the cough (most common finding), bloody spu­ reduced need to solubilize cocaine solutions tum, chest pain, fever, and weight loss. with heat (Chambers et al. 1987). Recent immigrants from countries where TB is prevalent, socioeconomically disadvantaged populations, homeless persons, people who Bacterial pneumonia use illicit drugs, incarcerated people, and Bacterial pneumonia can result from immune people who live in areas where infection with system dysfunction, interference with normal HIV is prevalent, are at increased risk for respiratory defense mechanisms (from alcohol this disease and should be tested. Further­ or smoked drugs), direct toxicity, or aspiration. more, new strains of multidrug­resistant TB are appearing, especially among the homeless The treating physician should be aware that population (Borgdorff et al. 2000; Moss et al. the usual pathogens found in community­ 2000). acquired pneumonia (i.e., Streptococcus pneumoniae) may not be the causative agent TB is endemic in many areas of the world in pneumonias seen in patients dependent on (Asia, Africa, and South and Central alcohol. Haemophilis influenzae, Klebsiella America) (Gupta et al. 2004). As a public pneumoniae, and other gram­negative health concern, testing all patients is of the microorganisms must be suspected and treat­ utmost importance, even more so for patients ment given until definitive culture results are from regions where TB is endemic. It is reported. Among patients who use parenteral important to remember that immunocompro­ drugs, pneumonia is the most common reason mised patients may not react to the skin tests for admission to the hospital, accounting for (anergy). Diagnosis is made with tuberculin 38 percent of all hospitalizations in this popu­ skin testing, sputum smears and cultures, and lation (Marantz et al. 1987). radiographic findings. For more information on dealing with tuberculosis in detoxification Special considerations and treatment settings see TIP 18, The Careful use of respiratory depressants is rec­ Tuberculosis Epidemic: Legal and Ethical ommended. Indications for hospitalization of Issues for Alcohol and Other Drug Abuse the patient with pneumonia (Neu 1994) include Treatment Providers (CSAT 1995i). the following: •Old age Skin infections •Dehydration Skin infections frequently are seen as a result •Vomiting and inability to take in oral fluids of the intravenous administration of drugs. and medications Staphylococcus aureus and Streptococcus •Multilobar disease pyogenes are frequently the infectious agents. •Low white blood cell count The patient presents with tenderness, swelling, pain, erythema, and warmth in the •Respiratory acidosis injection area. The type and route of antibi­ •pO2 less than 55 mm Hg otic is determined by the infecting organism •Significant concomitant diseases and the extent and severity of the infection. Clinicians should remember that injection •HIV sites can be found virtually any place on the body where there is access to the venous sys­ Tuberculosis tem. Tuberculosis (TB) is caused by acid­fast rod (Mycobacterium tuberculosis). Transmission Patients who use drugs intravenously, is by droplets spread through the air. The patients with peripheral vascular disease, and

Co­Occurring Medical and Psychiatric Conditions 133 patients with diabetes (particularly with ing still should be educated about the risk infections of the feet) should all be evaluated and prevention. carefully for skin disease. Due to increased virulence of syphilis in patients who are HIV positive, as well as Sexually transmitted increased resistance to the treatments indicat­ diseases ed in the usual treatment protocols, all such patients should be tested for syphilis and all Sexually transmitted diseases can be seen in the patients who test positive for syphilis should form of urethritis, vaginitis, cervicitis, and gen­ be sent for HIV testing (McNeil et al. 2004). ital lesions. These disorders are caused by a variety of microorganisms, and a complete his­ Special considerations tory and physical that includes examination of If methadone is being used in withdrawal pro­ the genitalia is indicated in all patients. The tocols, or maintenance is being continued, the clinical picture and cultures frequently can clinician should be aware that certain HIV guide the treatment protocols. Patients who use medications can cause an increased metabolism drugs intravenously occasionally display a of methadone: false­positive serologic test for syphilis, possibly due to a nonspecific reaction to repeated expo­ •Efavirenz (Sustiva) sure of injected antigens (Hook 1992). •Nevirapine (Viramune) •Lopinavir/ritonavir (Kaletra) HIV/AIDS •Rifampin (a drug to prevent mycobacterium avium complex, a serious bacterial infection, HIV/AIDS is a serious and prevalent medical in HIV­positive clients) condition among persons with substance use disorders, especially those who inject drugs •Amprenavir (Agenerase) and may share needles with other users. •Abacavir Patients with AIDS can present with a spec­ •Ritonavir trum of complaints and illnesses ranging from an asymptomatic history to complaints of TIP 37, Substance Abuse Treatment for fever, enlargement of the lymph nodes, diffi­ Persons With HIV/AIDS (CSAT 2000e) pro­ culty swallowing, diarrhea, weight loss, skin vides further information about substance lesions, shortness of breath (due to abuse treatment for patients with HIV/AIDS. Pneumocystis carinii pneumonia), headaches (due to Toxoplasma gondii), seizures, and dementia. As a rule of thumb, no complaint Other Conditions in the patient infected with HIV should be dismissed as irrelevant. Cancer Gay men and patients who use drugs intra­ Cancer occurrence is increased in people with venously may be at higher risk for HIV/AIDS substance use disorders due to the carcino­ than other groups; thus, testing or referral genicity of the drugs used. Cigarette smoking for testing should be done and appropriate is linked to lung, larynx, oral cavity, esopha­ counseling offered. All such patients should gus, stomach, bladder, and pancreatic can­ be tested for HIV/AIDS or referred for test­ cer. Heavy alcohol consumption is associated ing. Some States, such as Colorado, require with an increased incidence of oral, pharyn­ that a risk assessment be administered to all geal, esophageal, laryngeal, respiratory tract, clients and that clients be advised of their and breast cancer (Polednak 2005). risk and referred for testing if they are at risk Synergism is seen with alcohol and smoking for HIV/AIDS. Patients who decline HIV test­ being associated with even higher risks of cancer (Fagerstrom 2002). A history of weight

134 Chapter 5 loss could suggest many chronic diseases, disorders appear to be particularly prone to though cancer should be considered in the accidents of all kinds, with a spectrum of com­ differential. There may be an increase in plications from head trauma to falls with frac­ head and neck cancers in persons with heavy tures. Chronic pain frequently is seen in cannabis use (Donald 1991). Liver cancer patients as a result of trauma (treated or may be seen in patients with hepatitis C and untreated), poor health maintenance, or an those using anabolic steroids (Socas et al. inability to deal with pain without drug use. 2005). There is a particular interrelationship Chronic pain treatment and the issues of opioid among alcohol intake, hepatitis C, and hepa­ use have to be considered for each patient on tocellular carcinoma (Yoshihara et al. 1998). an individual basis.

The surgeon should Diabetes consider drug with­ Patients who use drugs intravenously may drawal in the differ­ experience infections that affect diabetic con­ ential diagnosis of trol, though any infection in any detoxification any physical or neu­ Certain HIV patient needs to be addressed both from an rologic symptoms or infectious disease and diabetic viewpoint. signs that emerge during the perioper­ medications can Special considerations ative period. There Several medications can lead to impaired glu­ is a two­ to threefold cause an increased cose tolerance and an elevated serum glucose increase in postoper­ (Garber 1994). Some examples include ative morbidity in metabolism of patients with alcohol •Thiazide diuretics use disorders, the methadone. •Clonidine most frequent com­ •Glucocorticoids plications being infections, bleeding, •Haloperidol cardiopulmonary •Lithium carbonate insufficiency, and •Phenothiazines withdrawal compli­ •Tricyclic antidepressants cations (Tonnesen and Kehlet 1999). •Indomethacin Special considerations •Olanzapine Opioids may be used to control pain in the ini­ •Risperdol tial period of trauma. Detoxification protocols should be started prior to anticipated surgery Antidiabetic agents in concert with alcohol may and continued throughout the perioperative produce hypoglycemia and lactic acidosis. period. Pain that causes an increased heart Diabetes mellitus also is seen in patients who rate, as well as postoperative temperature ele­ present with new­onset hyperglycemia (elevated vation, may impact the detoxification parame­ glucose) or with a history of diabetes and poor ters. control. Due to tolerance to opioids, the daily methadone dose in a methadone­maintained Acute trauma/fractures individual will not serve as an analgesic for Acute trauma/fractures can be seen in any pain relief from surgical or other illnesses. patient with a substance use disorder due to an Full therapeutic doses of analgesic drugs altered level of consciousness or impaired gait should be given to methadone­maintained when intoxicated. Patients with substance use

Co­Occurring Medical and Psychiatric Conditions 135 patients who have co­occurring painful condi­ Treatment of tions (CSAT 2005d; Ho and Dole 1979). Co­Occurring Since most medications for pain management are drugs with a high abuse potential, pro­ Psychiatric Conditions grams may need to alter their policies regard­ Pharmacological agents can be used as indi­ ing the use of such drugs. Pain patients do cated for co­occurring psychiatric conditions not require detoxification from prescribed in patients with substance use disorders. medications unless they meet the criteria for Incidence of the co­occurrence of psychiatric opioid abuse or dependence described in the conditions and substance use disorders is American Psychiatric Association’s high; moreover, there is a higher rate of psy­ Diagnostic and Statistical Manual of Mental chiatric conditions in patients dependent on Disorders, Fourth Edition. Treatments for alcohol than that found in the general popula­ pain include physical therapy, transcutaneous tion (Kessler et al. 2003; Modesto­Lowe and electrical nerve stimulation, and therapeutic Kranzler 1999). heat and cold. Trials of nons­ Comorbidity of substance use and co­occur­ teroidal anti­inflam­ ring mental disorders serves to complicate matory agents or diagnosis and treatment for patients (Salloum nerve block should and Thase 2000). It is difficult to accurately The effects of be considered prior access underlying psychopathology in a per­ to the use of highly son undergoing detoxification. The effects of drug toxicity and addictive and abus­ drug toxicity and withdrawal often can mimic able medications. psychiatric disorders. For this reason, it may withdrawal often be best to conduct psychiatric evaluations The use of after several weeks of abstinence; however, acetaminophen in can mimic this should be weighed against the time an the patient with an individual has been in detoxification and alcohol use disorder what treatment plan is set up for him. Some psychiatric always has been patients also present to detoxification while questioned, espe­ taking medications to treat underlying psychi­ disorders. cially if there is evi­ atric disorders, such as depression and anxi­ dence of liver dis­ ety. The risk of not treating a severe comor­ ease. However, a bid psychiatric disorder predisposes the review article of the patient to relapse; the decision needs to be medical literature weighed against the risk of prescribing medi­ showed that repeat­ cations when the clinician is not entirely cer­ ed ingestion of a therapeutic dose of tain that a comorbid condition exists. If a acetaminophen over 48 hours by patients with period of recent extended abstinence exists, severe alcoholism did not produce an increase the patient’s mental condition when abstinent in hepatic aminotransferase enzyme levels or can be better evaluated. any clinical manifestations as compared to a placebo group (Dart et al. 2000). Although it is the philosophy of some physi­ cians to discontinue all psychiatric medica­ tions upon entering a detoxification program, this course of action is not always in the best interest of the patient. Abrupt cessation of psychotherapeutic medications may cause withdrawal symptoms or the re­emergence of the psychiatric disorder. As a general rule,

136 Chapter 5 therapeutic doses of medications should be times is the best way to assess the patient’s continued through any withdrawal if the need for the medication; however, it may not patient has been taking the medication as pre­ be the best practice or in the best interest of scribed. Decisions about discontinuing medi­ the patient, particularly for those with a seri­ cations should be deferred until after the ous mental illness. For more information on individual has completed detoxification. If, working with patients with co­occurring sub­ however, the patient has been abusing a medi­ stance use and mental disorders, see TIP 42, cation or the psychiatric symptoms were Substance Abuse Treatment for Persons With clearly caused by substance abuse, then the Co­Occurring Disorders (CSAT 2005c). rationale for discontinuing the medication is strengthened. Finally, practitioners should consider withholding medications that lower Treatment for Co­Occurring the seizure threshold (e.g., bupropion or con­ Conditions ventional antipsychotics) during the acute The treatment of substance use disorders can alcohol withdrawal period, or at a minimum be difficult without adequate treatment of any prescribing a loading dose or scheduled taper co­occurring mental disorders. For instance, of benzodiazepine. a patient with schizophrenia who is halluci­ During detoxification, some patients decom­ nating and delusional, but who also abuses pensate and lapse into psychosis, depression, substances, cannot participate in substance or severe anxiety. In such cases, careful abuse treatment without adequate control observation of the withdrawal medication reg­ over the psychosis. Likewise, patients with imen is of paramount importance. If the mania who are euphoric and delusional, decompensation is a result of inadequate dos­ patients who are depressed, or patients with ing with withdrawal medication, the appro­ agoraphobia who also have a substance use priate response is to increase the dose of med­ disorder, will have difficulty cooperating with ication. If it appears that the withdrawal substance abuse treatment. Treatment of the medication is adequate, other medications substance use disorder is necessary to may be needed. Before choosing such an improve the course of both the substance alternative, it is important to take into abuse and co­occurring mental disorder. account additional considerations, such as the Psychotherapy should serve as one aspect of side effects of the added medication and the rehabilitation, initially focused around possibility of interaction with the withdrawal relapse prevention (Aviram et al. 2001). medication. Highly effective treatment programs may include a combination of therapeutic tech­ A patient with psychosis may need to take niques. Programs should be long­term and neuroleptics. Medications that have a minimal approach recovery in stages. Drake and col­ effect on the seizure threshold are recom­ leagues (2001) suggest that treatment for co­ mended, particularly if the patient is being occurring substance use and other mental dis­ withdrawn from alcohol or benzodiazepines. orders include skill building, illness manage­ Small, frequent doses of Haldol, such as 1mg ment, cultural sensitivity, and support to every 2 hours, may be used until the patient’s patients for the pursuit of practical goals. symptoms of psychosis begin to disappear. The case for emergency use of antidepres­ sants is weaker than for other psychiatric Limitations of pharmacologi­ medications because of the 2­ to 3­week lag cal agents in persons with time between initiation of medication and substance dependence therapeutic response. After detoxification, the patient’s need for medication should be Pharmacologic agents have limitations in the reassessed. A trial without medications some­ population of persons with substance use dis­

Co­Occurring Medical and Psychiatric Conditions 137 orders. Medications may impair cognition and Standard of Care for blunt feelings, sometimes subtly. Clinicians treating substance use disorders advocate Co­Occurring that clients need clear thinking and access to emotions in order to make fundamental Psychiatric Conditions changes in themselves. A person recovering After detoxification and stabilization with from a substance use disorder must take an pharmacologic agents, the current treatment active part in changing attitudes and aban­ of choice for substance use disorders is non­ doning a long­held belief that alcohol or other pharmacologic. Further, several studies have drugs can “treat” life problems and uncom­ shown that treating substance use disorders fortable psychological states. Although these with abstinence alone results in improvement are potential risks, the intent of pharma­ of the psychiatric syndromes associated with cotherapy is to enhance a person’s ability to the substance use (Anderson and Kiefer sustain abstinence and benefit fully from con­ 2004). Severe syndromes induced by alcohol current psychosocial interventions and treat­ that may otherwise meet criteria for major ments. Still, many psychiatric disorders, if depressive and anxiety disorders are best untreated, result in mood, anxiety, or thought classified as substance­induced disorders if disorders that prevent or retard the behav­ they resolve within days to weeks with absti­ ioral changes necessary to recover from sub­ nence. Likewise, manic syndromes induced by stance use disorders. cocaine resolve within hours to days, and schizophrenia­like syndromes (e.g., hallucina­ Risks versus benefits of pharmacological tions and delusions) induced by cocaine and agents need to be considered carefully. PCP often resolve within days to weeks with Untreated anxiety, mood, or thought disor­ abstinence. ders can be powerful relapse triggers, espe­ cially for people with a long­standing pattern Further studies are needed to confirm the of relying on alcohol or other drugs to man­ clinical experience that psychiatric symptoms age their symptoms. In many instances, the (including anxiety, depression, and personali­ benefits and reduced relapse risk that appro­ ty disorders) respond to specific treatment of priate pharmacotherapy can provide far out­ the addiction. For example, cognitive–behav­ weighs the risk of taking medications. Some ioral techniques employed in the 12­Step clinicians believe that the “no pain, no gain” treatment approach have been effective in the approach has far greater risk of interfering management of anxiety and depression associ­ with recovery than of promoting it. Symptoms ated with addiction. Although challenging, such as anxiety and depression in persons treatment of both addiction and co­occurring recovering from substance use disorders psychiatric conditions has proven cost­effec­ might be vital to recovery, and pharma­ tive in some studies (Goldsmith 1999). cotherapy to treat such symptoms needs to be considered carefully in this context. Clinically, anxiety and depression can pro­ Psychotropics for Co­Occurring vide the motivation to change when the Psychiatric Conditions patient otherwise has little awareness of the need to alter behavior. General aspects Because alcohol and other drugs can induce almost any psychiatric symptom or sign or mimic any psychiatric disorder, their effects always must be considered before a co­occur­ ring condition diagnosis is established or treated.

138 Chapter 5 With an understanding of the interactions panic and phobia disorders, posttraumatic between substance use and other mental dis­ stress disorder, victimization, and eating dis­ orders, a rational approach can be applied to orders. Deficits in the management of mood the use of pharmacologic therapies in co­ disturbances may be self­medicated through occurring conditions. The use of medications alcohol consumption in females. It has been for psychiatric symptoms should begin only proposed that the outcomes of substance after the knowledge of the natural history of abuse in women are different when compared the addictive disorder and other psychiatric to those of men. For these reasons, the effica­ disorders is clarified. Further, it is important cy of treatment for substance use disorders to be able to identify the respective roles of needs to be assessed independently for both substance use and other mental disorders in genders (Becker and Walton­Moss 2001; the generation of psychiatric symptoms. Brady and Randall 1999). Generally, substance­induced psychiatric symptoms resolve within days to weeks of Anxiety abstinence. In many studies, the prevalence Disorders Major depressive rates for anxiety and affective disorders in persons dependent on alcohol were not and anxiety greater than those for persons not dependent General on alcohol (Schneider et al. 2001). approach disorders are best A retrospective history of psychiatric symp­ Prevalence rates for toms often can lead to an inflated diagnosis of the co­occurrence of classified as these conditions because of rationalizations anxiety and sub­ regarding drinking and drug use by the indi­ stance use disorders substance­induced vidual. Typically, psychiatric symptoms are in the general popu­ emphasized by both the patient and the psy­ lation range from 5 disorders if they chiatric examiner. to 20 percent in epi­ demiologic and clini­ Longitudinal observation frequently clarifies cal studies resolve within the role of alcohol and other drugs in the pro­ (Merikangas et al. duction of anxiety, affective, psychotic, or 1996). days to weeks with personality symptoms, particularly if objec­ tive criteria are relied on in addition to the Some antianxiety abstinence. subjective report of the person who is addict­ agents can overse­ ed. Also, specific treatment of substance use date and dull the disorders can result in improvement of mood, individual’s reaction psychotic behavior, and personality distur­ to internal and external influences. Because bances if related to the alcohol or other drug anxiety in recovery can be critically impor­ use. Mood lability and personality states can tant for emotional growth, the individual will be a manifestation of substance use disorders, feel a certain amount of anxiety to motivate and treatment of the addictive disorder can change in behavior, attitudes, and emotions. lead to stabilization of these psychiatric (The expression “emotional growth” is related symptoms. to the anxiety or discomfort a recovering indi­ vidual feels while undergoing the process of Furthermore, treatment plans and efficacy change to reach a more mature state.) It is may rely on the gender of the patient. Women important for the clinician to distinguish with a substance use disorder appear to have between anxiety that can promote growth and higher rates of co­occurring mental disorders, anxiety that can impair a person’s ability to such as depression and anxiety, as well as make change. Adapting behavior in response higher rates of physical and sexual abuse, to anxiety or other emotion requires coping

Co­Occurring Medical and Psychiatric Conditions 139 skills that may not be available to persons in patient from participating in treatment. A early recovery. A fully symptomatic anxiety thorough evaluation to assess whether the disorder may significantly limit a person’s individual is abstinent, involved in continuing capacity to learn nonpharmacological coping treatment, and/or attending self­help meetings strategies. Medications with minimal addic­ usually is necessary before a diagnosis of a tion potential can be helpful and in some co­occurring psychiatric condition can be def­ cases necessary if patients are to make initely established. After such an evaluation, progress in their recovery. treatment of the anxiety disorder can proceed separately from similar symptoms arising Depressants (e.g., alcohol) can produce anxi­ from the addictive disorder. ety during withdrawal, and stimulants (e.g., cocaine) can produce anxiety during intoxica­ tion. Because people with substance use dis­ Pharmacologic therapies orders are in a relatively constant state of The ideal medication works against abnormal withdrawal (it is anxiety but not against the “normal” anxiety impossible to main­ needed for recovery. Some of the physical tain a constant symptoms of anxiety include sweating, blood level), they tremors, palpitations, muscle tension, and regularly experi­ increased urination. Psychological symptoms Medication is ence anxiety as the include nervousness, feelings of dread or result of pharmaco­ impending doom, unpleasant tenseness, and indicated when logical withdrawal many more. from dependence. the anxiety is As the substance The most common agents used in anxiety dis­ abuse becomes orders are benzodiazepines and antidepres­ preventing the more chronic, the sants. The benzodiazepines most frequently anxiety produced used are alprazolam and lorazepam. patient from by withdrawal from Diazepam and clonazepam are used less pharmacologic often. Because the benzodiazepines can cause dependence can significant problems in patients who are participating in become increasingly addicted as well as in patients who are not severe. Relapse addicted, they generally are not recommend­ treatment. and/or periods of ed for people with substance use disorders or abstinence (some­ for long­term treatment of anxiety or depres­ times prolonged— sive disorders. for weeks or months) should be Antidepressants may be considered sooner if considered (confirm depression is a known pre­existing condition abstinence with laboratory drug testing, if or historical experience and collateral infor­ necessary) before the effects of depressant or mation suggests a comorbid depression. Again stimulant drugs in inducing anxiety can be the risk of treating prematurely needs to be ruled out. It can take weeks or months for weighed against the risk of not treating a con­ these effects to subside completely, although a dition that may prevent recovery from a sub­ period of only a few days to weeks often is stance use disorder. Antidepressants such as sufficient in clinical practice. imipramine and nortriptyline and selective serotonin reuptake inhibitors (SSRIs) such as Treatment is indicated when the anxiety per­ fluoxetine (Prozac) have a low addiction sists after adequate effort in a substance potential and can be used with relative safety. abuse treatment program, or when the clini­ They differ in their tendency to produce cian suspects that anxiety is preventing the sedation and anxiety and have a withdrawal

140 Chapter 5 syndrome of their own. Because of its anti­ fered by the patient with an addictive disor­ cholinergic properties, imipramine is more der. Likewise, and analogous to the role of sedating, but nortriptyline and the SSRIs can anxiety, depression also is a part of the heal­ produce anxiousness in some individuals and ing process that the patient with a substance sedation in others. Not all individuals react use disorder experiences during recovery. the same way to these medications. Depressant drugs (e.g., alcohol) can produce When medications are used, a specific target depression during intoxication which often symptom should be the focus. Also, medica­ resolves following abstinence. A survey of 69 tions should be tried in time­limited intervals, adults with alcohol use disorders showed a such as weeks to months. A “drug holiday” strong correlation between the reduction in (i.e., a brief period where the patient stops cravings for alcohol over 2 weeks of absti­ taking medications) should then be attempted nence and the lifting of depressive mood. The to see if the medication is still necessary. patients’ cravings were assessed with the Obsessive­Compulsive Drinking Scale (OCDS) The patient should be instructed that the and their depressive symptoms measured with medications will not “cure” the addiction, the Self­rating Depressive Scale (SDS). that treatment of anxiety will not control the Between day 1 and day 14, their cravings addiction, and that treatment of the addiction score dropped nearly a third, while the scores will not necessarily ameliorate the anxiety dis­ for severity of depression fell by about one order. In essence, the substance use disorder fourth. The correlation between the reduction must be treated independently of the anxiety in cravings and the lifting of depression per­ disorder and vice versa. sisted after controlling for sex, age, duration and extent of alcohol abuse, and the amount Depressive Disorders of clomethiazole administered (Anderson and Kiefer 2004). General approach Stimulant drugs (e.g., cocaine) can produce Prevalence rates for the co­occurrence of depression during withdrawal. These effects depressive and addictive disorders range may be prolonged with certain drugs that from 5 to 25 percent in epidemiologic and linger in the body (i.e., are stored in fat), clinical studies. Depressive disorders include such as cannabis and benzodiazepines. These major depressive and dysthymic disorders, drugs can produce depression or anxiety that which can occur independently with addictive is indistinguishable from other psychiatric disorders, or similar depressive symptoms causes of depression. Therefore, they must be can be induced by substance use disorders. considered causative whenever depression is Major depressive disorder is more common in present, and the possibility of addiction needs older individuals and in women and can be to be assessed when these drugs are identi­ difficult to distinguish from substance­ fied. While depression may persist for weeks induced depression. or months, it often resolves within days with abstinence from these drugs. Depression can be viewed as protective and can be associated with “healing” in many con­ ditions involving emotions. For example, a Pharmacologic therapies grief reaction is an expected experience after The use of medication is recommended if the loss, with depression an essential emotion in depression persists beyond a few weeks of this process. Recovery from a substance use drug withdrawal or arises during confirmed disorder has been compared to a grief reac­ abstinence (laboratory drug testing may be tion because of losses (e.g., of the substance necessary to confirm abstinence). The risk of or relationships based on substance use) suf­ suppressing normal depressive processes dur­

Co­Occurring Medical and Psychiatric Conditions 141 ing recovery versus the benefit from sup­ Bipolar disorder may be complicated by the pressing depression that is interfering with influence of substances (Sonne and Brady function should be weighed, as is the case 1999). The manic state can be produced by with anxiety disorders. stimulants (e.g., cocaine) during intoxication, and from depressants (e.g., alcohol) during Antidepressants are the main treatment for withdrawal. A period of confirmed abstinence depression. The target symptoms are a sad usually is necessary before mood­stabilizing mood, tearfulness, appetite and sleep distur­ drugs are started. Generally, a period of a bances, and other neurovegetative symptoms. week or two may be required for the role of Depression can be found in many conditions, drugs in inducing manic symptoms to be including a variety of psychiatric and medical properly assessed. conditions. SSRIs are the drug of choice for many physicians treating depressed patients with substance use disorders. Although some Pharmacologic therapies are costly, they provide adequate treatment Mood stabilizers control bipolar disorders in of depression with fewer side effects than patients with or without co­occurring sub­ other medications commonly used (Thase et stance use disorder. These medications can al. 2001). control either the manic or depressed phase, Depressive disorders are thought to have a or both. significant biological component, including Manic episodes can occur cyclically, alterna­ deficiencies in such central nervous system tively, and concurrently with depressive neurotransmitters as serotonin, nore­ episodes. One theory of the pathogenesis of pinephrine, and dopamine. Interestingly, bipolar disorder involves the neurotransmit­ these neurotransmitters are also affected by ter norepinephrine (i.e., excessive in mania substances of abuse. These agents are thought and deficient in depression). to act by increasing the activity of these neu­ rotransmitters, ultimately alleviating depres­ Lithium is a natural salt, available in the car­ sion and stabilizing mood. bonate form and slow release preparations. Its exact mechanism of action is unknown, but it can be effective in reducing or prevent­ Bipolar Disorders ing the recurrence of manic and depressive episodes. Lithium carbonate must be taken General approach daily in doses of 600 to 2,400mg to achieve Prevalence rates for the co­occurrence of plasma levels in the 0.5 to 1.5­m equiv/L bipolar and addictive disorders range from 30 range. It should be noted that studies have to 60 percent, depending on the population shown that lithium has no conclusively posi­ studied, in epidemiologic and clinical studies tive effect on rates of abstinence in either (Chen et al. 1998; Sallom and Thase 2000; depressed or nondepressed patients. Sonne and Brady 1999; Strakowski and Anticonvulsant mood stabilizers, such as DelBello 2000). divalproex sodium and carbamazepine, can Mania is a condition associated with elevated be effective in controlling mania and, some mood, grandiosity, hyperactive behavior, evidence suggests, in co­occurring addictive poor judgment, and lack of insight. The conditions as well. Carbamazepine is known patient with mania will show excess such as to be as effective as some benzodiazepines in spending sprees, sexual promiscuity, intru­ inpatient treatment of alcohol withdrawal siveness, and abnormal alcohol and drug use. and, because of its anticonvulsant properties, A manic episode can follow, precede, or alter­ it may be a good choice for treating those nate with depressive moods. patients at high risk of withdrawal seizures

142 Chapter 5 (Malcolm et al. 2001). One theoretical expla­ the neurotransmitter dopamine at its postsy­ nation for the mechanism of action for carba­ naptic receptor sites. mazepine involves suppression of mood cen­ ters in the limbic system that act like seizure foci. In this context, a “kindling” model has Adverse been proposed for both mood and addictive Effects disorders (Gelenberg and Bassuk 1997). Antianxiety A period of Psychotic Disorders agents confirmed While benzodi­ General approach azepines are useful abstinence usually Prevalence rates for co­occurrence of in the short term, their efficacy wanes schizophrenic and addictive disorders range is necessary from 40 to 80 percent, depending on the pop­ with long­term use, probably because of ulation studied, in epidemiologic and clinical before mood­ studies. the development of pharmacologic toler­ Schizophrenia is a chronic illness character­ ance and depen­ stabilizing drugs ized by bizarre thinking and behavior. dence. It should be Hallucinations and delusions are “positive” noted that benzodi­ are started. symptoms of the psychotic process, while azepines can be symptoms such as social withdrawal and addicting, particu­ poverty of emotions are “negative” symptoms larly in those already (or deficit syndrome). Conventional neurolep­ addicted to other tics are more effective for positive symptoms, substances. whereas behavioral, group, and individual psychotherapy are more effective for negative symptoms. New agents such as clozapine and Antipsychotic agents risperidone may be more effective in treating Antipsychotics can produce sedation and both the positive and negative symptoms. hypotension (at times causing lightheadedness in some individuals), particularly with postu­ Psychosis can be caused by stimulant drug ral changes. Conventional neuroleptics pro­ use during intoxication and depressant duce acute extrapyramidal reactions, which drug/alcohol use during withdrawal. A period include pseudoparkinsonism, dystonia, and of weeks or months may be necessary to akathisia. Dystonia usually responds to treat­ assess the effects of substances of abuse, but ment with anticholinergic drugs such as ben­ as with anxiety, depression, or mania, medi­ ztropine or diphenhydramine. Akathisia is cations can be started at almost any time as the subjective feeling of anxiety and tension, the psychosis is persistent and waiting is not causing the patient to feel compelled to move possible. Moreover, the greater the number of about restlessly. This symptom usually psychiatric admissions, the greater the proba­ requires beta blocker, as a decrease in the bility of a chronic mental disorder associated antipsychotic dose does not have the desired with the co­occurring psychiatric disorder. effect. Alternatively, switching to risperidone may accomplish the intended effect while High­ or moderate­potency neuroleptics (e.g., avoiding intolerable neurologic syndromes. haloperidol or atypical agents) generally are the agents of choice in the treatment of schizophrenia. The clinical potency correlates with the drug’s ability to block the action of

Co­Occurring Medical and Psychiatric Conditions 143 Antidepressants use the 12 steps of Alcoholics Anonymous (AA) and to accept psychiatric advice will Antidepressants, particularly the tricyclics, depend on clear thinking and emotional bal­ can produce sedation, hypotension, syncope, ance, which is stressed as central to the and other anticholinergic effects. The SSRIs recovery process in AA. In other cases—such can produce anxiousness, sedation, insomnia, as patients with traumatic brain injuries— and gastrointestinal upset. A withdrawal syn­ treatment venues should be adaptable to their drome also has been reported with most cognitive abilities. antidepressant medications. Accordingly, the use of medications should be The SSRIs are preferred in patients with conservative, taking into consideration the addiction and co­occurring psychiatric condi­ pros and cons of their expected positive and tions because of their reduced side effect pro­ negative effects. Unfortunately, few psychi­ file and low risk of dangerous drug interac­ atric medications are totally free of mood­ tions; for example, there are no anticholiner­ altering properties. However, the cognitive gic effects on the senses and no risk of lethal state of individuals who have a serious mental effects from overdose. illness often is more distorted when not medi­ cated appropriately. The very nature of their Cognitive State in Recovery illness is a disruption to their cognitive pro­ cesses. A person recovering from a substance use dis­ order must have a clear mind and a stable mood. Medications have a tendency, some­ Dosing times subtly and other times obviously, to dull Because of inherent susceptibility to drug the senses and thinking and blunt or disrupt effects by people with substance use disorders, the emotions. People with substance use dis­ it is important to use the lowest effective doses orders must eventually change and control possible. Also, the intervals for administration feelings to remain abstinent and also to com­ should be selected to reduce effects on cogni­ ply with psychiatric management. The ability tion and feelings. of a person with a substance use disorder to

144 Chapter 5 6 Financing and Organizational Issues In This Chapter… Preparing and Developing a Preparing and Program Developing a Developing a detoxification program is a major financial challenge, Program whether the program requires building an entirely new organization or is part of an existing treatment entity. The process of program Working in development requires careful planning, especially to ensure adequate Today’s Managed financial support for the operation. The decision to develop a detoxifi­ Care Environment cation program should be based on a well­developed strategic plan­ ning process (see chapter 2) and a clear understanding of what a Preparing for the detoxification program entails. Because the new program will incur Future major costs for office space, furniture, staff, computers, and other equipment before clients can be provided with services and payment can be received, significant amounts of initial capital may be needed.

As soon as the administrator or planner identifies a market need for detoxification services, potential fiscal support and other resources should be identified and checked to see if such support is likely and sufficient. Both implementation and initial operating costs must be covered. It may be possible to find strategic partners who will provide resources, work with the program planner, provide office space, or help obtain funding. Community organizations that see a need for establishing detoxification and treatment services are likely partners. Locally based foundations and businesses also may be approached for assistance with developing a program, especially if a case can be made to the potential funder that ongoing costs can be covered from opera­ tions.

It is important to have documented assurance from major referral and payment sources that they will refer patients with information on payment sources; that is, by the referral source, by a third party, or

145 by patients who have the documented finan­ health plans may be necessary to ensure both cial resources to pay for detoxification treat­ private sector demand for services and ment themselves. Signed contracts with appropriate reimbursement of the services. expected payors may be useful to ensure ade­ quate cash flow and to establish a budget for Forming strategic alliances with other compo­ the new program’s fee structure. nents of the treatment environment can be both an important source for referrals and a Identifying and recruiting strategic partners resource for clients with needs other than is one of the most important steps in the pro­ detoxification. Vertical alliances facilitate gram development process. Before and during referrals up and down the continuum of care. the program development process, adminis­ An alliance with a larger organization can trators and planners should work closely with increase leverage when negotiating with an potential referral and payment sources to MCO. determine their needs and to see if the detoxi­ fication program will fit those needs. Programs also will need to learn whether The Dramatically Changing referral sources are open to new partners, the Pattern of Utilization of types of contracts they utilize, their time­ Detoxification Services frames for reimbursement, and the process for negotiating a contract. Among useful tac­ The settings for detoxification services have tics to employ is holding focus groups and changed dramatically over the last decade, as strategy meetings with individuals from have patients’ primary substances of abuse. As potential referral sources; these groups can the setting for detoxification services has shift­ suggest the types of services they need and for ed from inpatient to outpatient, the primary which they will reimburse. Potential referral substance abuse problem of clients has shifted sources will be more invested in the program from alcohol and cocaine/crack to heroin and if they are involved throughout the planning other opioids. This shift has created significant process. All potential stakeholders should be opportunities in the market for detoxification informed regularly of the developing plans services for community­based and and milestones achieved. entrepreneurial providers that are not part of hospitals, or for freestanding detoxification Program planners should follow up on all facilities that are owned by hospitals. potential leads for both funding sources and potential referral sources. Relationships with Changes in practice patterns and in the epi­ referral sources are important to build and demiology of substance abuse in the last maintain. Obviously, referral sources need to decade have been dramatic. Between 1993 be carefully assessed to ensure that they can and 2000, the number of admissions to hospi­ provide patients who have needs and tal inpatient settings for detoxification of resources appropriate for the services the patients with a primary problem of alcohol program will provide. Leads for potential abuse declined by 79.6 percent. During the sources of funding and referrals may include same period, the total admissions to inpatient the contacts made during a focus group pro­ hospital detoxification services declined by cess, public system payors and planners, pri­ 69.3 percent, from 23.5 percent of total vate insurance plans, contracting agents for detoxification admissions in 1993 to 8.8 per­ private insurance (e.g., managed care organi­ cent of total detoxification admissions in zations [MCOs]), and local employers large 2000, while admissions to 24­hour free­stand­ enough to have employee assistance programs ing detoxification units increased by the same (EAPs) or managed behavioral health plans 14.7 percentage points, from 60.5 percent of that cover detoxification services. Direct con­ total admissions in 1993 to 75.1 percent of tact with the EAPs or managed behavioral total admissions for detoxification services in

146 Chapter 6 2000. During this same period, the number of the reporting needs and performance require­ alcohol admissions to free­standing clinics ments of each purchaser, to provide informa­ decreased by 32.0 percent and the number of tion that meets their requirements, and to cocaine/crack admissions decreased by 42.5 generate the appropriate bills/invoices. percent. Concurrently, heroin admissions (to Detoxification program administrators must free­standing clinics) increased substantially be knowledgeable about efficient business from just under a quarter of total detoxifica­ practices, the use of data­based performance tion admissions in 1993 to just over a third of measures, accounting, budgeting, financing, total admissions in 2000. and financial and clinical reporting.

Of course, these statistics reflect national It also is important to reach out to other trends and regional differences in patterns of potential sources of support such as founda­ both practice and substance abuse. Changes tions, board mem­ in specific geographic areas will vary. bers, and local or Prospective programs should carefully national corporate Identifying and research their own local market for detoxifi­ donation programs cation services and should obtain data on for any assistance current utilization of and demand for detoxi­ that will help to recruiting fication in their local area before proceeding reduce costs, with program development. increase revenue, or strategic partners improve productivity and effectiveness is one of the most Funding Streams and Other and aid in the suc­ Resources in the Substance cess of the organiza­ important steps in Abuse Treatment Environment tion. Searching for support does not end the program Substance abuse treatment and detoxification with ensuring initial services in the United States are financed funding. Planners development through a diverse mix of public and private must make good use sources, with substantially more being spent of the Internet to by the public sector. Public sources account uncover potential process. for 64 percent of all substance abuse treat­ cash and in­kind ment spending, a much higher percentage donations that can than public expenditure for the rest of health supplement major funding sources, discussed care (Coffey et al. 2001). The existence of below. diverse funding streams presents both man­ agement challenges and opportunities for pro­ Entrepreneurial, for­profit programs may be gram independence and stability. However, a able to attract private capital. Not­for­profit program with only one major funding source entities that are similarly entrepreneurial is financially and clinically vulnerable to may be able to take advantage of this poten­ changes in its major source’s budget and pri­ tial source of funding through establishment orities, and this situation should be avoided. of a for­profit subsidiary. Detoxification pro­ Diversification of funding sources should be a grams in particular, as opposed to some other major goal for detoxification programs. areas of substance abuse treatment, may be attractive candidates for private financing Usually, each funding stream has different because of their potential to serve privately approval and reporting requirements. insured and self­pay patients. However, Because of this, any new or existing detoxifi­ acceptance of private capital usually carries cation program requires a fairly sophisticated with it requirements for rapid growth in rev­ management and accounting system to meet

Financing and Organizational Issues 147 enues and profitability that may be difficult services. Any episode of detoxification may be to meet and may limit operational flexibility, denied reimbursement under a plan if medi­ at least in the short term. In the longer term, cal necessity is not demonstrated to the satis­ successful detoxification programs may be faction of the plan or if the service is provid­ able to generate profits. ed at a higher level of care than is judged medically necessary. Funding streams associated with public and private health insurance often provide bene­ It is important to decide whether to make a fits to covered individuals that vary according new detoxification program hospital­based, to whether or not the services are facility­ facility­based, or office­based. Services that based and accord­ are considered hospital­ or facility­based, like ing to the level or those in hospital outpatient departments, The Substance setting of care. often are eligible for higher payment rates Complexity arises than office­based services to reflect their Abuse Prevention because coverage greater capital and other overhead costs. and reimbursement Similarly, hospital inpatient services often are and Treatment depend both on reimbursed at a higher payment rate than whether a service is outpatient services, but medical necessity Block Grant considered to be a determinations also require patients to need medical service or a more intensive services. Sometimes, patient program is the substance abuse copayments or coinsurance rates may be treatment service higher for office­based services than facility­ cornerstone of and whether a ser­ based services. This is true for Medicare as vice is facility well as for other health insurance plans. Federal funding based. Detoxification programs that are parts of hos­ pitals, affiliated with a hospital, or consid­ Many public and for substance ered as a licensed facility themselves may be private benefit eligible for higher rates of reimbursement plans still classify abuse treatment than are those that are considered to be out­ substance abuse patient programs with no facility license. detoxification as a and detoxification However, utilization management criteria to medical rather than authorize payment for admission to and con­ a substance abuse programs. tinued stay in a hospital inpatient setting treatment service. require a significantly greater severity of In general, and patient diagnosis than do criteria for admis­ especially for sion and continued stay in a freestanding or employer­based outpatient program. On the other hand, often coverage, benefits under a medical plan are there are high barriers to obtaining a facility provided at higher reimbursement rates with license to open a freestanding 24­hour facility fewer limits and restrictions than are benefits or licensed outpatient detoxification facility. for substance abuse treatment (Merrick et al. Programs that are part of or affiliated with 2001). Requirements for out­of­pocket pay­ hospitals also must contend with overhead ments by those covered under these plans cost allocations from the hospital as well as typically are lower under the medical portion with oversight from hospital administrators of a plan than under the substance abuse who may know little about substance abuse treatment portion. However, it is important treatment or detoxification. In addition, some to note that benefit plan features are but one health insurance plans actually exclude cov­ component of coverage; utilization manage­ erage for hospital­based or freestanding facil­ ment procedures continue to play a very ity­based detoxification programs and others important role in a patient’s access to specific may subject admissions to such programs to

148 Chapter 6 more intensive review than admissions to intermediary agencies. Services may be paid non–facility­based detoxification programs. for through grants, contracts, fee­for­service, Program planners should consider carefully and/or managed care arrangements. The all alternatives; decisions concerning affilia­ Children’s Health Act of 2000 mandated a tion with a hospital or pursuit of a facility gradual transition from SAPT Block Grants license have far­reaching financial and politi­ to Performance Partnership Grants (PPGs). cal ramifications and should be made with as Providers should follow developments much information as possible. through their SSA, which include •Changes in reimbursement. Treatment Following is a discussion of the key funding purchasing systems may evolve over time; streams and resources that are available for managed care arrangements and require­ programs providing detoxification services. ments are increasingly common. •Performance outcome data. In accordance SAPT Block Grant with Federal legislation, PPGs eventually The Substance Abuse Prevention and will replace SAPT Block Grants and will Treatment (SAPT) Block Grant program is provide more flexibility for States as well as the cornerstone of Federal funding for sub­ require more accountability based on out­ stance abuse treatment and detoxification come and other performance data. programs. These funds are sent to the State’s Substance Abuse and Mental Health Single State Agency (SSA) for substance Services Administration (SAMHSA) and the abuse for distribution to counties, municipali­ States are establishing performance out­ ties, and designated programs. Some of the come measures for funding programs under funds are subject to required set­asides for the block grants. All data for core measures special populations. Each program should are collected from States receiving PPG check to see if the clients it intends to serve dollars. are eligible for block grant funding, either for set­asides or for other funds. Each State Medicaid maintains its own criteria for eligibility and Medicaid, administered by the Centers for the criteria and definitions vary greatly Medicare and Medicaid Services (CMS) in among States. Multistate providers will need conjunction with the States, provides finan­ to check specifically in each State in which cial assistance to States to pay for medical they operate. care of specifically defined eligible persons. The Substance Abuse and Mental Health Medicaid is being used by many States as a Services Administration (SAMHSA) provides vehicle for experimentation with public sector funding for substance abuse treatment and managed care in an effort to expand medical prevention through the block grants as well as coverage to the uninsured. About 2 percent of a large variety of other mechanisms, includ­ total Medicaid expenditures nationally are for ing both discretionary grants and contracts. substance abuse treatment services (Mark et A portion of the SAMHSA Web site is devoted al. 2003a) but Medicaid supports about 20 to various funding opportunities. percent of national expenditures for sub­ stance abuse services (Coffey et al. 2001). The The most recent available data indicate that level of expenditure varies greatly by State. the SAPT Block Grant accounts for approxi­ Medicaid is an entitlement program with sev­ mately 40 percent of public funds nationally eral distinct eligible groups: low­income chil­ expended for prevention and treatment of dren, pregnant women, the elderly, and peo­ substance abuse (U.S. Department of Health ple who are blind or disabled, all or some of and Human Services 2003). Funds from the whom can be enrolled in a detoxification pro­ block grant may come directly from the SSA gram population. Some substance abuse or be channeled through regional or county treatment programs will want to target pro­

Financing and Organizational Issues 149 grams to the Medicaid population; if the the IMD exclusion in their program planning State’s coverage and payment rates are mini­ process. mal, however, other funders should be explored in greater depth. The Medicaid Early Periodic Screening Detection and Treatment (EPSDT) mandate The reason for substantial variation in State requires States to screen all children and ado­ Medicaid expenditures and coverage is that lescents on Medicaid for physical and behav­ substance abuse treatment and rehabilitation ioral health disorders. Further, EPSDT is an optional benefit under Medicaid that requires that any needed medical treatment is States have the discretion to include or not provided to children, even if the service is not include in their Medicaid program. Medicaid in the State’s Medicaid plan submitted to may pay for substance abuse treatment either CMS. Although the procedures and screening directly through fee­for­service arrangements tools vary by State, and there is significant or through a managed behavioral health care variation in their identification of substance or other MCO with which it contracts. More abuse issues, the EPSDT program is an than one type of arrangement may exist with­ important entrance to substance abuse treat­ in the same State. Rates of payment/reim­ ment for children and adolescents (Semansky bursement are determined by each State inde­ et al. 2003). pendently and may vary within the State among the various coverage arrangements. If When available, Medicaid coverage offers the a State decides to include benefits for sub­ following advantages: stance abuse treatment in its Medicaid pro­ •It can provide significant treatment funding gram, it can choose the precise services and for certain high­risk groups, such as low­ levels of care that will be reimbursed. The income mothers and adolescents. services provided under managed care may •Client copays traditionally have not been differ from those under fee­for­service required so the program receives the entire arrangements. Although most States offer negotiated fee without having to collect funds some coverage for detoxification services from clients. (However, some States have under their Medicaid program (Office of the changed this provision due to budget crises.) Inspector General 1998), not all types or set­ •A Medicaid contract can provide a useful tings for detoxification programs are covered lower limit for rate negotiations with com­ in those States that do provide coverage. mercial payors by essentially prohibiting Therefore, a State Medicaid program may acceptance of contract terms with any other cover certain substance abuse treatment ser­ purchaser at rates lower than those estab­ vices but not cover detoxification services. lished for Medicaid. For more information, readers should contact their State Medicaid office. •Certification as a Medicaid provider also can position the program to receive patients from An important distinction of the Medicaid ben­ other public sector referral sources, making efit structure since its inception has been the it possible to obtain patients from sources exclusion of coverage for services provided in such as social services, indigent care funds, an Institute for Mental Disorders (IMD), and criminal justice systems. defined as a facility with more than 16 beds •The criminal justice and juvenile justice sys­ that treats mental disorders, including sub­ tems and drug court administrators typically stance abuse, for individuals between the ages favor providers that are eligible for Medicaid of 21 and 64 (Rosenbaum et al. 2002). reimbursement because treatment of some Although services furnished by outpatient offenders can then be billed to Medicaid in detoxification programs are not excluded, some States. detoxification programs should be aware of

150 Chapter 6 Medicaid link to Medicare­certified medical practitioners; however, clients whose services are reim­ Supplemental Security bursed under Part B are required to pay 50 Income percent of Medicare­approved amounts. For Supplemental Security Income (SSI) is a pro­ more information, contact the Social Security gram financed through general tax revenues. Administration, Medicare provider enrollment SSI recipients are one of the mandated popu­ department, or State Medicare services. lations for Medicaid, but specific provisions vary by State. SSI disability benefits are Medicare link to Social payable to adults or children who are blind or have certain other disabilities that make it Security Disability Insurance impossible for them to work, who have limit­ The Social Security Administration provides ed income and resources, who meet the living Social Security Disability Insurance (SSDI) to arrangement requirements, and who are oth­ individuals and cer­ erwise eligible. Congress has excluded a pri­ tain members of mary diagnosis of substance abuse as a quali­ their family if they Medicaid supports fying disability under the Social Security have worked long Administration’s programs, but if there is enough and paid about 20 percent another primary disability that qualifies the Social Security person for SSI, a secondary substance abuse taxes. Recipients of diagnosis remains acceptable. Many SSI SSDI benefits are and Medicare recipients with a mental disorder diagnosis covered by Medicare have a co­occurring substance abuse following a 2­year supports about diagnosis. waiting period. SSDI is a program 8 percent Medicare financed with Social Security taxes paid of national Medicare provides coverage to individuals by workers, employ­ over age 65, people under the age of 65 with ers, and self­ expenditures for certified disabilities, and people with end­ employed persons. stage renal disease. Medicare supports about In order to be eligi­ substance abuse 8 percent of national expenditures for sub­ ble for a Social stance abuse treatment services. Medicare Security benefit, the treatment may provide Part A coverage to clients in worker must earn detoxification programs that are based in hos­ sufficient credits pitals certified by Medicare. However, detoxi­ based on taxable services. fication programs that provide only a struc­ work. Disability tured environment, socialization, and/or benefits are payable vocational rehabilitation are not covered by to disabled workers, disabled widow(er)s, or Medicare. Medicare imposes very strict adults disabled since childhood, who are oth­ review requirements for detoxification pro­ erwise eligible. A substance abuse diagnosis grams based in hospitals and detoxification was excluded by Congress as a qualifying dis­ programs that are considered to be partial ability for SSDI, but a secondary substance hospitalization programs, and for patients in abuse diagnosis is acceptable if the person is those detoxification programs. Alternatively, qualified by another primary diagnosis, such Medicare may provide Part B coverage to as mental illness, which often co­occurs. clients in detoxification programs with

Financing and Organizational Issues 151 State Children’s Health Navy, and Air Force with networks of civilian healthcare professionals. TRICARE consists Insurance Program of TRICARE Prime, where Military The State Children’s Health Insurance Treatment Facilities are the principal source Program (SCHIP) provides funds for sub­ of health care; TRICARE Extra, a preferred stance abuse treatment of children and ado­ provider option; and TRICARE Standard, a lescents in many States. This program pro­ fee­for­service option that replaced the pro­ vides low­cost health insurance for children gram formerly known as CHAMPUS. The of low­income fami­ TRICARE Extra and Standard benefits lies who are not eli­ include treatment for substance abuse, sub­ gible for Medicaid. ject to preauthorization requirements, but Substance abuse States have the programs will need to check to see if detoxifi­ option of providing cation programs are eligible or preauthorized treatment and SCHIP benefits under TRICARE managed care arrange­ under their existing ments. TRICARE is run by managed care detoxification Medicaid program contractors, each of whom may have different or designing a sepa­ authorization procedures. services in the rate children’s health insurance Indian Health Service United States are program entirely separate from The Indian Health Service (IHS) is an agency Medicaid. If the funded through a within the Department of Health and Human program is part of Services that operates a comprehensive health Medicaid, then the service delivery system for approximately 1.6 diverse mix of substance abuse million of the Nation’s estimated 2.6 million benefits will mirror American Indians and Alaska Natives. Most public and private those under IHS funds are appropriated for American Medicaid. If the Indians who live on or near reservations. sources. State designs its Congress also has authorized programs that own program, CMS provide some access to care for Indians who has promulgated a live in urban areas. IHS services are provid­ set of rules to ed directly and through tribally contracted ensure that coverage meets minimum stan­ and operated health programs. Health ser­ dards. A State’s Alcohol and Drug Abuse vices also include health care purchased from Agency also may be able to provide informa­ more than 9,000 private providers annually. tion on resources available for treatment of The IHS behavioral health program supports transition­age youth who have exceeded the alcoholism and other drug dependency treat­ maximum age for the SCHIP program in the ment, detoxification, rehabilitation, and pre­ State. For more information see the State vention services for individuals and their SCHIP program office. families.

TRICARE Department of Veterans TRICARE is a regionally managed health Affairs care program for active duty and retired The Department of Veterans Affairs provides members of the uniformed services and their the Civilian Health and Medical Program of the families and survivors. TRICARE supple­ Veterans Administration to eligible beneficia­ ments the healthcare resources of the Army,

152 Chapter 6 ries. Medically necessary treatment of sub­ Workforce Investment Boards, Workforce stance abuse is a covered benefit; beneficiaries Development Boards, and similar bodies at are entitled to three substance use disorder the State and community levels. Although treatment benefit periods in their lifetimes. States may not use TANF funds for “medi­ cal” services, States have considerable lati­ Social Services tude in the definition of “medical,” and Funding for substance abuse treatment, have used TANF funds to support the fol­ which may include detoxification services, lowing substance abuse treatment services: also may be available through arrangements screening/assessment, detoxification, outpa­ with agencies funded by the U.S. Depart­ tient treatment, non­hospital residential ments of Labor, Housing and Urban treatment, case management, education/ Development (HUD), and Education (ED). prevention, housing, employment services, Some Federal sources of funding for sub­ and monitoring (Rubinstein 2002). Even if stance abuse treatment under these programs these funds are not available for substance may prohibit use of funds for “medical” ser­ abuse treatment in a State or program, the vices. However, services performed by those program’s clients may be able to access this not in the medical profession (e.g., coun­ source of assistance for employment train­ selors, technicians, social workers, psycholo­ ing, child care, and other support needs. gists) and services not provided in a hospital •Social Services Block Grant. Under Title or clinic (including 24­hour care programs) XX of the Social Security Act, the may be considered nonmedical. The precise Administration for Children and Families definition of “medical” under some of these provides a block grant to each State for the Federal programs may be determined by each purpose of furnishing social services. Funds State individually, so administrators need to may not be used for medical services check with their State authorities to deter­ (except initial detoxification of an individu­ mine exactly which services may be funded al who is alcohol or drug dependent). In through these sources. Even if funding for 2002, these funds provided close to $8 mil­ detoxification services is not available lion for substance abuse treatment in 14 through these programs, programs may be States (Administration for Children and able to link their clients to them for support Families 2002). for services that enable them to initiate and •Public housing. HUD funds substance complete treatment successfully. Oppor­ abuse treatment of public housing residents tunities include the following: under the Public Housing Drug Elimination •Temporary Assistance to Needy Families Program. HUD awards grants to public (TANF). Under the TANF programs, each housing authorities, tribes, or tribally desig­ State receives a Federal block grant to fund nated housing entities to fund treatment. treatment for eligible unemployed persons Funds are channeled to local public housing and their children, usually women with authorities, which contract with service dependent children. Services that overcome providers. In addition, special housing pro­ barriers to employment (e.g., substance grams are available for people who are home­ abuse treatment) are eligible for formula less and have substance use disorders. grants—with one quarter of the money allo­ •Vocational rehabilitation. Federal ED cated to local communities through a com­ funds support services that help people with petitive grant process. The funding chan­ disabilities participate in the workforce. nels vary by State. Funds may be directed Treatment of substance use disorders is eli­ through Private Industry Councils, gible for funding. Funds are channeled to

Financing and Organizational Issues 153 the State agencies responsible for vocational •Correctional residential facilities serve rehabilitation. offenders returning from a State correction­ •Children’s protective services. Title IV of al system; the programs may extend con­ the Social Security Act provides funding tracts for substance abuse treatment to pre­ for foster care and services to prevent child vent relapse of treated offenders. abuse and neglect. Eligible services include •Juvenile court systems may provide con­ substance abuse treatment for parents who tracts to programs with expertise in treating are ordered by a court to obtain treatment adolescents to treat juvenile offenders in and are at risk for losing custody of their correctional facilities or who are otherwise children. Medicaid also covers these chil­ involved in the criminal justice system. dren, as they are a mandatory eligibility group. Providers should understand the culture, val­ Ryan White. ues, and needs of the CJ/JJ system so they • The Federal Ryan White can develop responsive services for this spe­ CARE Act, enacted in 1990, provides cial needs population. For more information, health care for people with HIV disease. see TIP 21, Combining Alcohol and Other Under Title I of the Ryan White CARE Act, Drug Abuse Treatment With Diversion for which provides emergency assistance to Juveniles in the Justice System (CSAT Eligible Metropolitan Areas that are most 1995b), TIP 30, Continuity of Offender severely affected by the HIV/AIDS epidem­ Treatment for Substance Use Disorders From ic, funds are available for substance abuse Institution to Community (CSAT 1998b), and treatment. Over 500,000 people are served TIP 44, Substance Abuse Treatment for through this program each year. Adults in the Criminal Justice System (CSAT 2005b). Criminal justice/juvenile justice (CJ/JJ) systems Byrne Formula Grant Both State and local CJ/JJ systems purchase Program substance abuse treatment services. The man­ ner in which these systems work varies across The Byrne Formula Grant Program awards locales. The following are common components grants to States to improve the functioning of these systems: of the criminal justice system. Grants may •State corrections systems may provide be used to provide rehabilitation of offend­ funds for treatment of offenders who are ers who violate State and local laws. One of returning to the community, through parole the 26 Byrne Formula Grant purpose areas offices, halfway houses, or residential cor­ is providing programs that identify and rectional facilities. meet the treatment needs of adult and juve­ nile offenders who are drug and alcohol Community corrections systems • may dependent. However, the availability of include a system of presentence diversion or Byrne Formula Grant funds depends on parole services, including drug court, that annual Congressional appropriations and may mandate substance abuse treatment in declines have been proposed for funding in lieu of incarceration. recent years. •Community drug courts may send low­risk, nonviolent offenders to substance abuse treatment in lieu of incarceration—pro­ grams can be under contract to provide this treatment.

154 Chapter 6 County and local efits offered by their health plans are inade­ governments quate. •Contracts with EAPs. Some employers have County and local governments often contract EAPs that can provide direct service con­ for the delivery of substance abuse treatment tracts for a particular detoxification pro­ services using locally available funds. The gram. annual availability of these funds depends in part on State fiscal conditions. Contributions By developing relationships with people in the Schools community, an administrator can find new Local public schools may be a source of fund­ sources for support of capital and operations. ing for assessments; however, they rarely pay Even if a source is reluctant to provide funds to for ongoing treatment. Some services may be support treatment reimbursable under the special entitlements for services directly, children with disabilities. other aspects of pro­ gram development, Many public and organizational Private Payors growth, and opera­ private benefit Private sources of revenue include a range of tions or equipment entities from large MCOs to local or self­ may be eligible for plans still classify insured national employers. Most health support. A variety of plans offered by large employers operate support may be detoxification as a under managed care arrangements. available from Sometimes, a health plan may cover some sources in the com­ medical rather substance abuse treatments under the mental munity, ranging from health benefit portion of their plan; others financial support to than a substance may provide coverage through the medical donations of time, expertise, used or component. In many cases, substance abuse abuse treatment treatment benefits, when offered, are provid­ low­cost furniture ed through Managed Behavioral Healthcare and equipment, and Organizations (MBHOs) (see “Working In space for a variety of service. Today’s Managed Care Environment,” p. activities. Some 157, for a more detailed discussion of man­ potential sources aged care arrangements). Because substance include abuse coverage is a minor cost to employers, •Fundraisers. People who do fundraising accounting for about 0.4 percent of the cost can help the program develop a campaign. of health insurance overall (Schoenbaum et Many States and the District of Columbia al. 1998), it may be difficult to get employers’ require that charitable organizations regis­ attention, despite the high profile that sub­ ter and report to a governmental authority stance abuse problems sometimes present. In before they solicit contributions in their general, three broad categories of private jurisdiction. funding may be distinguished: •Foundations and local charities. A pro­ •Contracts with health plans, MCOs, and gram may qualify as a recipient of funds for MBHOs. capital, operations, or other types of sup­ •Direct service contracts with local employers. port such as board development from foun­ Local employers may contract directly with dations, the Community Chest, United Way, substance abuse services providers if the ben­ or other charities.

Financing and Organizational Issues 155 •Alumni. Graduates from a program may gram for women, enhancing the cultural com­ donate money to the program or provide petence of staff members, or treating under­ support for clients. served populations. •Internships. Local colleges and universities Writing grant applications requires special may need internship slots for their students skills. A program can hire a consultant to who are planning careers in human ser­ write the application or use its own planning vices. or research staff, if available. Successful •Volunteers. Some programs use volunteers grant applications address areas of genuine in various capacities. Sources include local need, propose ideas worthy of support, retirement organizations and faith­based express these ideas well, and explicitly follow agencies. the requirements of the request for applica­ •Community groups. Faith­based agencies tion or proposal. To design a fundable pro­ and community centers may let the program ject, the program may need to establish links use rooms for meetings, alumni groups, with other resources. Each donor agency or recovery support groups, or classes. foundation has its own application format Community groups can contribute reading and requirements that should be followed materials, clothes, toys for clients’ children, exactly. It is especially important when using furniture, or computers. a consultant to have program staff closely •Local stores and vendors. Local businesses involved in the process of developing a grant may contribute useful supplies such as application to ensure that affirmations in the snacks, office supplies, or even computers. application are completely aligned with agen­ cy capabilities. Programs that fail to involve their own staff in the grant application pro­ Research funding cess risk falling into the “implementation In addition to SAMHSA’s other roles, such as trap” when a grant is awarded for projects technical assistance, helping communities use they are not prepared to perform. SAMHSA research findings to implement effective treat­ offers a variety of resources to assist commu­ ment programs, and funding of prevention and nity­based organizations and others in devel­ treatment, the institutes of the National oping successful grant applications. See the Institutes of Health conduct research on best text box on page 157 for sources of informa­ practices in substance abuse treatment. tion on grants for treatment and detoxifica­ The Research Assistant tion programs. (http://www.theresearchassistant.com) may be a helpful source for information. For current funding opportunities, visit the National Self­pay patients Institute on Drug Abuse Web site Some patients pay for some or all of a course (http://www.nida.nih.gov) and the National of treatment themselves, without seeking Institute on Alcohol Abuse and Alcoholism Web reimbursement from a third­party payor. site (http://www.niaaa.nih.gov). These patients may have no or inadequate third­party coverage for substance abuse treatment and are not eligible for public pay­ Grants ment sources. Some patients who have cover­ Government agencies and private foundations age may prefer to pay out of their own pock­ offer funding through competitive grants. ets due to concerns about the confidentiality Grant money usually is designated for discrete of their information with their employer or projects, such as creating a videotape on family others. issues, providing childcare services in a pro­

156 Chapter 6 Where To Get Information on Grants

•SAMHSA provides information about the grants it provides at http://www.samhsa.gov/grants/block-grants. Information on grants throughout the Federal government is available from http://www.grants.gov. •The Web site http://www.cybergrants.com provides information about corporate foundations. •The National Center on Addiction and Substance Abuse at Columbia University’s Web site at http://www.casacolumbia.org provides links to several helpful sites. •The Substance Abuse Funding Week provides public and private funding announcements for alcohol, tobacco, and drug abuse programs. It is available by subscription in print. •The Grantsmanship Center at http://www.tgci.com offers some useful information. •The Non-Profit Resource Center, http://www.nprcenter.org/, has information on a variety of funding sources.

Working in Today’s Behavioral health care carve-outs, so named because management of substance abuse Managed Care treatment and mental health benefits are sep- arated (carved out) from the provision and Environment management of other healthcare services, are All healthcare providers, including those who now the dominant approach to managed care provide substance abuse treatment services, for mental health treatment. However, this is increasingly operate in a world in which care not the case for substance abuse; many is managed in all sectors, both public and pri- behavioral health carve-outs retain substance vate. Among individuals covered by employ- abuse coverage in the medical MCO. The er-sponsored benefits in 2003, 95 percent “carve-in” approach, which theoretically were covered under managed care arrange- integrates traditional medical services with ments (Kaiser Family Foundation and Health services for substance use and other mental Research and Educational Trust 2003). The disorders, is re-emerging but as of 2004 was penetration of managed care into employer- still relatively rare. Even when health plans sponsored health plans is relatively new; as carve-in substance abuse services, they often recently as 1993, 46 percent were covered by use a subcontracted specialty vendor or a indemnity plans. It is estimated that more separate internal division with specialty than 160 million Americans have their behav- expertise to manage the carve-in benefits. ioral health care (treatment for substance use and mental disorders) covered by a managed MCOs are becoming more prevalent in the behavioral health care organization (Oss and public sector. In 2002, 51 percent of all sub- Clary 1999). Although managed care penetra- stance abuse treatment facilities had con- tion is lower in public programs than in tracts with MCOs and even 39 percent of employer-sponsored programs, it is still sig- facilities owned by State and local govern- nificant; in 2002, 58 percent of the Medicaid ments had such contracts (Office of Applied population was enrolled in managed care Studies 2002b). By 1998, all but four States arrangements (CMS 2002). Many States also had implemented some form of managed operate MCOs not connected with Medicaid behavioral health care in their public sector for provision of substance abuse treatment treatment programs. However there is wide services. variation among States and large counties in the extent and form of reliance on managed

Financing and Organizational Issues 157 care and in the vendors who operate such proposed contract and make certain that the programs on behalf of government or private financial components of the arrangement are entities. well understood by the program staff who have financial responsibilities. A distinct terminology has evolved in the managed care industry—terms such as capi­ Secondly, by negotiating and signing a man­ tation, network, or staff­model as well as a aged care contract, a detoxification program host of acronyms. or its parent agency becomes a member of that MCO’s managed care network. MCOs generally have a network of contracted and Contracts Are Primary Tools credentialed providers who supply services at Managed care arrangements have four funda­ a negotiated rate to members who are mental aspects with which all program admin­ enrolled in the plans. Each organizational istrators should be member of the network must satisfy the familiar. First, an MCO’s minimum requirements for licensure arrangement begins of staff, programs, and facilities to be eligible It is estimated that with a managed for a managed care contract. care contract that more than 160 specifies the obliga­ The third fundamental aspect of managed tions of each party. care arrangements is the requirement for per­ formance measurement and reporting. All million Americans It should be noted that small communi­ MCOs apply a wide range of standard perfor­ mance measures to each of their contracted have their ty providers may have little or no providers and may have financial or referral negotiating leverage incentives or disincentives associated with behavioral health in the contracting measured performance. process; their only care (treatment Finally, the fourth aspect involves utilization decision may be management and case management. These whether or not to for substance use tasks generally are performed by MCO staff, accept what is typically nurses or social workers, with offered, including supervision from Ph.D. clinicians or physi­ and mental the rate of payment cians. The staff makes a determination of and all other con­ what services are “medically necessary” and disorders) covered tract provisions. therefore eligible for health plan reimburse­ Nevertheless, a ments. Utilization management compares a by a managed clear and detailed provider’s proposed treatment plan with simi­ understanding of lar or expected plans for individuals with sim­ behavioral health the contract is ilar conditions and diagnoses. The utilization required to ensure management approach may vary not just by successful perfor­ care organization. MCO but by MCO customer, with some cus­ mance. One key tomers preferring that utilization be highly aspect of any man­ scrutinized and meet the test of medical aged care contract necessity and others preferring that the MCO is the financial arrangement between the par­ use a light touch in managing utilization. If a ties, including the basis for payment and the treatment plan from a detoxification program amount of risk assumed by each party, if any. does not meet criteria for medical necessity, it Of course, some managed care contracts are is likely to be denied and referred to a higher not risk­based. It is important to have some­ level clinician for review, delaying approval one with expertise and experience in managed and payment. It makes sense to obtain each care contracts and financing examine any MCO’s protocols, as well as any specific

158 Chapter 6 arrangements and benefit plans for customers Elements of Financial Risk in whose employees or enrollees are in the detoxification program’s client population. Managed Care Contracts Case management programs operated in the Cost of services private sector often are utilization review To assess and negotiate a managed care con­ programs rather than the clinical case man­ tract and to monitor a program’s perfor­ agement programs typical in the public sec­ mance under that contract, it is imperative to tor. Moreover, the process of case manage­ know what it costs the detoxification program ment in the private sector often differs from to provide each unit of service that is pro­ the one found in traditional public sector duced. The cost of services includes staff time mental health or substance abuse treatment spent with clients, administrative time spent agencies. Instead, it primarily involves tele­ on meetings and paperwork, and capital and phone contact, usually with a nurse, in high­ operating expenses. Only when the actual cost risk or high­cost cases. Case management of delivering a unit of a particular service is usually is not performed onsite or in person known can an agency negotiate a reasonable in MCOs unless under contract to a public rate for specific services when negotiating agency that requires this. If a detoxification contracts and a fiscally prudent arrangement. program client has a public sector and a man­ Determining the cost of services often entails aged care case manager, the detoxification many challenges but is absolutely essential in program will have to interact with both to the current environment of accountability. obtain initial and continuing approvals of See the text box on page 160 for a list of treatment in what is called a case or utiliza­ resources from the literature. Following are tion management program. the recognized but evolving cost methodolo­ In general, programs will be required to gies developed specifically for substance obtain utilization management approval abuse services: and/or case management approval for any •The first systematic cost data collection proposed treatment plan before they can bill method, the Drug Abuse Treatment Cost the MCO. Programs will have to bear the cost Analysis Program (DATCAP) (French 2003a, of pursuing denials and requesting exceptions b), was developed in the early 1990s by as well. The more the program’s staff can economists at Research Triangle Institute develop a relationship with the MCO’s utiliza­ (French et al. 1997). The Treatment Services tion management and case management staff, Review used with DATCAP provides unit ser­ the more they will learn about the internal vice costs (French et al. 2000). criteria and protocols that drive approval or •The Uniform System of Accounting and denial decisions and the more latitude they Cost Reporting for Substance Abuse will have to request special arrangements for Treatment Providers is a cost estimation a particular client. Most MCOs and MBHOs method developed about the same time by have Web sites with provider portals. Once a CSAT (1998d). program identifies the name of the managed care plan from which payment is to be •Another estimation approach has been requested staff should be sure to check its developed by Yates (1996, 1999): the Web site. Some managed care plans offer Cost–Procedure–Process–Outcome electronic data interchange with network Analysis. providers to facilitate claims submission. •Anderson and colleagues (1998) have devel­ oped a cost of service methodology.

Financing and Organizational Issues 159 Resources on Service Costs Anderson, D.W., Bowland, B.J., Cartwright, W.S., and Bassin, G. Service­level costing of drug abuse treatment. Journal of Substance Abuse Treatment 15(3):201–211, 1998. Center for Substance Abuse Treatment. Measuring the Cost of Substance Abuse Treatment Services: An Overview. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998. Center for Substance Abuse Treatment. Uniform System of Accounting and Cost Reporting for Substance Abuse Treatment Providers. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998. Center for Substance Abuse Treatment. Summary Report on Assessment and Measurement of Treatment Costs. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000. Dunlap, L.J., and French, M.T. A comparison of two methods for estimating the costs of drug abuse treatment. Journal of Maintenance in the Addictions 1(3):29–44, 1998. Flynn, P.M., Porto, J.V., Rounds­Bryant, J., and Kristiansen, P.L. Costs and benefits of methadone treatment in DATOS—Part 1: Discharged versus continuing patients. Journal of Maintenance in the Addictions 2(1/2):129–150, 2003. French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): Program Version. 8th ed. Miami, FL: University of Miami, 2003. French, M.T. Drug Abuse Treatment Cost Analysis Program (DATCAP): User’s Manual. 8th ed. Miami, FL: University of Miami, 2003. French, M.T., Dunlap, L.J., Zarkin, G.A., and Karuntzos, G.T. The costs of an enhanced employee assistance program (EAP) intervention. Evaluation and Program Planning 21(2):227–236, 1998. French, M.T., Dunlap, L.J., Zarkin, G.A., McGeary, K.A., and McLellan, A.T. A structured instru­ ment for estimating the economic cost of drug abuse treatment. The Drug Abuse Treatment Cost Analysis Program (DATCAP). Journal of Substance Abuse Treatment 14(5):445–455, 1997. French, M.T., Roebuck, M.C., McLellan, A.T., and Sindelar, J.L. Can the Treatment Services Review be used to estimate the costs of addiction and ancillary services? Journal of Substance Abuse 12(4):341–361, 2000. French, M.T., McCollister, K.E., Sacks, S., McKendrick, K., and De Leon, G. Benefit­cost analysis of a modified therapeutic community for mentally ill chemical abusers. Evaluation and Program Planning 25(2):137–148, 2002. French, M.T., Salome, H.J., and Carney, M. Using the DATCAP and ASI to estimate the costs and ben­ efits of residential addiction treatment in the State of Washington. Social Science & Medicine 55(12):2267–2282, 2002. Yates, B.T. Analyzing Costs, Procedures, Processes, and Outcomes in Human Services. Applied social research methods series v. 42. Thousand Oaks, CA: Sage, 1996. Yates, B.T. Measuring and Improving Cost, Cost­Effectiveness, and Cost­Benefit for Substance Abuse Treatment Programs: A Manual. NIH Publication No. 99­4518. Rockville, MD: National Institute on Drug Abuse, 1999. Zarkin, G.A., and Dunlap, L.J. Implications of managed care for methadone treatment. Findings from five case studies in New York State. Journal of Substance Abuse Treatment 17(1­2):25–35, 1999. Zarkin, G.A., Dunlap, L.J., and Homsi, G. The substance abuse services cost analysis program (SAS­ CAP): A new method for estimating drug treatment services costs. Evaluation and Program Planning 27(1):35–43, 2004.

160 Chapter 6 •The Substance Abuse Services Cost Analysis For more information on managed care pur­ Program (Zarkin et al. 2004) is an emerging chasing and negotiation from the perspective treatment services cost estimation method. of a purchaser, see TAP 22, Contracting for •Variants of these methods have been applied Managed Substance Abuse and Mental Health to several treatment studies (Flynn et al. Services: A Guide for Public Purchasers 2003; Koenig et al. 1999; Mojtabai and (CSAT 1998c). Zivin 2003). Three major categories of financial arrange­ Networks, Accreditation, and ments may be distinguished in managed care Credentialing contracts: (1) fee­for­service agreements, (2) To join an MCO’s network of providers and capitation agreements, and (3) case rate negotiate a contract specific MCO minimum agreements. Program administrators need to standards for staff credentials and program understand the differences among these types accreditation must be met. These minimum of arrangements so they can manage financial standards generally are not negotiable risk. Sometimes, administrators may think because they have their basis in that MCO’s that the contract itself is the goal. However, accreditation requirements. The provider the existence of a contract is no guarantee of credentialing requirements vary by MCO and a referral; it only enables referrals that are by customer within the MCO and often medically necessary. The closer the relation­ include primary verification of specific aca­ ship the program staff can develop with a demic degrees or specific levels of licensure given MCO, the easier it will be for them to for staff, as well as verified minimum levels of understand their clinical criteria, to obtain malpractice insurance. Some MCOs may use more than intermittent referrals, and to nego­ what are called independent Credentialing tiate a financial arrangement for the program Verification Organizations (CVOs) for this that is reasonable and fair. process. These CVOs verify the credentials of Managed care contracts vary according to two providers on behalf of MCOs to ensure, for principal dimensions: (1) the method of pay­ example, that their licenses are valid and up ment and the corresponding type of risk to date. assumed by the provider, and (2) the amount MCOs sometimes are not familiar with sub­ of payment. Each of the three major types of stance abuse treatment and, moreover, typi­ financial arrangements or methods of pay­ cally include only those types of providers ment (described in Figure 6­1, p. 162) is asso­ that are licensed by a given State to engage in ciated with major financial risks that private practice in their provider networks. providers should be aware of in negotiating Usually such providers are licensed in psy­ each type. Risk, of course, is a continuous chology, nursing, medicine, or social work. variable, so that no arrangement is devoid of MCOs explain that this has to do with mal­ any risk whatsoever. The key is to ensure that practice insurance issues. This credentialing a program has the tools and capabilities to practice has a disproportionate impact on manage the risks it assumes. Many managed those substance abuse treatment providers care systems rely on fee­for­service arrange­ that do not have as many staff with these cre­ ments with providers, so that most providers dentials as do mental health providers, by are paid on a discounted fee­for­service basis, presenting an obstacle to contracting with based on a schedule of fees described in the these MCOs. However, it is not an insur­ contract. Capitation agreements usually are mountable obstacle. Substance abuse treat­ reserved for very large networks of ment providers often must help MCOs under­ providers, who in turn pay individual stand the substance abuse treatment environ­ providers on a fee­for­service basis. ment, the types of providers that deliver ser­

Financing and Organizational Issues 161 Figure 6­1 Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Fee­for­Service Agreement. Fee­for­service pro­ When negotiating a fee­for­service contract, an grams are the least risky to providers. They gen­ administrator needs to ensure that the rate is suf­ erally require precertification and utilization ficient to cover the actual costs to a program of management for some or all procedures and ser­ providing the specified services. During negotia­ vices. The client’s benefit plan document or the tions, the MCO has the option of saying that it will public payor’s contract dictate the services that not pay for some of the bundled services. All ser­ may be approved. In a fee­for­service contract, a vices should be costed out prior to negotiation, so rate is received for the services provided; typical­ actual costs of treatment components are known ly, a standard program session with specific ser­ and can be compared to the reimbursement vices bundled in. This is referred to as an “all­ offered. Programs must understand that even if a inclusive rate.” fee­for­service contract is successfully negotiated, referrals may or may not follow. Some common bundled services are urine drug screens and group, family, and individual counsel­ ing. Thus the payment rate for one visit may include a 50­minute group counseling session and a urine drug screen. The rate for a day of treat­ ment could include, for example, one­fifth of a 25­ minute psychologist visit, one­half of a urine drug screen, one­half of a vocational training session, and two sessions of group counseling. The assumption is that these services will occur at a specified frequency during the course of the client’s treatment. Psychiatric services can be incorporated into the bundled services, but usual­ ly they are negotiated separately and treated as an additional service.

vices, and the qualifications and standards fication benefits may be considered either they must meet so that the MCO can modify medical or behavioral benefits. its policies appropriately. MCOs often are more willing to contract with organizations In addition to the credentials of the staff and that have a facility license from their State practitioners, the program itself may have to be than with individual substance abuse treat­ accredited by one of the major national health­ ment providers who may not possess creden­ care accrediting organizations. These include tials that meet the MCO’s licensure criteria. the Commission on Accreditation of Rehabilitation Facilities, the National Many managed care plans have separate Committee for Quality Assurance and the Joint provider networks for behavioral health ser­ Commission on Accreditation of Healthcare vices. It is important for detoxification Organizations.In general, accreditation from providers to participate in both medical and CARF is considered most important by sub­ behavioral health networks, given that detoxi­ stance abuse treatment providers for their

162 Chapter 6 Figure 6­1 (continued) Financial Arrangements for Providers

Method of Reimbursement Cautions/Risks for Programs

Capitation Agreement. A managed care company The two critical elements are the per member/per may establish a stipulated dollar amount to cover month (pm/pm) rate and the utilization rate. If treatment costs for a group of people using one many more people than are predicted require per­person rate for everyone, which is the MCO’s treatment, the provider may not be able to cover capitation rate. The MCO may then subcapitate a service delivery costs, much less make a profit/sur­ stipulated dollar amount to a treatment provider plus. The key is to have reliable information on or organization, and the MCO and the treatment the historical use rates of a given managed care provider negotiate an agreement in which the plan’s enrollees. If the provider bears in mind provider is paid a fixed amount per subscriber these caveats, this regular, guaranteed payment per month, rather than billing on a fee­for­service can be an excellent arrangement but carries with it basis. The provider agrees to provide all or some the risks of both “overutilization” (when com­ of the treatment services for an expected number pared to the assumption used in developing the of managed care “covered lives” (e.g., for 100,000 rate) and the need for a greater intensity of treat­ subscribers). Usually only large service providers ment than the capitation rate can cover. In some have the assets and volume of services to engage in cases a program may want to accept a somewhat capitated agreements. speculative capitation rate in order to join a panel and then renegotiate that rate after the program has collected data that show that it needs a higher rate to cover its costs. In any case, it is crucial to track actual dollars against the budget in real time to avoid unexpected deficits.

Case Rate Agreement. The case rate is a fixed A case rate agreement removes some of the utiliza­ rate per client paid for delivery of specific ser­ tion risk from the service provider. However, the vices to specified types of consumers. For this fee, risk remains that clients will need services more a provider such as a clinic covers all the services frequently or at higher levels than the case rate that a client requires for a specific period. In covers. It is essential that programs track costs by essence, the MCO is saying, “You provide the specific client in order to assess the adequacy of a client what he needs from this set of services and I proposed case rate. However, it is a mistake to will pay you this set amount.” What usually dis­ consider a case rate as a cap for any specific tinguishes case rate from capitation is that essen­ patient; the goal is to ensure that the average cost tially all of the case rate clients are anticipated to per case is lower than the negotiated case rate, not be receiving some service; that is, at least case that the cost for each case is less than the negotiat­ management. Usually those receiving services ed rate. Once again, it is crucial to track actual under capitation are a small minority of those average dollars per case against the contracted covered. The case rate may be “risk­adjusted” to case rate in real time to avoid unexpected deficits. compensate for the higher costs of serving clients who predictably need more services than average.

Financing and Organizational Issues 163 programs. However, providers that wish to external performance measures implemented offer inpatient detoxification services general­ by MCOs can be extremely important to a ly must obtain accreditation from JCAHO to program’s financial and organizational suc­ meet the requirements of most MCOs. cess, affecting a program’s ability to remain a viable, respected network provider. Some performance management systems implement­ Organizational Performance ed by MCOs also use financial incentives Measurement and/or disincentives keyed to performance. Performance measurement is becoming an Regardless of the specific measures imple­ increasingly important component of man­ mented by particular MCOs, well­managed aged and fee­for­service care in both the organizations will also develop and use their public and private sectors. SAMHSA’s SAPT own internal performance measures and con­ Block Grants now require the collection of stantly strive to improve their own perfor­ measures of program performance and out­ mance. Among these should be measures of comes. MCOs have their own performance both process and outcomes, such as measures established by the agencies that •The percentage of clients who complete a accredit them, such as the NCQA. Their cus­ defined treatment regimen that meets their tomers, employers, or public purchasers may individual needs use adequacy of performance on these mea­ sures in their decisions to acquire or retain •The percentage of clients who drop out of their plans for their employees. NCQA has treatment in the first 7 days following treat­ established a set of measures specifically ment initiation relating to substance abuse and mental •The percentage of clients who remain in doc­ health treatment services for all the MCOs umented but less intensive treatment 30 days that it accredits, including new measures of after discharge from the program the identification of enrollees with substance •The percentage of clients who are employed abuse diagnoses, the rate of initiation of or attending school 6 months after discharge treatment, and a measure of treatment from the program engagement. Programs will be asked to par­ ticipate in measuring these indicators and When using performance measures, it is impor­ report that information to the MCO, and tant for programs to account for differences doing so will likely be a condition of the con­ among clients that may affect measured results, tract. The MCO may reward good perfor­ such as a client’s previous history of abuse or mance with an additional fee. medical conditions. Nevertheless, it is equally important to recognize that employing mea­ Similarly, MCOs evaluate the performance of surement is an integral component of external the members of their provider network. Each and internal accountability as well as continu­ MCO has its own measures and procedures ous clinical improvement. for implementation, some of which are pre­ scribed by the organizations that accredit One of the primary independent entities them. Not all MCOs are diligent about this involved in the construction of national per­ provider evaluation process. Only a few formance measures for substance abuse treat­ MCOs have implemented sophisticated mea­ ment is the Washington Circle Group. surement systems, and some of the methods NCQA’s new substance abuse performance used today may be crude but they still are measures on identification and initiation of required. Nevertheless, regardless of how treatment and treatment engagement were simple or complex they may be, the results of developed by the WCG over a 4­year period.

164 Chapter 6 They have identified four major “domains” receive subsequent substance abuse services for substance abuse treatment measures: from the formal treatment system and that the 1. Prevention/Education lack of substance abuse treatment following detoxification has been getting worse instead of 2. Recognition or Identification of Substance better (Mark et al. 2002). It is incumbent on Abuse providers of detoxification services to ensure 3. Treatment that clients are linked to substance abuse treat­ •Initiation of alcohol and other plan ser­ ment following detoxification. vices •Linkage of detoxification and alcohol and Recordkeeping and manage­ other drug plan services ment information systems •Treatment engagement Like indemnity insurers, MCOs also require •Use of interventions for family members detailed records of and significant others services provided to 4. Maintenance of Treatment Effects clients in order for them to pay for ser­ Performance These and other substance abuse performance vices received. The measures are now used in NCQA’s MCO program’s account­ accreditation process. The WCG and others measurement is ing system needs to have defined a variety of such measures and track counselors’ administrators should think of these measures becoming an time spent on the as ways to improve their own performance, as phone, on paper­ an essential element in the reporting system, increasingly work, and directly and as a means for documenting success to with clients. Clinical their customers and other stakeholders. records should important compo­ Performance measurement is becoming reflect accurately increasingly important outside of managed care the claims records nent of managed contracts as well as inside them. For example, submitted to the as mentioned in the previous section on fund­ MCO. Periodically, and fee­for­service ing, SAMHSA began integrating performance payors and MCOs measurement into the SAPT Block Grant as of may audit the clini­ care in both the fiscal year 2004. Each State will expect pro­ cal records to grams to understand and be able to measure ensure that the ser­ public and private the required indicators accurately and in a vices billed for actu­ timely way. ally have been pro­ sectors. vided. Failure to One of the most important performance mea­ adequately docu­ sures in the future for detoxification programs ment clinical ser­ is likely to be linkages to substance abuse treat­ vices can result in nonpayment and put a con­ ment following detoxification (Mark et al. tract in jeopardy. On the other hand, individ­ 2002). Research has shown that patients who uals’ private information and identity must receive continuing care following detoxification be handled in a confidential manner pursuant have better outcomes in terms of drug absti­ to the Health Insurance Portability and nence and readmission rates than those who do Accountability Act (HIPAA) and Federal con­ not receive continuing care. This focus on link­ fidentiality requirements for persons with ages is a likely result of research indicating that substance abuse. many people who undergo detoxification do not

Financing and Organizational Issues 165 Managing multiple contracts requires sophis­ should be billed as payor number one and the ticated management, a fiscal management drug court as payor number two. Any unpaid information system (MIS), and constant portion might then be billed to the block scrutiny. The need for information is even grant agency as payor of last resort, if it is an more crucial for capitation­based arrange­ eligible service under the block grant. Some ments that place risk on the service provider providers have successfully used the strategy than it is for fee­for­service arrangements. In of first using the reimbursement of those pay­ essence, the MIS needs to be capable of two­ ors with the most restrictive array of services; way information transfer between the MCO later, the more flexible funds can be used to and the program. Data such as membership, cover the remaining services. A clearly docu­ benefits, copays, deductible amounts, and mented strategy for managing payment that is other financial information must be passed communicated effectively to the accounts between the pro­ payable staff is critical and will help pro­ gram and the grams be successful in this important area. Successfully insured entity or payor. The MIS Utilization and Case addressing the also should be able to analyze key per­ Management needs of the formance data for All MCOs use methods to manage the service internal and exter­ utilization of their members and ensure that nal reports. The utilization and they are receiving the most appropriate array MIS must pass use­ of services in the most appropriate environ­ ful data to staff case management ment or level of care for the appropriate members responsi­ length of time. Although technically, utiliza­ ble for managing tion management focuses on a single type of staff at MCOs is a benefits and pro­ service and case management focuses on the viding services. coordination of the appropriate array of ser­ critical element in Program data will vices needed by a specific individual, in prac­ need to meet State tice the same individual professionals may be the relationship data requirements responsible for both types of management. as well as require­ Utilization and case management staff at an with an MCO. ments by each MCO authorize specific services for purposes payor, while of payment. A wide variety of specific criteria respecting confiden­ and protocols may be used to determine tiality. whether services may be authorized for sub­ stance abuse, typically including the American Society of Addiction Medicine Managing payment from (ASAM) patient placement criteria (ASAM multiple funding streams 2001) and other level of care or diagnosis­ based criteria sets. Especially in the public arena, multiple con­ tracts with and grants from several funding Successfully addressing the needs of the uti­ streams and payors may be used to support lization and case management staff at MCOs services for a single client. These contracts responsible for authorizing care is a critical will specify order of payment. The provider element in the relationship with an MCO and needs to manage the funds carefully and in maintaining the program’s clinical and appropriately to be in compliance with con­ financial viability. To do so, program staff tracts and grants. For example, a contract must understand what their counterparts do with a drug court may specify that Medicaid and be well trained in conducting professional

166 Chapter 6 relationships over the telephone, be familiar additional costs of these services need to be with the criteria and protocols employed by a component of a program’s rate and con­ the MCOs with which the program has con­ tract. Having highly reputable, recognized, tracts, and have easy access to the multitude and efficient providers is a major marketing of clinical and service information required and regulatory advantage for the health by an MCO to help them complete a review plan, as well as for the program. All these and authorize services. Excellent records are program characteristics can be marketing essential. Program staff also should be famil­ advantages. Programs also may apply to iar with each MCO’s appeal or exceptions SAMHSA’s National Registry of Evidence­ process for those occasions when the outcome based Programs and Practices, which recog­ of a first­level review is unsatisfactory. nizes model, effective, and promising pro­ grams. Check SAMHSA’s Web site to find Utilization management cannot proceed if the out how to apply for this status, which is a program is not recognized as an eligible net­ major achievement and marketing asset. work provider; the program will have to Serve specific populations. ensure that it is an accepted network • Providing low­ provider before it can participate in the uti­ cost, high­quality treatment to a population lization management or case management no other program serves (e.g., adolescents, process. clients with HIV/AIDS, clients with co­ occurring mental disorders, pregnant women, women with young children, clients Strengthening the Financial who are deaf) also is a possible marketing Base and Market Position of a advantage. Treating these clients can result in client referrals from a larger geographic Program area and multiple sources. Such clients may The following strategies may strengthen the bring with them higher reimbursement rates market position of a detoxification program to too, but this also may simply reflect higher facilitate both larger numbers of patients and costs to provide care to the population. greater revenues per patient: Using special capabilities to attract clients is •Achieve recognition for the quality and a good idea, but not at the cost of inade­ effectiveness of services. If a program has quate payment for services. a reputation for providing effective care, •Develop economies of scale. Adding clinic then managed care enrollees and other sites or increasing the number of branch potential clients will want to use it. A pro­ clinics may permit spreading some fixed gram can be of value to a client, a purchas­ costs (e.g., management, information, er, and/or an MCO if it can reduce repeated financial systems, executive staff) among a detoxification, repeated treatment, and re­ larger number of patients, thus driving admissions, and thus manage unnecessary down a program’s per capita costs. costs and interventions. Effective substance However, larger size requires greater abuse treatment provided promptly may administrative coordination, which itself reduce medical care and hospitalization can be costly. costs in the long run. A program that effec­ •Gain community visibility and support. tively manages the care of high­utilization Having governmental, community agency substance abuse clients by also providing executives, or political figures (e.g., the psychiatric treatment, case management, mayor, council members) as board members and housing support is a good candidate for raises the program’s profile in the commu­ “preferred” or “core” status with one or nity. Of course, programs should be sure to several MCOs or MBHOs. Of course, the include board members who have specific

Financing and Organizational Issues 167 skills and connections that will advance the and assurance of funding from reputable and purposes of the detoxification program. varied referral sources are essential for new •Form alliances with other treatment and existing programs. As a buffer against providers. Setting up coalitions to compete shrinking budgets, all programs should con­ with or work with MCOs and other pur­ sider broadening their funding streams and chasers such as Medicaid may be useful. referral sources, expanding the range of However, consultation with an attorney is clients they can serve, and promptly referring strongly advised prior to developing such a clients for other services not provided on site. coalition or other collaboration with local Partnerships can be a critical factor to the treatment providers as the laws regarding financial success of a program. To operate antitrust and other matters related to such effectively, administrators and other staff relationships are complex. For programs must thoroughly understand the managed serving publicly funded clients, technical care and community political environment assistance may be available through including its terminology, contracts, negotia­ SAMHSA; the SSA can provide details. tions, payments, appeals, and priority popu­ lations. A successful working relationship with an MCO, a health plan, other pur­ Preparing for the chasers, or with another agency or group of Future agencies depends on day­to­day interactions in which staff members serve as informed, Major forces that shape and limit provider professional advocates for their clients and financing are unlikely to change substantially the program. in the near future. Careful strategic planning

168 Chapter 6 Appendix A: Bibliography

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170 Appendix A American Society of Addiction Medicine. Angres, D.H., and Easton, M. Treatment Patient Placement Criteria for the management for acute and continuing Treatment of Substance­Related care. In: Smith, D.E., and Easton, M., Disorders: ASAM PPC­2. 2d ed. Chevy eds. Manual of Therapeutics for Chase, MD: American Society of Addiction Addictions. New York: Wiley­Liss, 1997. Medicine, 1996. pp. 269–284. American Society of Addiction Medicine. Anton, R.F. What is craving?: Models and Patient Placement Criteria for the implications for treatment. Alcohol Treatment of Substance­Related Research and Health 23(3):165–173, 1999. Disorders: ASAM PPC­2R. 2d ed. Anton, R.F. Carbohydrate­deficient transfer­ Revised. Chevy Chase, MD: American rin for detection and monitoring of sus­ Society of Addiction Medicine, 2001. tained heavy drinking. What have we Anderson, C.B., and Wetter, D.W. learned? Where do we go from here? Behavioral and pharmacologic approaches Alcohol 25(3):185–188, 2001. to smoking cessation. Cancer and Anton, R.F., Kranzler, H.R., McEvoy, J.P., Metastasis Reviews 16(3­4):393–404, 1997. Moak, D.H., and Bianca, R. A double­ Anderson, D.J. Delivery of essential services blind comparison of abecarnil and to alcoholics through the “continuum of diazepam in the treatment of uncomplicat­ care.” Cancer Research 39(7 pt 2): ed alcohol withdrawal. 2855–2858, 1979. Psychopharmacology 131:123–129, 1997. Anderson, D.W., Bowland, B.J., Cartwright, Apte, M.V., Wilson, J.S., and Korsten, M.A. W.S., and Bassin, G. Service­level costing Alcohol­related pancreatic damage: of drug abuse treatment. Journal of Mechanisms and treatment. Alcohol Substance Abuse Treatment Health and Research World 21(1):13–20, 15(3):201–211, 1998. 1997. Anderson, F., and Kiefer, F. Depressive mood Aragon, T., and Sande, M.A. Infective endo­ and craving during alcohol withdrawal: carditis. In: Stein, J.H., ed. Internal Association and interaction. German Medicine. 4th ed. St. Louis, MO: Mosby, Journal of Psychiatry 7(2):6–11, 2004. 1994. pp. 189–202. Anderson, F., Paluzzi, P., Lee, J., Huggins, Arfken, C.L., Klein, C., di Menza, S., and G., and Huggins, G. Illicit use of clonidine Schuster, C.R. Gender differences in in opiate­abusing pregnant women. problem severity at assessment and treat­ Obstetrics and Gynecology 90(5):790–794, ment retention. Journal of Substance 1997a. Abuse Treatment 20(1):53–57, 2001. Anderson, M., Elk, R., and Anderes, R.L. Argyropoulos, S.V., and Nutt, D.J. The use Social, ethical and practical aspects of of benzodiazepines in anxiety and other perinatal substance use. Journal of disorders. European Substance Abuse Treatment Neuropsychopharmacology 9(Suppl 6): 14(5):481–486, 1997b. S407–S412, 1999. Andrulis, D., and Hopkins, S. Public hospi­ Armenian, S.H., Chutuape, M.A., and tals and substance abuse services for preg­ Stitzer, M.L. Predictors of discharges nant women and mothers: Implications for against medical advice from a short­term managed­care programs and Medicaid. hospital detoxification unit. Drug and Journal of Urban Health 78(1):181–198, Alcohol Dependence 56(1):1–8, 1999. 2001.

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174 Appendix A Buchert, R., Obrocki, J., Thomasius, R., Burnam, M.A., Hough, R.L., Karno, M., Vaterlein, O., Petersen, K., Jenicke, L., Escobar, J.I., and Telles, C.A. Bohuslavizki, K.H., and Clausen, M. Acculturation and lifetime prevalence of Long­term effects of “ecstasy” abuse on psychiatric disorders among Mexican the human brain studied by FDG PET. Americans in Los Angeles. Journal of Nuclear Medicine Communications Health and Social Behavior 28(1):89–102, 22(8):889–897, 2001. 1987. Bucholz, K.K., Sheline, Y., and Helzer, J.E. Butcher, J.N., Nezami, E., and Exner, J. The epidemiology of alcohol use, prob­ Psychological assessment of people in lems, and dependence in elders: A review. diverse cultures. In: Kazarian, S.S., and In: Beresford, T.P., and Gomberg, E., Evans, D.R., eds. Cultural Clinical eds. Alcohol and Aging. New York: Oxford Psychology: Theory, Research, and University Press, 1995. pp. 19–41. Practice. New York: Oxford University Press, 1998. pp. 61–105. Budney, A.J., Hughes, J.R., Moore, B.A., and Novy, P.L. Marijuana abstinence Buttner, A., Mall, G., Penning, R., and Weis, effects in marijuana smokers maintained S. The neuropathology of heroin abuse. in their home environment. Archives of Forensic Science International 113(1­3): General Psychiatry 58(10):917–924, 2001. 435–442, 2000. Bureau of Justice Assistance. Byrne Formula Buxton, N., and McConachie, N.S. Grant Program Guidance and Application Amphetamine abuse and intracranial Kit. Washington, DC: Bureau of Justice haemorrhage. Journal of the Royal Society Assistance, 2002. of Medicine 93(9):472–477, 2000. Burke, A.P., Kalra, P., Li, L., Smialek, J., Caetano, R., Clark, C.L., and Tam, T. and Virmani, R. Infectious endocarditis Alcohol consumption among racial/ethnic and sudden unexpected death: Incidence minorities: Theory and research. Alcohol and morphology of lesions in intravenous Health and Research World addicts and non­drug abusers. Journal of 22(4):233–238, 1998. Heart Valve Disease 6(2):198–202, 1997. Callahan, K.P., Malinin, A.I., Atar, D., and Burkett, G., Gomez­Marin, O., Yasin, S.Y., Serebruany, V.L. Platelet activation as a and Martinez, M. Prenatal care in universal trigger in the pathogenesis of cocaine­exposed pregnancies. Obstetrics acute coronary events after cocaine abuse. and Gynecology 92(2):193–200, 1998. Swiss Medicine Weekly 131(33­ 34):487–489, 2001. Burling, T.A., Burling, A.S., and Latini, D. A controlled smoking cessation trial for sub­ Canino, G.J., Bird, H.R., Shrout, P.E., stance­dependent inpatients. Journal of Rubio­Stipec, M., Bravo, M., Martinez, Consulting and Clinical Psychology R., Sesman, M., Guzman, A., Guevara, 69(2):295–304, 2001. L.M., and Costas, H. The Spanish Diagnostic Interview Schedule. Reliability Burling, T.A., Marshall, G.D., and Seidner, and concordance with clinical diagnoses in A.L. Smoking cessation for substance Puerto Rico. Archives of General abuse inpatients. Journal of Substance Psychiatry 44(8):720–726, 1987. Abuse 3(3):269–276, 1991.

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176 Appendix A Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Combining Substance Abuse Treatment Combining Alcohol and Other Drug With Intermediate Sanctions for Adults in Treatment with Diversion for Juveniles in the Criminal Justice System. Treatment the Justice System. Treatment Improvement Protocol (TIP) Series 12. Improvement Protocol (TIP) Series 21. HHS Publication No. (SMA) 94­3004. HHS Publication No. (SMA) 95­3051. Rockville, MD: Substance Abuse and Rockville, MD: Substance Abuse and Mental Health Services Administration, Mental Health Services Administration, 1994c. 1995b. Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Intensive Outpatient Treatment for Developing State Outcomes Monitoring Alcohol and Other Drug Abuse. Treatment Systems for Alcohol and Other Drug Improvement Protocol (TIP) Series 8. Abuse Treatment. Treatment HHS Publication No. (SMA) 99­3306. Improvement Protocol (TIP) Series 14. Rockville, MD: Substance Abuse and HHS Publication No. (SMA) 95­3031. Mental Health Services Administration, Rockville, MD: Substance Abuse and 1994d. Mental Health Services Administration, 1995c. Center for Substance Abuse Treatment. Screening and Assessment for Alcohol and Center for Substance Abuse Treatment. Other Drug Abuse Among Adults in the Detoxification From Alcohol and Other Criminal Justice System. Treatment Drugs. Treatment Improvement Protocol Improvement Protocol (TIP) Series 7. (TIP) Series 19. HHS Publication No. HHS Publication No. (SMA) 94­2076. (SMA) 95­3046. Rockville, MD: Center for Rockville, MD: Substance Abuse and Substance Abuse Treatment, 1995d. Mental Health Services Administration, Center for Substance Abuse Treatment. 1994e. LAAM in the Treatment of Opiate Center for Substance Abuse Treatment. Addiction. Treatment Improvement Simple Screening Instruments for Protocol (TIP) Series 22. HHS Publication Outreach for Alcohol and Other Drug No. (SMA) 95­3052. Rockville, MD: Abuse and Infectious Diseases. Treatment Substance Abuse and Mental Health Improvement Protocol (TIP) Series 11. Services Administration, 1995e. HHS Publication No. (SMA) 94­2094. Center for Substance Abuse Treatment. Rockville, MD: Substance Abuse and Matching Treatment to Patient Needs in Mental Health Services Administration, Opioid Substitution Therapy. Treatment 1994f. Improvement Protocol (TIP) Series 20. Center for Substance Abuse Treatment. HHS Publication No. (SMA) 95­3049. Alcohol and Other Drug Screening of Rockville, MD: Substance Abuse and Hospitalized Trauma Patients. Treatment Mental Health Services Administration, Improvement Protocol (TIP) Series 16. 1995f. HHS Publication No. (SMA) 95­3041. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1995a.

Bibliography 177 Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Planning for Alcohol and Other Drug Substance Abuse Treatment and Domestic Abuse Treatment for Adults in the Violence. Treatment Improvement Criminal Justice System. Treatment Protocol (TIP) Series 25. HHS Publication Improvement Protocol (TIP) Series 17. No. (SMA) 97­3163. Rockville, MD: HHS Publication No. (SMA) 95­3039. Substance Abuse and Mental Health Rockville, MD: Substance Abuse and Services Administration, 1997b. Mental Health Services Administration, Center for Substance Abuse Treatment. 1995g. Comprehensive Case Management for Center for Substance Abuse Treatment. The Substance Abuse Treatment. Treatment Role and Current Status of Patient Improvement Protocol (TIP) Series 27. Placement Criteria in the Treatment of HHS Publication No. (SMA) 98­3222. Substance Use Disorders. Treatment Rockville, MD: Substance Abuse and Improvement Protocol (TIP) Series 13. Mental Health Services Administration, HHS Publication No. (SMA) 95­3021. 1998a. Rockville, MD: Substance Abuse and Center for Substance Abuse Treatment. Mental Health Services Administration, Continuity of Offender Treatment for 1995h. Substance Use Disorders From Institution Center for Substance Abuse Treatment. The to Community. Treatment Improvement Tuberculosis Epidemic: Legal and Ethical Protocol (TIP) Series 30. HHS Publication Issues for Alcohol and Other Drug Abuse No. (SMA) 98­3245. Rockville, MD: Treatment Providers. Treatment Substance Abuse and Mental Health Improvement Protocol (TIP) Series 18. Services Administration, 1998b. HHS Publication No. (SMA) 95­3047. Center for Substance Abuse Treatment. Rockville, MD: Substance Abuse and Contracting for Managed Substance Abuse Mental Health Services Administration, and Mental Health Services: A Guide for 1995i. Public Purchasers. Technical Assistance Center for Substance Abuse Treatment. Publication (TAP) Series 22. HHS Treatment Drug Courts: Integrating Publication No. (SMA) 98­3173. Rockville, Substance Abuse Treatment With Legal MD: Substance Abuse and Mental Health Case Processing. Treatment Improvement Services Administration, 1998c. Protocol (TIP) Series 23. HHS Publication Center for Substance Abuse Treatment. No. (SMA) 96­3113. Rockville, MD: Measuring the Cost of Substance Abuse Substance Abuse and Mental Health Treatment Services: An Overview. Services Administration, 1996. Rockville, MD: Substance Abuse and Center for Substance Abuse Treatment. A Mental Health Services Administration, Guide to Substance Abuse Services for 1998d. Primary Care Clinicians. Treatment Center for Substance Abuse Treatment. Improvement Protocol (TIP) Series 24. Naltrexone and Alcoholism Treatment. HHS Publication No. (SMA) 97­3139. Treatment Improvement Protocol (TIP) Rockville, MD: Substance Abuse and Series 28. HHS Publication No. (SMA) 98­ Mental Health Services Administration, 3206. Rockville, MD: Substance Abuse 1997a. and Mental Health Services Administration, 1998e.

178 Appendix A Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Treatment for Stimulant Use Disorders. Treatment Improvement Protocol (TIP) Treatment Improvement Protocol (TIP) Series 26. HHS Publication No. (SMA) 98­ Series 33. HHS Publication No. (SMA) 99­ 3179. Substance Abuse and Mental Health 3296. Rockville, MD: Substance Abuse Services Administration Center for and Mental Health Services Substance Abuse Treatment, 1998f. Administration, 1999e. Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Substance Use Disorder Treatment for Treatment of Adolescents With Substance People With Physical and Cognitive Use Disorders. Treatment Improvement Disabilities. Treatment Improvement Protocol (TIP) Series 32. HHS Publication Protocol (TIP) Series 29. HHS Publication No. (SMA) 99­3283. Rockville, MD: No. (SMA) 98­3249. Rockville, MD: Substance Abuse and Mental Health Substance Abuse and Mental Health Services Administration, 1999f. Services Administration, 1998g. Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Brief Changing The Conversation: Improving Interventions and Brief Therapies for Substance Abuse Treatment. The National Substance Abuse. Treatment Improvement Treatment Improvement Plan Initiative: Protocol (TIP) Series 34. HHS Publication Panel Reports, Public Hearings, and No. (SMA) 99­3353. Rockville, MD: Participant Acknowledgements. HHS Substance Abuse and Mental Health Publication No. (SMA) 00­3479. Rockville, Services Administration, 1999a. MD: Substance Abuse and Mental Health Services Administration, 2000a. Center for Substance Abuse Treatment. Cultural Issues in Substance Abuse Center for Substance Abuse Treatment. Treatment. HHS Publication No. (SMA) Changing The Conversation: Improving 99­3278. Rockville, MD: Substance Abuse Substance Abuse Treatment. The National and Mental Health Services Treatment Improvement Plan Initiative. Administration, 1999b. HHS Publication No. (SMA) 00­3480. Rockville, MD: Substance Abuse and Center for Substance Abuse Treatment. Mental Health Services Administration, Enhancing Motivation for Change in 2000b. Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 35. Center for Substance Abuse Treatment. HHS Publication No. (SMA) 99­3354. Integrating Substance Abuse Treatment Rockville, MD: Substance Abuse and and Vocational Services. Treatment Mental Health Services Administration, Improvement Protocol (TIP) Series 38. 1999c. HHS Publication No. (SMA) 00­3470. Rockville, MD: Substance Abuse and Center for Substance Abuse Treatment. Mental Health Services Administration, Screening and Assessing Adolescents for 2000c. Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 31. Center for Substance Abuse Treatment. HHS Publication No. (SMA) 99­3282. Substance Abuse Treatment for Persons Rockville, MD: Substance Abuse and With Child Abuse and Neglect Issues. Mental Health Services Administration, Treatment Improvement Protocol (TIP) 1999d. Series 36. HHS Publication No. (SMA) 00­ 3357. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2000d.

Bibliography 179 Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons Substance Abuse Treatment for Persons With HIV/AIDS. Treatment Improvement With Co­Occurring Disorders. Treatment Protocol (TIP) Series 37. HHS Publication Improvement Protocol (TIP) Series 42. No. (SMA) 00­3459. Rockville, MD: HHS Publication No. (SMA) 05­3992. Substance Abuse and Mental Health Rockville, MD: Substance Abuse and Services Administration, 2000e. Mental Health Services Administration, 2005c. Center for Substance Abuse Treatment. A Provider’s Introduction to Substance Center for Substance Abuse Treatment. Abuse Treatment for Lesbian, Gay, Medication­Assisted Treatment for Opioid Bisexual, and Transgender Individuals. Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Treatment Improvement Protocol (TIP) Mental Health Services Administration, Series 43. HHS Publication No. (SMA) 05­ 2001. 4048. Rockville, MD: Substance Abuse and Mental Health Services Center for Substance Abuse Treatment. Administration, 2005d. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Center for Substance Abuse Treatment. Addiction. Treatment Improvement Improving Cultural Competence in Protocol (TIP) Series 40. HHS Publication Substance Abuse Treatment. Treatment No. (SMA) 04­3939. Rockville, MD: Improvement Protocol (TIP) Series. Substance Abuse and Mental Health Rockville, MD: Substance Abuse and Services Administration, 2004a. Mental Health Services Administration, in development a. Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Center for Substance Abuse Treatment. Therapy. Treatment Improvement Substance Abuse: Administrative Issues in Protocol (TIP) Series 39. Rockville, MD: Outpatient Treatment. Treatment Substance Abuse and Mental Health Improvement Protocol (TIP) Series. Services Administration, 2004b. Rockville, MD: Substance Abuse and Mental Health Services Administration, in Center for Substance Abuse Treatment. development c. Substance Abuse Treatment: Group Therapy. Treatment Improvement Center for Substance Abuse Treatment. Protocol (TIP) Series 41. HHS Publication Substance Abuse: Clinical Issues in No. (SMA) 05­3991. Rockville, MD: Intensive Outpatient Treatment. Substance Abuse and Mental Health Treatment Improvement Protocol (TIP) Services Administration, 2005a. Series. Rockville, MD: Substance Abuse and Mental Health Services Center for Substance Abuse Treatment. Administration, in development d. Substance Abuse Treatment for Adults in the Criminal Justice System. Treatment Center for Substance Abuse Treatment. Improvement Protocol (TIP) Series 44. Substance Abuse Treatment: Addressing HHS Publication No. (SMA) 05­4056. the Specific Needs of Women. Treatment Rockville, MD: Substance Abuse and Improvement Protocol (TIP) Series. Mental Health Services Administration, Rockville, MD: Substance Abuse and 2005b. Mental Health Services Administration, in development e.

180 Appendix A Center for Substance Abuse Treatment. Chakko, S., and Myerburg, R.J. Cardiac Substance Abuse Treatment: Men’s Issues. complications of cocaine abuse. Clinical Treatment Improvement Protocol (TIP) Cardiology 18(2):67–72, 1995. Series. Rockville, MD: Substance Abuse Chambers, H.F., Morris, D.L., Tauber, and Mental Health Services M.G., and Modin, G. Cocaine use and the Administration, in development g. risk for endocarditis in intravenous drug Center for Substance Abuse Treatment. users. Annals of Internal Medicine Substance Abuse and Trauma. Treatment 106(6):833–836, 1987. Improvement Protocol (TIP) Series. Chan, A.W.K., Pristach, E.A., Welte, J.W., Rockville, MD: Substance Abuse and and Russell, M. Use of the TWEAK test in Mental Health Services Administration, in screening for alcoholism/heavy drinking in development h. three populations. Alcoholism, Clinical, Centers for Disease Control and Prevention. and Experimental Research HIV Prevention Community Planning for 17(6):1188–1192, 1993. HIV Prevention Cooperative Agreement Chance, J.F. Emergency department treat­ Recipients. Atlanta, GA: Centers for ment of alcohol withdrawal seizures with Disease Control and Prevention, 1999. phenytoin. Annals of Emergency Medicine Centers for Disease Control and Prevention. 20(5):520–522, 1991. HIV Prevention Strategic Plan Through Chang, P. Treating Asian/Pacific American 2005. Atlanta, GA: Centers for Disease addicts and their families. In: Krestan, Control and Prevention, 2001. J.A., ed. Bridges to Recovery: Addiction, Centers for Disease Control and Prevention. Family Therapy, and Multicultural Cigarette smoking among adults—United Treatment. New York: Free Press, 2000. States, 2000. Morbidity and Mortality pp. 192–218. Weekly Report 51(29):642–645, 2002a. Chappel, J.N., and DuPont, R.L. Twelve­ Centers for Disease Control and Prevention. step and mutual help programs for addic­ HIV/AIDS Surveillance Report, 2001 tive disorders. Psychiatric Clinics of North 13(2):1–44, 2002b. America 22(2):425–446, 1999. Centers for Disease Control and Prevention. Charney, D.S., Heninger, G.R., and Kleber, Cigarette smoking among adults—United H.D. The combined use of clonidine and States, 2004. Morbidity and Mortality naltrexone as a rapid, safe, and effective Weekly Report 55(44):1121–1124, 2005. treatment of abrupt withdrawal from methadone. American Journal of Centers for Disease Control and Prevention Psychiatry 143(7):831–837, 1986. and Office of Minority Health. Native Hawaiian & Other Pacific Islander Charney, D.S., Riordan, C.E., Kleber, H.D., (NHOPI) Populations. 2004. Murburg, M., Braverman, P., Sternberg, D.E., Heninger, G.R., and Redmond, Centers for Medicare and Medicaid Services. D.E. Clonidine and naltrexone. A safe, Your Medicare Coverage. Baltimore: U.S. effective, and rapid treatment of abrupt Department of Health and Human withdrawal from methadone therapy. Services, Centers for Medicare and Archives of General Psychiatry Medicaid Services, 2002. 39(11):1327–1332, 1982.

Bibliography 181 Chavkin, W., Breitbart, V., Elman, D., and Ciraulo, D.A., Alderson, L.M., Chapron, Wise, P.H. National survey of the states: D.J., Jaffe, J.H., Subbarao, B., and Policies and practices regarding drug­ Kramer, P.A. Imipramine disposition in using pregnant women. American Journal alcoholics. Journal of Clinical of Public Health 88(1):117–119, 1998. Psychopharmacology 2(1):2–7, 1982. Chen, Y.R., Swann, A.C., and Johnson, B.A. Ciraulo, D.A., and Jaffe, J.H. Tricyclic Stability of diagnosis in bipolar disorder. antidepressants in the treatment of depres­ Journal of Nervous & Mental Disease sion associated with alcoholism. Journal of 186(1):17–23, 1998. Clinical Psychopharmacology 1(3):146–150, 1981. Cherpitel, C.J. Screening for alcohol prob­ lems in the emergency room: A rapid alco­ Clark, H.W., McClanahan, T.M., and Sees, hol problems screen. Drug and Alcohol K.L. Substance abuse services in systems Dependence 40(2):133–137, 1995. of care: Linkages and issues in serving cul­ turally diverse populations. In: Cherpitel, C.J. Comparison of screening Hernandez, M., and Isaacs, M.R., eds. instruments for alcohol problems between Promoting Cultural Competence in Black and White emergency room patients Children’s Mental Health Services. from two regions of the country. Baltimore: Paul H. Brookes Publishing, Alcoholism: Clinical and Experimental 1998. pp. 207–227. Research 21(8):1391–1397, 1997. Closser, M.H., and Blow, F.C. Special popu­ Childress, A.R., Mozley, P.D., McElgin, W., lations: Women, ethnic minorities, and the Fitzgerald, J., Reivich, M., and O’Brien, elderly. Psychiatric Clinics of North C.P. Limbic activation during cue­induced America 16(1):199–209, 1993. cocaine craving. American Journal of Psychiatry 156(1):11–18, 1999. Cochran, S.D., and Mays, V.M. Relation between psychiatric syndromes and behav­ Chiles, J.A., Von Cleve, E., Jemelka, R.P., iorally defined sexual orientation in a sam­ and Trupin, E.W. Substance abuse and ple of the US population. American psychiatric disorders in prison inmates. Journal of Epidemiology 151(5):516–523, Hospital Community Psychiatry 2000. 41(10):1132–1134, 1990. Coffey, R.M., Mark, T., King, E., Harwood, Christophersen, A.S. Amphetamine designer H., McKusick, D., Genuardi, J., drugs: An overview and epidemiology. Dilonardo, J., and Chalk, M. National Toxicology Letters (Mar 15): Estimates of Expenditures for Substance 112, 113–127, 131, 2000. Abuse Treatment, 1997. HHS Publication Church, O.M., and Anderson, R. Managed No. SMA 01­3511. Rockville, MD: Center care in the substance abuse arena: for Substance Abuse Treatment, 2001. Challenges and choices. Part II. Journal Coffey, S.F., Dansky, B.S., Carrigan, M.H., of Substance Use 4(3):103–105, 2000. and Brady, K.T. Acute and protracted Chutuape, M.A., Jasinski, D.R., Fingerhood, cocaine abstinence in an outpatient popu­ M.I., and Stitzer, M.L. One­, three­, and lation: A prospective study of mood, sleep six­month outcomes after brief inpatient and withdrawal symptoms. Drug and opioid detoxification. American Journal of Alcohol Dependence 59:277–286, 2000. Drug and Alcohol Abuse 27(1):19–44, 2001.

182 Appendix A Collins, K.S., Hughes, D.L., Doty, M.M., Cook, C.A., Booth, B.M., Blow, F.C., Ives, B.L., Edwards, J.N., and Tenney, K. Gogineni, A., and Bunn, J.Y. Alcoholism Diverse Communities, Common Concerns: treatment, severity of alcohol­related med­ Assessing Health Care Quality For ical complications, and health services uti­ Minority Americans. The Commonwealth lization. Journal of Mental Health Fund, 2002. Administration 19(1):31–40, 1992. Comer, V.G., and Annitto, W.J. Cook, J.W., Spring, B., McChargue, D.E., Buprenorphine: A safe method for detoxi­ Borrelli, B., Hitsman, B., Niaura, R., fying pregnant heroin addicts and their Keuthen, N.J., Kristeller, J. Influence of unborn. American Journal on Addictions fluoxetine on positive and negative affect 13(3):317–318, 2004. in a clinic­based smoking cessation trial. Psychopharmacology 173:153–159, 2004. Comfort, M., Hagan, T., and Kaltenbach, K. Psychosocial History. Philadelphia: Cooper­Patrick, L., Gallo, J.J., Powe, N.R., Family Center, Thomas Jefferson Steinwachs, D.S., Eaton, W.W., and Ford, University, 1996. D.E. Mental health service utilization by African Americans and Whites: The Comfort, M., Zanis, D.A., Whiteley, M.J., Baltimore Epidemiologic Catchment Area Kelly­Tyler, A., and Kaltenbach, K.A. Follow­Up. Medical Care 37(10): Assessing the needs of substance abusing 1034–1045, 1999. women: Psychometric data on the psy­ chosocial history. Journal of Substance Corcoran, K., and Vandiver, V. Maneuvering Abuse Treatment 17(1–2):79–83, 1999. the Maze of Managed Care: Skills for Mental Health Practitioners. New York: Compton, W.M., III, Cottler, L.B., Ben The Free Press, 1996. Abdallah, A., Phelps, D.L., Spitznagel, E.L., and Horton, J.C. Substance depen­ Costa, L.G., Guizzetti, M., Burry, M., and dence and other psychiatric disorders Oberdoerster, J. Developmental neurotox­ among drug dependent subjects: Race and icity: Do similar phenotypes indicate a gender correlates. American Journal on common mode of action? A comparison of Addictions 9(2):113–125, 2000. fetal alcohol syndrome, toluene embryopa­ thy and maternal phenylketonuria. Connors, G.J., Carroll, K.M., DiClemente, Toxicology Letters 127(1­3):197–205, C.C., Longabaugh, R., and Donovan, 2002. D.M. The therapeutic alliance and its rela­ tionship to alcoholism treatment participa­ Cote, G., and Hodgins, S. Co­occurring men­ tion and outcome. Journal of Consulting tal disorders among criminal offenders. and Clinical Psychology 65(4):588–598, Bulletin of the American Academy of 1997. Psychiatry and the Law 18(3):271–281, 1990. Connors, G.J., DiClemente, C.C., Dermen, K.H., Kadden, R., Carroll, K.M., and Cottler, L.B., Shillingtron, A.M., Compton, Frone, M.R. Predicting the therapeutic W.M.I., Mager, D., and Spitznagel, E.L. alliance in alcoholism treatment. Journal Subjective reports of withdrawal among of Studies on Alcohol 61(1):139–149, 2000. cocaine users: Recommendations for DSM­ IV. Drug and Alcohol Dependence Conyne, R.K. What to look for in groups: 33:97–104, 1993. Helping trainees become more sensitive to multicultural issues. Journal for Specialists in Group Work 23(1):22–32, 1998.

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202 Appendix A McElhatton, P.R., Bateman, D.N., Evans, McLellan, A.T., Lewis, D., O’Brien, C.P., C., Pughe, K.R., and Thomas, S.H. Hoffmann, N.G., and Kleber, H.D. Is Congenital anomalies after prenatal ecsta­ Drug Dependence a Chronic Medical sy exposure. Lancet 354(9188):1441–1442, Illness: Implications for Treatment, 1999. Insurance and Outcome Evaluation. Philadelphia: Treatment Research McGee, M.D., and Mee­Lee, D. Rethinking Institute, 2002. patient placement: The human service matrix model for matching services to McLellan, A.T., Lewis, D.C., O’Brien, C.P., needs. Journal of Substance Abuse and Kleber, H.D. Drug dependence, a Treatment 14(2):141–148, 1997. chronic medical illness: Implications for treatment, insurance, and outcomes evalu­ McGinnis, J.M., and Foege, W.H. Actual ation. Journal of the American Medical causes of death in the United States. Association 284(13):1689–1695, 2000. Journal of the American Medical Association 270(18):2207–2212, 1993. McLellan, A.T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H.L., and McLaughlin, L.A., and Braun, K.L. Asian O’Brien, C.P. New data from the and Pacific Islander cultural values: Addiction Severity Index: Reliability and Considerations for health care decision validity in three centers. Journal of making. Health and Social Work Nervous and Mental Disease 23(2):116–126, 1998. 173(7):412–423, 1985. McLellan, A.T., Alterman, A.I., Metzger, McLellan, A.T., Luborsky, L., Woody, G.E., D.S., Grissom, G.R., Woody, G.E., and O’Brien, C.P. An improved diagnostic Luborsky, L., and O’Brien, C.P. evaluation instrument for substance abuse Similarity of outcome predictors across patients: The Addiction Severity Index. opiate, cocaine, and alcohol treatments: Journal of Nervous and Mental Disease Role of treatment services. Journal of 168(1):26–33, 1980. Consulting and Clinical Psychology 62(6):1141–1158, 1994. McLellan, A.T., and McKay, J.R. Components of successful treatment pro­ McLellan, A.T., Grissom, G.R., Brill, P., grams: Lessons from the research litera­ Durell, J., Metzger, D.S., and O’Brien, ture. In: Graham, A.W., Schultz, T.K., C.P. Private substance abuse treatments: and Wilford, B.B., eds. Principles of Are some programs more effective than Addiction Medicine. 2d ed. Chevy Chase, others? Journal of Substance Abuse MD: American Society of Addiction Treatment 10(3):243–254, 1993. Medicine, 1998. pp. 327–343. McLellan, A.T., Hagan, T.A., Levine, M., McNiel, J., Sheffield, J.V.L., and Bartlett, Gould, F., Meyers, K., Bencivengo, M., J.G. Core elements of HIV primary care. and Durell, J. Supplemental social ser­ In: Bartlett, J.G., Cheever, L.W., vices improve outcomes in public addiction Johnson, M.P., and Paauw, D.S. A Guide treatment. Addiction 93(10):1489–1499, to Primary Care of People with 1998. HIV/AIDS. Rockville, MD: Health McLellan, A.T., Kushner, H., Metzger, D., Resources and Services Administration, Peters, R., Smith, I., Grissom, G., 2004. Pettnati, H., and Argeriou, M. The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment 9(3):199–213, 1992.

Bibliography 203 Merikangas, K.R., Angst, J., Eaton, W., Miller, N.S., and Flaherty, J.A. Effectiveness Canino, G., Rubio­Stipec, M., Wacker, of coerced addiction treatment (alternative H., Wittchen, H.U., Andrade, L., Essau, consequences): A review of the clinical C., Whitaker, A., Kraemer, H., Robins, research. Journal of Substance Abuse L.N., and Kupfer, D.J. Comorbidity and Treatment 18(1):9–16, 2000. boundaries of affective disorders with anx­ Miller, N.S., and Gold, M.S. Organic solvents iety disorders and substance misuse: and aerosols: An overview of abuse and Results of an international task force. The dependence. Annals of Clinical Psychiatry British Journal of Psychiatry 2:85–92, 1990. (Supplement) (30):58–67, 1996. Miller, N.S., and Gold, M.S. Abuse, addic­ Merrick, E.L., Garnick, D.W., Horgan, tion, tolerance, and dependence to benzo­ C.M., Goldin, D., Hodgkin, D., and diazepines in medical and nonmedical pop­ Sciegaj, M. Benefits in behavioral health ulations. American Journal of Alcohol carve­out plans of Fortune 500 firms. Abuse 17(1):27–37, 1991a. Psychiatric Services 52(7):943–948, 2001. Miller, N.S., and Gold, M.S. Dual diagnoses: Meyers, R.J., Miller, W.R., Hill, D.E., and Psychiatric syndromes in alcoholism and Tonigan, J.S. Community reinforcement drug addiction. American Family and family training (CRAFT): Engaging Physician 43(6):2071–2076, 1991b. unmotivated drug users in treatment. Journal of Substance Abuse Miller, N.S., and Gold, M.S. The psychia­ 10(3):291–308, 1998. trist’s role in integrating pharmacological and nonpharmacological treatments for Miles, D.R., Svikis, D.S., Kulstad, J.L., and addictive disorders. Psychiatric Annals Haug, N.A. Psychopathology in pregnant 22(8):436–440, 1992. drug­dependent women with and without comorbid alcohol dependence. Alcoholism: Miller, N.S., and Gold, M.S. Dissociation of Clinical and Experimental Research “conscious desire” (craving) from and 25(7):1012–1017, 2001. relapse in alcohol and cocaine depen­ dence. Annals of Clinical Psychiatry Miller, N.S. Psychiatric consequences of alco­ 6(2):99–106, 1994. hol and drugs of abuse and addiction. In: Miller, N.S., ed. Pharmacology of Alcohol Miller, N.S., and Gold, M.S. Management of and Drugs of Abuse and Addiction. New withdrawal syndromes and relapse preven­ York: Springer­Verlag, 1991. pp. 77–87. tion in drug and alcohol dependence. American Family Physician 58(1):139–146, Miller, N.S. Comorbidity of psychiatric and 1998. alcohol/drug disorders: Interactions and independent status. Journal of Addictive Miller, N.S., Mahler, J.C., Belkin, B.M., and Diseases 12(3):5–16, 1993. Gold, M.S. Psychiatric diagnosis in alco­ hol and drug dependence. Annals of Miller, N.S., Belkin, B.M., and Gold, M.S. Clinical Psychiatry 3:79–89, 1991a. Multiple addictions: Co­synchronous use of alcohol and drugs. New York State Miller, N.S., Mahler, J.C., and Gold, M.S. Journal of Medicine 90(12):596–600, Suicide risk associated with drug and alco­ 1990a. hol dependence. Journal of Addictive Diseases 10(3):49–61, 1991b. Miller, N.S., and Chappel, J.N. History of the disease concept. Psychiatric Annals 21(4):196–205, 1991.

204 Appendix A Miller, N.S., Owley, T., and Eriksen, A. Miotto, K., Roth, B., and Texas Commission Working with drug/alcohol­addicted on Alcohol and Drug Abuse. GHB patients in crisis. Psychiatric Annals Withdrawal Syndrome. Austin, TX: Texas 24(11):592–597, 1994. Commission on Alcohol and Drug Abuse, 2001. Miller, S.I., Frances, R.J., and Holmes, D.J. Psychotropic medications. In: Miller, Mitchell, E.R. Fighting Drug Abuse With W.R., ed. Alcoholism Treatment Acupuncture: Treatment That Works. Approaches. New York: Pergamon Press, Berkeley, CA: Pacific View Press, 1995. 1990b. pp. 231–241. Mizes, J.S., Sloan, D.M., Pingitore, R., Miller, W.R., Brown, J.M., Simpson, T.L., Seagraves, K., Spring, B., and Kristellar, Handmaker, N.S., Bien, T.H., Luckie, J. The influence of weight­related vari­ L.F., Montgomery, H.A., Hester, R.K., ables on smoking cessation. Behavior and Tonigan, J.S. What works? A method­ Therapy 29:371–385, 1998. ological analysis of the alcohol treatment Moak, D.H., and Anton, R.F. Alcohol­related outcome literature. In: Hester, R.K., and seizures and the kindling effect of repeated Miller, W.R., eds. Handbook of detoxifications: The influence of cocaine. Alcoholism Treatment Approaches: Alcohol and Alcoholism 31(2):135–143, Effective Alternatives. 2d ed. Boston: 1996. Allyn and Bacon, 1995. pp. 12–44. Modesto­Lowe, V., and Kranzler, H.R. Miller, W.R., Meyers, R.J., and Tonigan, Diagnosis and treatment of alcohol­depen­ J.S. Engaging the unmotivated in treat­ dent patients with comorbid psychiatric ment for alcohol problems: A comparison disorders. Alcohol Research and Health of three strategies for intervention through 23(2):144–149, 1999. family members. Journal of Consulting and Clinical Psychology 67(5):688–697, Moffic, H.S., and Kinzie, J.D. The history 1999. and future of cross­cultural psychiatric services. Community Mental Health Miller, W.R., and Rollnick, S. Motivational Journal 32(6):581–592, 1996. Interviewing: Preparing People for Change. 2d ed. New York: Guilford Press, Moggi, F., Ouimette, P.C., Finney, J.W., and 2002. Moos, R.H. Effectiveness of treatment for substance abuse and dependence for dual Miller, W.R., and Rollnick, S. Motivational diagnosis patients: A model of treatment Interviewing: Preparing People to Change factors associated with one­year outcomes. Addictive Behavior. New York: Guilford Journal of Studies on Alcohol Press, 1991. 60(6):856–866, 1999. Miller, W.R., and Sanchez, V.C. Motivating Mojtabai, R., and Zivin, J.G. Effectiveness young adults for treatment and lifestyle and cost­effectiveness of four treatment change. In: Howard, G.S., and Nathan, modalities for substance disorders: A P.E., eds. Alcohol Use and Misuse by propensity score analysis. Health Services Young Adults. Notre Dame, IN: Notre Research 38(1):233–259, 2003. Dame University Press, 1994. pp. 55–81. Moller, H.J. Effectiveness and safety of ben­ Minnis, J.R. Toward an understanding of zodiazepines. Journal of Clinical alcohol abuse among the elderly: A socio­ Psychopharmacology 19(6):2S–11S, 1999. logical perspective. Journal of Alcohol and Drug Education 33(3):32–40, 1988.

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206 Appendix A Nebelkopf, E. Herbs and substance abuse Nutt, D., Adinoff, B., and Linnoila, M. treatment: A 10­year perspective. Journal Benzodiazepines in the treatment of alco­ of Psychoactive Drugs 20(3):349–354, holism. Recent Developments in 1988. Alcoholism 7:283–313, 1989. Nelipovich, M., and Buss, E. Alcohol abuse O’Connor, P.G., and Kosten, T.R. Rapid and and persons who are blind: Treatment ultrarapid opioid detoxification tech­ considerations. Alcohol Health and niques. Journal of the American Medical Research World 13(2):129–131, 1989. Association 279(3):229–234, 1998. Neu, H.C. Pneumonia. In: Stein, J.H., ed. Office of Applied Studies. Summary of Internal Medicine. 4th ed. St. Louis, MO: Findings from the 2000 National Mosby, pp. 1868–1876. 1994. Household Survey on Drug Abuse. HHS Publication No. (SMA) 01­3549. Rockville, Newman, C.F. Establishing and maintaining a MD: Substance Abuse and Mental Health therapeutic alliance with substance abuse Services Administration, 2001. patients: A cognitive therapy approach. In: Onken, L.S., Blaine, J., and Boren, Office of Applied Studies. Results from the J.D., eds. Beyond the Therapeutic 2001 National Household Survey on Drug Alliance: Keeping the Drug­Dependent Abuse: Vol.1. Summary of National Individual in Treatment. NIDA Research Findings. National Household Survey on Monograph 165. NIH Publication No. 97­ Drug Abuse Series: H­17. HHS 4142. Rockville, MD: National Institute on Publication No. (SMA) 02­3758. Rockville, Drug Abuse, 1997. pp. 181–206. MD: Substance Abuse and Mental Health Services Administration, 2002a. News and Notes. Study finds widespread implementation of managed behavioral Office of Applied Studies. National Survey of health care programs in the public sector. Substance Abuse Treatment Services Psychiatric Services 50(2):278, 1999. (N–SSATS): 2000. Data on Substance Abuse Treatment Facilities. DASIS Series: Niaura, R., Spring, B., Borrelli, B., S­16. HHS Publication No. (SMA) 02­ Hedeker, D., Goldstein, M.G., Keuthen, 3668. Rockville, MD: Substance Abuse N., DePue, J., Kristeller, J., Ockene, J., and Mental Health Services Prochazka, A., Chiles, J.A., and Abrams, Administration, 2002b. D.B. Multicenter trial of fluoxetine as an adjunct to behavioral smoking cessation Office of Applied Studies. Treatment Episode treatment. Journal of Consulting and Data Set (TEDS): 1992­2000. National Clinical Psychology 70(4):887–896, 2002. Admissions to Substance Abuse Treatment Services. Drug and Alcohol Services Nordahl, T.E., Salo, R., Natsuaki, Y., Information System Series: S­17. Galloway, G.P., Waters, C., Moore, C.D., Rockville, MD: Substance Abuse and Kile, S., and Buonocore, M.H. Mental Health Services Administration, Methamphetamine users in sustained 2002c. abstinence: a proton magnetic resonance spectroscopy study. Archives of General Office of Applied Studies. The National Psychiatry 62(4):444–452, 2005. Survey of Substance Abuse Treatment Services (N–SSATS). The DASIS Report. NIH Panel Issues Consensus Statement on Rockville, MD: Substance Abuse and Acupuncture. NIH News Release. Mental Health Services Administration, Bethesda, MD: National Institutes of 2003a. Health, 1997.

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218 Appendix A Waksman, J., Taylor, R.N., Bodor, G.S., Wesson, D.R., and Smith, D.E. Cocaine: Daly, F.F., Jolliff, H.A., and Dart, R.C. Treatment perspectives. In: Kozel, N.J., Acute myocardial infarction associated and Adams, E.H., eds. Cocaine Use in with amphetamine use. Mayo Clinic America: Epidemiologic and Clinical Proceedings 76(3):323–326, 2001. Perspectives. NIDA Research Monograph No. 61. HHS Publication No. ADM 85­ Walsh, D.C., Hingson, R.W., Merrigan, 1414. Rockville, MD: National Institute on D.M., Levenson, S.M., Cupples, L.A., Drug Abuse, 1985. pp. 193–203. Heeren, T., Coffman, G.A., Becker, C.A., Barker, T.A., and Hamilton, S.K. A ran­ West, P.M., and Graham, K. Clients speak: domized trial of treatment options for Participatory evaluation of a noncon­ alcohol­abusing workers. New England frontational addictions treatment program Journal of Medicine 325(11):775–782, for older adults. Journal of Aging and 1991. Health 11(4):540–564, 1999. Walsh, S.L., Preston, K.L., Stitzer, M.L., Westermeyer, J. Substance­related disorders. Cone, E.J., and Bigelow, G.E. Clinical In: Ammerman, R.T., and Hersen, M., pharmacology of buprenorphine: Ceiling eds. Handbook of Prevention and effects at high doses. Clinical Treatment With Children and Pharmacology and Therapeutics Adolescents: Intervention in the Real 55(5):569–580, 1994. World Context. New York: John Wiley and Sons, 1997. pp. 604–628. Wartenberg, A.A., Nirenberg, T.D., Liepman, M.R., Silvia, L.Y., Begin, A.M., Westermeyer, J., and Neider, J. Predicting and Monti, P.M. Detoxification of alco­ treatment outcome after ten years among holics: Improving care by symptom­trig­ American Indian alcoholics. Alcoholism: gered sedation. Alcoholism: Clinical and Clinical and Experimental Research Experimental Research 14(1):71–75, 1990. 8(2):179–184, 1984. Washburn, A.M., Fullilove, R.E., Fullilove, Westermeyer, J., Specker, S., Neider, J., and M.T., Keenan, P.A., McGee, B., Morris, Lingenfelter, M.A. Substance abuse and K.A., Sorensen, J.L., and Clark, W.W. associated psychiatric disorder among 100 Acupuncture heroin detoxification: A sin­ adolescents. Journal of Addictive Diseases gle­blind clinical trial. Journal of 13(1):67–89, 1994. Substance Abuse Treatment Western Interstate Commission for Higher 10(4):345–351, 1993. Education. Cultural Competence Weddington, W.W., Brown, B.S., Haertzen, Standards in Managed Mental Health Care C.A., Cone, E.J., Dax, E.M., Herning, for Four Underserved/Underrepresented R.I., and Michaelson, B.S. Changes in Racial/Ethnic Groups. Boulder, CO: mood, craving, and sleep during short­ Western Interstate Commission for Higher term abstinence reported by male cocaine Education, 2000. addicts: A controlled residential study. Westmaas, J.L., Nath, V., and Brandon, T.H. Archives of General Psychiatry Contemporary smoking cessation. Cancer 47(September):861–868, 1990. Control 7(1):56–62, 2000. Weisner, C., Mertens, J., Tam, T., and Westman, E.C., Tomlin, K.F., and Rose, J.E. Moore, C. Factors affecting the initiation Combining the nicotine inhaler and nico­ of substance abuse treatment in managed tine patch for smoking cessation. care. Addiction 96(5):705–716, 2001. American Journal of Health Behavior 24(2):114–119, 2000.

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Bibliography 221 Appendix B: Common Drug Intoxication Signs and Withdrawal Symptoms

Cocaine Alcohol Heroin Cannabis (marijuana)

Intoxication

Action Stimulant Sedative Sedative, euphori­ Euphoriant, at ant, analgesic high doses may induce hallucina­ tions

Characteristics of D BP, HR, temp, • Sedation, Drowsiness, “nod­ bBP, DHR, intoxication Denergy, brespiration, ding,” euphoria bintraocular pres­ Dparanoia, • Depresses CNS (happy giddiness) sure (pressure in Dfatigue, system, can the eyes) bappetite, result in coma, conjunctival injec­ move bowels/ death tion (reddening of urinate the eyes)

Withdrawal

Onset Depends upon 24–48 hours after Within 24 hours Some debate type of cocaine blood alcohol level of last use about this, may be used: for crack drops a few days will begin within hours of last use

Duration 3–4 days 5–7 days 4–7 days May last up to several weeks

223 Cocaine Alcohol Heroin Cannabis (marijuana)

Characteristics Sleeplessness or DBP, DHR, Nausea, vomiting, Irritability, excessive restless Dtemp, diarrhea, goose appetite distur­ sleep, appetite nausea/vomiting/ bumps, runny bance, sleep dis­ increase, depres­ diarrhea, nose, teary eyes, turbance, nausea, sion, paranoia, seizures, delirium, yawning concentration decreased energy death problems, nystag­ mus, diarrhea

Medical/ Stroke, cardiovas­ Virtually every During withdrawal psychiatric issues cular collapse, organ system is individual may myocardial and affected (e.g., car­ become dehydrat­ other organ infarc­ diomyopathy, liver ed tion, paranoia, disease, esophageal violence, severe and rectal depression, suicide varices); fetal alco­ hol syndrome and other problems with fetus

224 Appendix B Appendix C: Screening and Assessment Instruments

Please note that this list of screening and assessment instruments has been divided into two sections. The first section comprises those instru­ ments used for patients with suspected alcohol abuse or dependence only; the second lists instruments used to screen and assess for abuse of or dependence on any substances. Thus those tools that screen for all substances of abuse are listed in section II.

Section I: Screening and Assessment for Alcohol Abuse This section of the appendix lists common screening and assessment instruments specifically used in cases where abuse of or dependence upon alcohol is in question.

The Alcohol Use Disorders Identification Test (AUDIT) Purpose: The purpose of the AUDIT is to identify persons whose alco­ hol consumption has become hazardous or harmful to their health.

Clinical utility: The AUDIT screening procedure is linked to a deci­ sion process that includes brief intervention with heavy drinkers or referral to specialized treatment for patients who show evidence of more serious alcohol involvement.

Groups with whom this instrument has been used: Adults, particular­ ly primary care, emergency room, surgery, and psychiatric patients; DWI offenders; offenders in court, jail, and prison; enlisted men in the armed forces; workers receiving help from employee assistance programs and in industrial settings.

225 Norms: Yes, heavy drinkers and people with Administrator training and qualifications: No alcohol use disorders training required.

Format: A 10-item screening questionnaire Fee for use: No with 3 questions on the amount and frequen- cy of drinking, 3 questions on alcohol depen- Available from: Can be downloaded from dence, and 4 on problems caused by alcohol. Project Cork Web site: http://www.projectcork.org Administration time: Two minutes Scoring time: One minute CAGE Questionnaire Computer scoring? No Purpose: Used to detect alcoholism.

Administrator training and qualifications: Clinical utility: The CAGE Questionnaire is a The AUDIT is administered by a health profes- very useful bedside, clinical desk instrument sional or paraprofessional. Training is required and has become the favorite of many family for administration. A detailed user’s manual practice and general internists and among and a videotape training module explain prop- nurses. er administration, procedures, scoring, inter- Groups with whom this instrument has been pretation, and clinical management. used: Adults and adolescents (over 16 years Fee for use: No old)

Available from: Department of Mental Health Norms: Yes and Substance Dependence, World Health Format: Very brief, relatively nonconfronta- Organization, CH-1211 Geneva 27, tional questionnaire for detection of alco- Switzerland; request document holism, usually directed “have you ever” but WHO/MSD/MSB/01.6a. may be focused to delineate past or present use. Brief Michigan Alcoholism Screening Test (BMAST) Administration time: Less than 1 minute Purpose: Used to screen for alcoholism with a Scoring time: Instantaneous variety of populations. Computer scoring? No Clinical utility: The BMAST can save clini- cians time when integrated with instruments Administrator training and qualifications: No used to screen for other behavioral health training required for administration; it is problems (Pokorny et al. 1972). easy to learn, easy to remember, and easy to replicate. Groups with whom this instrument has been used: Adults Fee for use: No

Norms: N/A Available from: Can be downloaded from Project Cork Web site: Format: Ten-item questionnaire; interview or http://www.projectcork.org paper-and-pencil

Administration time: Five minutes

Scoring time: Two to 3 minutes

Computer scoring? No

226 Appendix C Clinical Institute Withdrawal Norms: N/A Assessment (CIWA-Ar) Format: Consists of 25 questions Purpose: Converts DSM-III-R items into Administration time: Ten minutes scores to track severity of withdrawal; mea- sures severity of alcohol withdrawal. Scoring time: Five minutes

Clinical utility: Aid to adjustment of care Computer scoring? No related to withdrawal severity. Administrator training and qualifications: No Groups with whom this instrument has been training required. used: Adults Fee for use: Fee for a copy, no fee for use Norms: N/A Available from: Can be downloaded from Format: A 10-item scale for clinical quantifi- Project Cork Web site: cation of the severity of the alcohol withdraw- http://www.projectcork.org al syndrome. Administration time: Two minutes TWEAK Scoring time: Four to 5 minutes Purpose: Screens for heavy drinking and alcohol dependence in the past year in male Computer scoring? No and female samples of the general household population and hospital clinic outpatients Administrator training and qualifications: (Chan et al. 1993). Training is required; the CIWA-Ar can be administered by nurses, doctors, research Clinical utility: The TWEAK provides a associates, and detoxification unit workers. quick and easy method of targeting outpa- tients and inpatients in need of more thor- Fee for use: No ough assessments of their alcohol use patterns Available from: Center for Substance Abuse and problems to determine whether treatment Treatment. A Guide to Substance Abuse is needed. The TWEAK has also been used to Services for Primary Care Clinicians. screen for periconceptional risk drinking Treatment Improvement Protocol (TIP) among obstetric outpatients (Russell et al. Series 24. HHS Publication No. (SMA) 97- 1994), which may improve pregnancy out- 3139. Rockville, MD: Substance Abuse and come among high-risk drinkers. Mental Health Services Administration, 1997. Groups with whom this instrument has been used: Adults

Michigan Alcoholism Norms: Yes Screening Test (MAST) Format: Five items; pencil and paper self- Purpose: Used to screen for alcoholism with a administered, administered by interview, or variety of populations. computer self-administered. Clinical utility: A 25-item questionnaire Administration time: Less than 2 minutes designed to provide a rapid and effective screen for lifetime alcohol-related problems Scoring time: Approximately 1 minute and alcoholism. Computer scoring? No Groups with whom this instrument has been used: Adults

Screening and Assessment Instruments 227 Administrator training and qualifications: No Administrator training and qualifications: A training required. self-training packet is available as well as onsite training by experienced trainers. Fee for use: No Fee for use: No cost; minimal charges for Available from: Can be downloaded from photocopying and mailing may apply Project Cork Web site: http://www.projectcork.org Available from: A. Thomas McLellan, Ph.D. Building 7 Section II: Screening PVAMC University Avenue and Assessment for Philadelphia, PA 19104 Alcohol and Other Phone: (800) 238-2433 Drug Abuse This section of the appendix lists common Cocaine Selective Severity screening and assessment instruments used in Assessment (CSSA) cases where abuse of or dependence upon sub- Purpose: Measures early cocaine abstinence stances (including alcohol) is in question. signs and symptoms. Addiction Severity Index (ASI) Clinical utility: The CSSA is able to predict a patient’s response to treatment and could be Purpose: The ASI is most useful as a general used to identify patients at greater risk for intake screening tool. It effectively assesses a treatment failure so that these patients could client’s status in several areas, and the com- be targeted for additional interventions. This posite score measures how a client’s need for instrument could also be used to evaluate the treatment changes over time. effectiveness of medications intended to treat Clinical utility: The ASI has been used exten- cocaine abstinence symptoms. sively for treatment planning and outcome Groups with whom this instrument has been evaluation. Outcome evaluation packages for used: Adults individual programs or for treatment systems are available. Norms: N/A

Groups with whom this instrument has been Format: Eighteen items used: Designed for adults of both sexes who are not intoxicated (on illicit drugs or alcohol) Administration time: Less than 10 minutes when interviewed. It is also available in Spanish. Scoring time: N/A

Norms: The ASI has been used with males Computer scoring? No and females with substance use disorders in Administrator training and qualifications: both inpatient and outpatient settings. Requires little training; clinician-adminis- Format: Structured interview tered

Administration time: Fifty minutes to 1 hour Available from: Kampman, K.M., Volpicelli, J.R., McGinnis, D.E., Alterman, A.I., Scoring time: Five minutes for severity rating Weinrieb, R.M., D’Angelo, L., and Epperson, L.E. Reliability and validity of the Computer scoring? Yes

228 Appendix C Cocaine Selective Severity Assessment. Format: A psychiatric interview form in Addictive Behaviors 23(4):449–461, 1998. which diagnosis can be made by the examiner asking a series of approximately 10 questions of a client. Objective Opiate Withdrawal Scale (OOWS) Administration time: Administration of Axis I and Axis II batteries may require more than 2 Purpose: Used to record symptoms of opiate hours each for patients with multiple diag­ withdrawal. noses. The Psychoactive Substance Use Clinical utility: Allows staff to share informa­ Disorders module may be administered by tion about a client’s withdrawal, especially itself in 30 to 60 minutes. objective signs observed by staff. Scoring time: Approximately 10 minutes

Groups with whom this instrument has been Computer scoring? No. Diagnosis can be used: Adults made by the examiner after the interview.

Norms: N/A Administrator training and qualifications: Format: Thirteen manifestations of with­ Designed for use by a trained clinical evalua­ drawal; observer scores tor at the master’s or doctoral level, although in research settings it has been used by bach­ Computer scoring? No elor’s level technicians with extensive train­ ing. Administrator training and qualifications: Staff must be familiar with withdrawal signs Fee for use: Yes (e.g., registered nurse, physician) or trained. Available from: Available from: Handelsman, L., Cochrane, American Psychiatric Publishing, Inc. K.J., Aronson, M.J., Ness, R., Rubinstein, 1400 K Street, N.W. K.J., and Kanof, P.D. Two new rating scales Washington, DC 20005 for opiate withdrawal. American Journal of Alcohol Abuse. 13:293–308, 1987. Stages of Change Readiness and Treatment Eagerness Structured Clinical Interview Scale (SOCRATES) for DSM­IV Disorders (SCID) Purpose: Designed to assess client motivation Purpose: Obtains Axis I and II diagnoses to change drinking­ or drug­related behavior. using the DSM­IV diagnostic criteria for Consists of five scales: precontemplation, con­ enabling the interviewer to either rule out or templation, determination, action, and main­ to establish a diagnosis of “drug abuse” or tenance. Separate versions are available for “drug dependence” and/or “alcohol abuse” or alcohol and illicit drug use. “alcohol dependence.” Clinical utility: The SOCRATES can assist Clinical utility: A psychiatric interview clinicians with necessary information about client motivation for change, an important Groups with whom this instrument has been predictor of treatment compliance and out­ used: Psychiatric, medical, or community­ come, and aid in treatment planning. based normal adults. Groups with whom this instrument has been Norms: No used: Adults

Screening and Assessment Instruments 229 Norms: N/A Clinical utility: Assessment of stages of change/readiness construct can be used as a Format: Forty items; paper­and­pencil predictor, and for treatment matching and Administration time: Five minutes determining outcome variables.

Computer scoring? No Groups with whom this instrument has been used: Both inpatient and outpatient adults Administrator training and qualifications: No training required. Norms: Yes, for an outpatient alcoholism treatment population Fee for use: No Format: The URICA is a 32­item inventory Available from: Center for Substance Abuse designed to assess an individual’s stage of Treatment. Enhancing Motivation for Change change located along a theorized continuum in Substance Abuse Treatment. Treatment of change. Improvement Protocol (TIP) Series 35. HHS Publication No. (SMA) 99­3354. Rockville, Administration time: Five to 10 minutes to MD: Substance Abuse and Mental Health complete Services Administration, 1999. Scoring time: Four to 5 minutes

Computer scoring? Yes, using computer Subjective Opiate Withdrawal scannable forms Scale (SOWS) Administrator training and qualifications: Purpose: Used to record client’s impressions N/A or complaints of opiate withdrawal symptoms. Fee for use: No—the instrument is in the Groups with whom this instrument has been public domain used: Adults Available from: Center for Substance Abuse Norms: N/A Treatment. Enhancing Motivation for Change Format: Sixteen­item questionnaire; interview in Substance Abuse Treatment. Treatment or paper­and­pencil Improvement Protocol (TIP) Series 35. HHS Publication No. (SMA) 99­3354. Rockville, Computer scoring? No MD: Substance Abuse and Mental Health Services Administration, 1999. Available from: Handelsman, L., Cochrane, K.J., Aronson, M.J., Ness, R., Rubinstein, K.J., and Kanof, P.D. Two new rating scales for opiate withdrawal. American Journal of Alcohol Abuse. 13:293–308, 1987.

University of Rhode Island Change Assessment (URICA) Purpose: The URICA operationally defines four theoretical stages of change (precontem­ plation, contemplation, action, and mainte­ nance), each assessed by eight items.

230 Appendix C Appendix D: Resource Panel

Note: The information given indicates each participant's affiliation dur- ing the time the panel was convened and may no longer reflect the indi- vidual's current affiliation.

Brad Austin Public Health Advisor Division of State and Community Assistance PPG Program Branch Center for Substance Abuse Treatment Rockville, Maryland

Christina Currier Public Health Analyst Practice Improvement Branch Division of Services Improvement Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Rockville, Maryland

Herman Diesenhaus Public Health Analyst Scientific Analysis Branch Office of Evaluation, Scientific Analysis and Synthesis Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Rockville, Maryland

Hendree E. Jones, M.A., Ph.D. Assistant Professor CAP Research Director Department of Psychiatry and Behavioral Sciences Johns Hopkins University Center Baltimore, Maryland

231 Robert Lubran, M.S., M.P.A. Dennis Scurry, M.D. Director Chief Medical Officer Division of Pharmacologic Therapies Addiction of Prevention and Recovery Center for Substance Abuse Treatment Administration Substance Abuse and Mental Health Government of the District of Columbia Services Administration Department of Health Rockville, Maryland Washington, DC

James J. Manlandro, D.O., FAOAAM, Alan Trachtenberg, M.D., M.P.H. FACOFP Medical Officer Medical Director Division of Pharmacologic Therapies Family Addiction Treatment Services, Inc. Center for Substance Abuse Treatment Somers Point, New Jersey Substance Abuse and Mental Health Services Administration Carol Rest­Mincberg Rockville, Maryland State Project Officer Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Rockville, Maryland

232 Appendix D Appendix E: Field Reviewers

Note: The information given indicates each participant's affiliation dur- ing the time the review was conducted and may no longer reflect the indi- vidual's current affiliation.

Karen C.O. Batia, M.A., Ph.D. Senior Director Mental Health and Addiction Services Heartland Health Outreach Chicago, Illinois

Thomas P. Beresford, M.D. Professor Department of Psychiatry University of Colorado School of Medicine Denver, Colorado

Barry Blood, LCPC Addiction Counselor Family Service Foundation Columbia, Maryland

Patricia T. Bowman Probation Counselor Fairfax Alcohol Safety Action Program Fairfax, Virginia

Barry S. Brown, M.S., Ph.D. Adjunct Professor University of North Carolina at Wilmington Carolina Beach, North Carolina

233 David A. Chiriboga, Ph.D. Robert Holden, M.A. Professor Program Director Department of Aging and Mental Health Partners in Drug Abuse Rehabilitation Florida Mental Health Institute Counseling University of South Florida Washington, DC Tampa, Florida Kyle M. Kampman, M.D. Carol J. Colleran, CAP, ICADC Associate Professor of Psychiatry Director of Primary Programs Medical Director Center of Recovery for Older Adults Treatment Research Center Hanley­Hazelden Center University of Pennsylvania West Palm Beach, Florida Philadelphia, Pennsylvania

Joy Davidoff Michael Warren Kirby, Jr., M.A., Ph.D. Coordinator of Addiction Medicine Chief Executive Officer New York State Office of Alcoholism and Arapahoe House, Inc. Substance Abuse Services Thornton, Colorado Albany, New York James J. Manlandro, D.O., FAOAAM, John P. de Miranda, Ed.M. FACOFP Executive Director Medical Director National Association on Alcohol, Drugs Family Addiction Treatment Services, Inc. and Disability, Inc. Somers Point, New Jersey San Mateo, California Ethan Nebelkopf, Ph.D., MFCC B.J. Dean Director Executive Director Family and Child Guidance Clinic Island Grove Regional Treatment Center, Native American Health Center Inc. Oakland, California Greeley, Colorado Robert E. Olson, M.S. Ralph W. Edwards, M.P.H., M.P.A. Project Director Director California Alcohol, Drug and Disability Office of Citizen Leadership Technical Assistance Project Massachusetts Department of Mental National Association on Alcohol, Drugs Health and Retardation and Disability, Inc. Boston, Massachusetts Belmont, California

Michael I. Fingerhood, M.D. Christopher Pond Associate Professor of Medicine Director of Adult Services Johns Hopkins Bayview Medical Center Arapahoe House, Inc. Baltimore, Maryland Thornton, Colorado

Michael M. Galer, D.B.A. Anthony B. Radcliffe, M.D. Chair Chief of Addiction Medicine Graduate School of Business Fontana SCPMG University of Phoenix Greater Boston Kaiser Permanente/CDRP Campus Fontana, California Braintree, Massachusetts

234 Appendix E Jay Renaud Leslie R. Steve, M.A. Member/Editor Native American Coordinator J & M Reports Center for the Application of Substance Guidepoints: Acupuncture in Recovery Abuse Technologies Vancouver, Washington University of Nevada Reno, Nevada Joseph P. Reoux, M.D. Assistant Professor Richard T. Suchinsky, M.D. Department of Psychiatry and Behavioral Associate Chief for Addictive Disorders and Sciences Psychiatric Rehabilitation VA Puget Sound Health Care System Mental Health and Behavioral Sciences University of Washington School of Services Medicine Department of Veterans Affairs Seattle, Washington Washington, DC

Timothy M. Scanlan, M.D. Nancy R. VanDeMark, M.S.W. Medical Director Director Addiction Specialists of Kansas Research and Program Evaluation Wichita, Kansas Arapahoe House, Inc. Thornton, Colorado Lawrence Schonfeld, Ph.D. Professor Melvin H. Wilson, M.B.A., LCSW­C Louis de la Parte Florida Mental Health Baltimore HIDTA Coordinator Institute Maryland Department of Parole and Department of Aging and Mental Health Probation University of South Florida Clinton, Maryland Tampa, Florida Ann S. Yabusaki, M.Ed., M.A., Ph.D. Steven Shevlin Substance Abuse Director Executive Director Psychologist Signs of Sobriety, Inc. Substance Abuse Programs and Training Ewing, New Jersey Coalition for a Drug­Free Hawaii Kaneohe, Hawaii Carla Shird, M.A., CSC­AD Counselor Mental Health Center Gallaudet University Kellogg Conference Center Washington, DC

Mickey J.W. Smith, M.S.W. Senior Policy Associate, Behavioral Health Program, Policy & Practice Unit Division of Professional Development & Advocacy National Association of Social Workers Washington, DC

Field Reviewers 235 Index

Because the entire volume is about detoxifica­ B tion and substance abuse treatment, the use barbiturates, 61–62 of these terms as entry points has been mini­ barriers to treatment mized in this index. Commonly known access, 43–44 acronyms are listed as main headings. Page administrative, 39 references for information contained in fig­ benzodiazepine ures appear in italics contraindications, 61 limitations in outpatient treatment, 60–61 and phenobarbital withdrawal equivalents, 77 A and pregnant women, 106, 108 acupuncture, 103–104, 113 symptom­triggered therapy, 58–59 acute care inpatient settings, 19–20 tapering dosages, 59 adolescents, 30–31, 118 and treatment of alcohol withdrawal, 58–61 and club drugs, 97 benzodiazepine withdrawal Adult Detoxification levels of care, 13 management with medication, 75–76 adults, older, 109–110 medical complications of, 75 African Americans, 113–115 signs and symptoms, 74–75 aggressive behavior, 27 biochemical markers, 48 strategies for de­escalating, 28 biomedical evaluation domains, 25 alcohol withdrawal bipolar disorders, 142–143 and benzodiazepine treatment, 58–61 blood alcohol content, 48–49 contraindications to using benzodiazepines breath alcohol levels, 50 during, 61 buprenorphine management with medication, 57–58 and opioid withdrawal, 71–72 management without medication, 55 and pregnant women, 107 medical complications, 54 bupropion, 92 and seizures, 64–65 Byrne Formula Grant Program, 154 signs and symptoms, 52–54 alternative treatment, 34, 103–104 C and disabilities, 113 carve­outs, 157 American Indians, 116–117 case management, 44 American Medical Association, position on case studies, 48, 102 alcoholism, 3 CDT levels, 51 Americans With Disabilities Act, 110 central nervous system depression, 66 amphetamines. See stimulants children’s protective services, 154 anabolic steroid withdrawal, 96 Civilian Health and Medical Program of the management, 97 Veterans Administration, 152–153 medical complications of, 96–97 client advocates, 33 patient care and comfort, 97 clinically managed residential detoxification, 17 signs and symptoms, 96 Clinical Practice Guidelines for Detoxification of anticonvulsants, 62 Chemically Dependent Inmates, 119 antipsychotics, 62 clonidine anxiety disorders, 139–141 detoxification, 72 antianxiety agents, 143 and opioid withdrawal, 70–71 Asians and Pacific Islanders, 115–116 and pregnant women, 107 assessment and rapid detoxification, 73 and determining rehabilitation plans, 40 club drugs, 97 of psychosocial needs, 39 ecstasy, 99–100 of severity of nicotine dependence, 86–87 GHB, 98–99 audience for this TIP, 2 hallucinogens, 98

Index 237 ketamine and PCP, 100–101 substance­related disorder, 5 and pregnant women, 109 substance withdrawal, 5 cocaine. See stimulants treatment/rehabilitation, 5–6 Commission on Accreditation of Rehabilitation delirium, 63–66 Facilities, 17, 27 delirium tremens, 63 Community Reinforcement and Family Training depressive disorders, 27, 141–142 (intervention), 34 antidepressants, 144 complementary medicine. See alternative detoxification treatment building a program, 145–146 confidentiality, 28, 165 clinically managed residential, 17 confrontation, 35 definition of, 4 Contracting for Managed Substance Abuse and as distinct from substance abuse treatment, 4 Mental Health Services: A Guide for history of services, 2–3 Public Purchasers, 161 inpatient versus outpatient programs, 20, 21 contracts, managed care, 158–159 linkage with substance abuse treatment, 8 co­occurring medical conditions, 24–26, 26, medical model of, 3 110–113 outpatient, 13 acute trauma, 135 principles for care during, 24 cancer, 134–135 rapid, ultrarapid, 73 cardiovascular disorders, 125–127 service setting changes, 146 diabetes, 135 social model of, 3, 55 gastrointestinal disorders, 122–125 strengthening market position of program, general principles of care, 122 167–168 hematologic disorders, 127–128 disabilities, 110–113, 112 infectious disease, 132–134 definitions, 111 neurologic system effects, 129–132 locating expert assistance, 114 pulmonary disorders, 128–129 domestic violence, 31 co­occurring psychiatric conditions, 27–28, Drug Addiction Treatment Act of 2000, 72 136–137 drug­free environment, maintaining, 34 anxiety disorders, 139–141 bipolar disorders, 142–143 E depressive disorders, 141–142 ecstasy, 99–100 and pharmacologic agents, 137–138 enhancing motivation, 34 psychotic disorders, 143 ERs, and urgent care facilities, 15 and psychotropic medications, 138–139 evaluation substance induced, 139 definition of, 4 cost methodologies, 159–161 initial, 24 criminal justice systems, 118–119, 154 cultural competence, 32–33, 44 F questions to guide practitioners, 32 Fetal Alcohol Syndrome, 108, 117 D fostering entry to treatment, definition of, 5 freestanding substance abuse treatment decisional balancing strategies, 37 facility, 16–17 definitions, 6 funding issues, 147–148, 155, 162–163 detoxification, 4 grant funding, 156, 157 disabilities, 111 multiple funding streams, 166 evaluation, 4 fostering entry to treatment, 5 G maintenance, 6 regarding disabilities, 111 gays and lesbians, 117–118 social detoxification, 17 GGT levels, 51 stabilization, 4 GHB, 98–99 substance, 5 grant funding, 156, 157 substance intoxication, 5 guiding principles, 7

238 Index H linkages hallucinogens, 98 to followup medical care, 45 hepatitis, and GGT levels, 51 to ongoing psychiatric services, 44 Hispanics/Latinos, 117 to treatment and maintenance activities, 42 history of detoxification services, 2–3 HIV/AIDS, 134 M detoxification as a means to inhibit spread malnutrition, 28 of, 3 managed care homeless patients, 43 accreditation, 161–162 contracts, 158–159 I financial risk in, 159–161 incarcerated persons, 118–119 performance measurement, 164–165 Indian Health Service, 152 recordkeeping, 165–166 infectious disease, 26–27, 132–134 marijuana, 95 inhalant/solvent withdrawal and pregnant women, 109 management with medication, 83 market position, strengthening, 167–168 management without medication, 82 MCV levels, 51 medical complications of, 82 Medicaid, 149–150 patient care and comfort, 83–84 medically monitored inpatient detoxification, 17 signs and symptoms, 82 medical model of detoxification, 3 inhalants/solvents, commonly abused, 83–84 Medicare, 151 inpatient detoxification programs, versus methadone outpatient programs, 20, 21 detoxification, 72 instruments, for dependence and withdrawal, 49 and opioid withdrawal, 69–70 intensive outpatient programs, 18–19 and pregnant women, 106 interventions motivational enhancements, 34 Community Reinforcement and Family Training, 34 N Johnson Intervention, 35 nicotine, 84–85 intoxication, signs and symptoms, 52, 53 assessing severity of dependence, 86–87 Fagerstrom Test for Nicotine Dependence, 87 J Glover­Nilsson Smoking Behavioral Johnson Intervention, 35 Questionnaire, 88 Joint Commission on Accreditation of and pregnant women, 108–109 Healthcare Organizations, 17, 27 Treating Tobacco Use and Dependence: Clinical Practice Guidelines, 90, 93 K nicotine replacement therapy, 91–92 combining, 93–94 ketamine, 100–101 and pregnant women, 109 kindling effect, 54, 56 nicotine withdrawal, 86 effects of abstinence on blood levels of L psychiatric medications, 90 least restrictive care, 12 interventions, 90–91, 91 levels of care, 39 management with medication, 91–94 acute care inpatient settings, 20 management without medication, 89–90 Adult Detoxification, 13 medical complications of, 87–89 ambulatory detoxification, 14 patient care and comfort, 94 clinically managed residential signs and symptoms, 85–86, 89 detoxification, 17 nutrition intensive outpatient programs, 18–19 deficits, 29–30 medically monitored inpatient evaluation, 28–29 detoxification, 17 urgent care facilities and ERs, 16

Index 239 O public housing, 153 office­based detoxification. See detoxification, public intoxication, prior to 1970s, 2–3 outpatient older adults, 109–110 R opioid withdrawal rapid detoxification, 73 and buprenorphine, 71–72 recordkeeping, 165–166 and clonidine, 70–71 referral sources, 146 management with medication, 68–69 Rehabilitation Act of 1973, 110 management without medication, 68 reimbursement systems, 8 and methadone, 69–70 relapse signs and symptoms, 66–68, 67 chronic, 33 outpatient programs, versus inpatient prevention, 62–63 programs, 20, 21 research funding, 156 rohypnol, 101 P Ryan White CARE Act, 154 parents, 31 partial hospitalization programs. See intensive S outpatient programs scope of this TIP, 2 patient care and comfort, 66, 73–74 sedative­hypnotics, and phenobarbital anabolic steroid withdrawal, 97 withdrawal equivalents, 78 inhalant/solvent withdrawal, 83–84 seizures, 63–66 nicotine withdrawal, 94 alcohol withdrawal, 64–65, 130 stimulant withdrawal, 81 what to do in the event of, 65 patient education, 33 self­pay patients, 156 Patient Placement Criteria, ASAM, 12–13, 39 service costs, resources on, 160 performance measurement, 164–165 service delivery, pitfalls of, 8 pharmacotherapy social detoxification, 3, 17, 55–57 and anxiety disorders, 140–141 Social Security Disability Insurance, 151 and bipolar disorders, 142–143 social services, 153–154 and depressive disorders, 141–142 Social Services Block Grant, 153 nonnicotine, 92–93 solvents, and pregnant women, 108 phenobarbital withdrawal stabilization, definition of, 4 and benzodiazepine, 77 staffing issues and sedative­hypnotics, 78 acute care inpatient settings, 20 physicians, and preparing patients to enter inpatient detoxification programs, 18 detoxification, 13 intensive outpatient programs, 19 placement matching, challenges to, 11–12 in outpatient detoxification, 14 polydrug abuse, 101–102 stages of change, 35–37, 36 prioritizing substances of abuse, 102–103 State Children’s Health Insurance Program, 152 pregnant women, 43, 105–106 steroids, anabolic, 96 and alcohol, 106 stimulants, 76 and marijuana, 109 and pregnant women, 108 and nicotine, 108–109 stimulant withdrawal and opioids, 106–108 management with medication, 81 and solvents, 108 management without medication, 80 and stimulants, 108 medical complications of, 80, 81 principles for care during detoxification, 24 patient care and comfort, 81 Provider’s Introduction to Substance Abuse symptoms, 79–80 Treatment for Lesbian, Gay, Bisexual, substance and Transgender Individuals, A, 118 changing patterns of use, 3 psychiatric services, linkages to, 44 definition of, 5 psychosocial evaluation domains, 25 dependence, chronic, 45 psychotic disorders, 143 ­induced psychiatric conditions, 139

240 Index intoxication, definition of, 5 Substance Abuse Among Older Adults (TIP 26), ­related disorder, definition of, 5 110 withdrawal, definition of, 5 Substance Abuse: Clinical Issues in Intensive substance abuse epidemiology, 146–147 Outpatient Treatment (in development), 19 Substance Abuse Prevention and Treatment Substance Abuse Treatment: Addressing the Block Grant, 149 Specific Needs of Women (in development), substance abuse treatment 39, 106, 108, 109 as distinct from detoxification, 4 Substance Abuse Treatment and Domestic funding issues, 147–148, 155, 156, 157, Violence (TIP 25), 32 162–163 Substance Abuse Treatment for Adults in the linkage with detoxification, 8 Criminal Justice System (TIP 44), 119, 154 suicide, 27 Substance Abuse Treatment for Persons With Supplemental Security Income, 151 Child Abuse and Neglect Issues (TIP 36), 44 support systems, 33–34 Substance Abuse Treatment for Persons With symptom­triggered benzodiazepine therapy, Co­Occurring Disorders (TIP 42), 27, 45, 93, 58–59 112, 121, 137 Substance Abuse Treatment for Persons With T HIV/AIDS (TIP 37), 134 tapering dosages, benzodiazepine, 59 Substance Abuse Treatment: Men’s Issues (in Temporary Assistance to Needy Families, 153 development), 39 THC abstinence syndrome, 95 Substance Use Disorder Treatment for People therapeutic alliance, 37–38 With Physical and Cognitive Disabilities (TIP and clinician characteristics, 38 29), 44, 110 TIPs cited Treatment of Adolescents With Substance Use Clinical Guidelines for the Use of Disorders (TIP 32), 31, 118 Buprenorphine in the Treatment of Opioid Tuberculosis Epidemic: Legal and Ethical Issues Addiction (TIP 40), 71 for Alcohol and Other Drug Abuse Combining Alcohol and Other Drug Abuse Treatment Providers, The (TIP 18), 133 Treatment With Diversion for Juveniles in transtheoretical model. See stages of change the Justice System (TIP 21), 119, 154 Treating Tobacco Use and Dependence: Clinical Comprehensive Case Management for Practice Guidelines, 90, 93 Substance Abuse Treatment (TIP 27), 44, 45 treatment Continuity of Offender Treatment for definition of, 5–6 Substance Use Disorders From Institution to initiation of, 42 Community (TIP 30), 119, 154 settings, 41 Detoxification From Alcohol and Other Drugs TRICARE, 152 (TIP 19), 1 Enhancing Motivation for Change in Substance U Abuse Treatment (TIP 35), 34, 35 ultrarapid detoxification, 73 Improving Cultural Competence in Substance Uniform Alcoholism and Intoxication Treatment Abuse Treatment (in development), 7, 44, Act, 3 114, 116, 117 urgent care facilities, and ERs, 15 Medication­Assisted Treatment for Opioid urine drug screens, 50 Addiction in Opioid Treatment Programs utilization and case management, 166–167 (TIP 43), 58, 69, 107 Role and Current Status of Patient Placement V Criteria in the Treatment of Substance Use Disorders, The (TIP 13), 13, 41 violence, 27 Screening and Assessing Adolescents for domestic, 31 Substance Use Disorders (TIP 31), 31, 118 vocational rehabilitation, 153–154 Screening for Infectious Diseases Among Substance Abusers (TIP 6), 132

Index 241 W National Institute on Drug Abuse, 156 Washington Circle Group, 4, 164 Patient Placement Criteria, ASAM, 166 Web sites public housing, 153 American Cancer Society, 94 Research Assistant, The, 156 American Lung Association, 94 Ryan White CARE Act, 154 Byrne Formula Grant Program, 154 SAMHSA funding opportunities, 149 children’s protective services, 154 Social Security Disability Insurance, 151 Civilian Health and Medical Program of the State Children’s Health Insurance Program,152 Veterans Administration, 152–153 Temporary Assistance to Needy Families, 153 Commission on Accreditation of TRICARE, 152 Rehabilitation Facilities, 17, 20, 21, 27, 162 vocational rehabilitation, 154 grant funding sources, 157 Washington Circle Group, 164 Health Insurance Portability and withdrawal, 24–26, 33. See also alcohol with­ Accountability Act, 165 drawal; anabolic steroid withdrawal; benzodi­ Indian Health Service, 152 azepine withdrawal; inhalant/solvent withdraw­ Joint Commission on Accreditation of al; nicotine withdrawal; opioid withdrawal; Healthcare Organizations, 17, 20, 21, 27, 162 stimulant withdrawal legal aspects of prescribing buprenorphine, 72 women, pregnant, 43, 105–106 Medicaid, 150 wraparound services, 43 Medicare, 151 model programs, 167 Z National Committee for Quality Assurance, Zyban, 92 162 National Institute on Alcohol Abuse and Alcoholism, 156

242 Index SAMHSA TIPs and Publications Based on TIPs

What Is a TIP? Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP) to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system. What Is a Quick Guide? A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so providers can refer back to the source document for more information. What Are KAP Keys? Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to locate information easily and to use this information to enhance treatment services. Ordering Information Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by TIP 13 Role and Current Status of Patient Placement TIP 43 Criteria in the Treatment of Substance Use Disorders TIP 2 Pregnant, Substance-Using Women —Replaced by Quick Guide for Clinicians TIP 51 Quick Guide for Administrators TIP 3 Screening and Assessment of Alcohol- and Other KAP Keys for Clinicians Drug-Abusing Adolescents—Replaced by TIP 31 TIP 14 Developing State Outcomes Monitoring Systems for TIP 4 Guidelines for the Treatment of Alcohol- and Other Alcohol and Other Drug Abuse Treatment Drug-Abusing Adolescents—Replaced by TIP 32 TIP 15 Treatment for HIV-Infected Alcohol and Other Drug TIP 5 Improving Treatment for Drug-Exposed Infants Abusers—Replaced by TIP 37

TIP 6 Screening for Infectious Diseases Among Substance TIP 16 Alcohol and Other Drug Screening of Hospitalized Abusers—Archived Trauma Patients Quick Guide for Clinicians TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice KAP Keys for Clinicians System—Replaced by TIP 44 TIP 17 Planning for Alcohol and Other Drug Abuse TIP 8 Intensive Outpatient Treatment for Alcohol and Treatment for Adults in the Criminal Justice System Other Drug Abuse—Replaced by TIPs 46 and 47 —Replaced by TIP 44 TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues TIP 9 Assessment and Treatment of Patients With for Alcohol and Other Drug Abuse Treatment Coexisting Mental Illness and Alcohol and Other Providers—Archived Drug Abuse—Replaced by TIP 42 TIP 19 Detoxification From Alcohol and Other Drugs— TIP 10 Assessment and Treatment of Cocaine- Abusing Replaced by TIP 45 Methadone-Maintained Patients—Replaced by TIP 43 TIP 20 Matching Treatment to Patient Needs in Opioid TIP 11 Simple Screening Instruments for Outreach for Substitution Therapy—Replaced by TIP 43 Alcohol and Other Drug Abuse and Infectious Diseases—Replaced by TIP 53 TIP 21 Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the TIP 12 Combining Substance Abuse Treatment With Justice System Intermediate Sanctions for Adults in the Criminal Quick Guide for Clinicians and Administrators Justice System—Replaced by TIP 44

243 TIP 22 LAAM in the Treatment of Opiate Addiction— TIP 31 Screening and Assessing Adolescents for Substance Replaced by TIP 43 Use Disorders See companion products for TIP 32. TIP 23 Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing TIP 32 Treatment of Adolescents With Substance Use Quick Guide for Administrators Disorders Quick Guide for Clinicians TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians KAP Keys for Clinicians

Concise Desk Reference Guide TIP 33 Treatment for Stimulant Use Disorders Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians KAP Keys for Clinicians

TIP 25 Substance Abuse Treatment and Domestic Violence TIP 34 Brief Interventions and Brief Therapies for Substance Linking Substance Abuse Treatment and Domestic Abuse Violence Services: A Guide for Treatment Providers Quick Guide for Clinicians Linking Substance Abuse Treatment and Domestic KAP Keys for Clinicians Violence Services: A Guide for Administrators Quick Guide for Clinicians TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment KAP Keys for Clinicians Quick Guide for Clinicians TIP 26 Substance Abuse Among Older Adults KAP Keys for Clinicians Substance Abuse Among Older Adults: A Guide for Treatment Providers TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues Substance Abuse Among Older Adults: A Guide for Social Service Providers Quick Guide for Clinicians Substance Abuse Among Older Adults: Physician’s KAP Keys for Clinicians Guide Helping Yourself Heal: A Recovering Woman’s Guide to Quick Guide for Clinicians Coping With Childhood Abuse Issues KAP Keys for Clinicians Also available in Spanish Helping Yourself Heal: A Recovering Man’s Guide to TIP 27 Comprehensive Case Management for Substance Coping With the Effects of Childhood Abuse Abuse Treatment Also available in Spanish Case Management for Substance Abuse Treatment: A Guide for Treatment Providers TIP 37 Substance Abuse Treatment for Persons With Case Management for Substance Abuse Treatment: A HIV/AIDS Guide for Administrators Quick Guide for Clinicians

Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators Drugs, Alcohol, and HIV/AIDS: A Consumer Guide

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by Also available in Spanish TIP 49 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for African Americans TIP 29 Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities TIP 38 Integrating Substance Abuse Treatment and Vocational Services Quick Guide for Clinicians

Quick Guide for Administrators Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators KAP Keys for Clinicians TIP 30 Continuity of Offender Treatment for Substance Use Disorders From Institution to Community TIP 39 Substance Abuse Treatment and Family Therapy Quick Guide for Clinicians Quick Guide for Clinicians KAP Keys for Clinicians Quick Guide for Administrators Family Therapy Can Help: For People in Recovery From Mental Illness or Addiction

244 TIP 40 Clinical Guidelines for the Use of Buprenorphine in TIP 50 Addressing Suicidal Thoughts and Behaviors in the Treatment of Opioid Addiction Substance Abuse Treatment Quick Guide for Physicians Quick Guide for Clinicians KAP Keys for Physicians Quick Guide for Administrators

TIP 41 Substance Abuse Treatment: Group Therapy TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women Quick Guide for Clinicians KAP Keys for Clinicians TIP 42 Substance Abuse Treatment for Persons With Co- Quick Guide for Clinicians Occurring Disorders Quick Guide for Administrators Quick Guide for Clinicians Quick Guide for Administrators TIP 52 Clinical Supervision and Professional Development of the Substance Abuse Counselor KAP Keys for Clinicians Quick Guide for Clinical Supervisors TIP 43 Medication-Assisted Treatment for Opioid Addiction Quick Guide for Administrators in Opioid Treatment Programs Quick Guide for Clinicians TIP 53 Addressing Viral Hepatitis in People With Substance Use Disorders KAP Keys for Clinicians Quick Guide for Clinicians and Administrators TIP 44 Substance Abuse Treatment for Adults in the KAP Keys for Clinicians Criminal Justice System Quick Guide for Clinicians TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders KAP Keys for Clinicians Quick Guide for Clinicians TIP 45 Detoxification and Substance Abuse Treatment KAP Keys for Clinicians

Quick Guide for Clinicians You Can Manage Your Chronic Pain To Live a Good Quick Guide for Administrators Life: A Guide for People in Recovery From Mental KAP Keys for Clinicians Illness or Addiction TIP 55 Behavioral Health Services for People Who Are TIP 46 Substance Abuse: Administrative Issues in Homeless Outpatient Treatment Quick Guide for Administrators TIP 56 Addressing the Specific Behavioral Health Needs of Men TIP 47 Substance Abuse: Clinical Issues in Outpatient Quick Guide for Clinicians Treatment KAP Keys for Clinicians

Quick Guide for Clinicians TIP 57 Trauma-Informed Care in Behavioral Health KAP Keys for Clinicians Services Quick Guide for Clinicians TIP 48 Managing Depressive Symptoms in Substance Abuse KAP Keys for Clinicians Clients During Early Recovery TIP 58 Addressing Fetal Alcohol Spectrum Disorders TIP 49 Incorporating Alcohol Pharmacotherapies Into (FASD) Medical Practice TIP 59 Improving Cultural Competence Quick Guide for Counselors Quick Guide for Physicians KAP Keys for Clinicians

245 TIP45-Cover_6-24-15_TIP 45 COVER 6/24/2015 4:12 PM Page 2

Detoxification and Substance Abuse Treatment

This TIP is a revision of TIP 19, Detoxification From Alcohol and Other Drugs, and was created by a panel of experts with diverse experience in detoxification services—physicians, psychologists, counselors, nurses, and social workers. This revision provides up- to-date information about changes in the role of detoxification in the continuum of services for patients with substance use dis- orders, increased knowledge of the physiology of withdrawal, pharmacological advances in the management of withdrawal, patient placement procedures, and new issues in the manage- ment of detoxification services within comprehensive systems of care. It also expands on the administrative, legal, and ethical issues commonly encountered in the delivery of detoxification services and suggests performance measures for detoxification programs.

Collateral Products Based on TIP 45

Quick Guide for Clinicians KAP Keys for Clinicians

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration

HHS Publication No. (SMA) 15-4131 Printed 2006 Revised 2008, 2012, 2013, and 2015