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Detoxification and Substance Abuse Treatment

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Detoxification and Substance Abuse Treatment 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 Center for Substance Abuse Treatment www.samhsa.gov DETOXIFICATION Detoxification and Substance Abuse Treatment Norman S. Miller, M.D., FASAM Consensus Panel Chair Steven S. Kipnis, M.D., FACP Consensus Panel Co-Chair A Treatment Improvement Protocol TIP 45 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments Public Domain Notice Numerous people contributed to the develop- All materials appearing in this volume except ment of this TIP (see pp. ix–xii and appendices those taken directly from copyrighted sources D and E). This publication was produced by are in the public domain and may be repro- The CDM Group, Inc. (CDM) under the duced or copied without permission from Knowledge Application Program (KAP) con- SAMHSA/CSAT or the authors. Do not repro- tract numbers 270-99-7072 and 270-04-7049 duce or distribute this publication for a fee with the Substance Abuse and Mental Health without specific, written authorization from Services Administration (SAMHSA), U.S. SAMHSA’s Office of Communications. Department of Health and Human Services (DHHS). Andrea Kopstein, Ph.D., M.P.H., Karl D. White, Ed.D., and Christina Currier Electronic Access and Copies served as the Center for Substance Abuse of Publication Treatment (CSAT) Government Project Copies may be obtained free of charge from Officers. Rose M. Urban, M.S.W., J.D., SAMHSA’s National Clearinghouse for Alcohol LCSW, CCAC, CSAC, served as the KAP and Drug Information (NCADI), (800) 729- Executive Project Co-Director. Elizabeth 6686 or (301) 468-2600; TDD (for hearing Marsh Cupino served as CDM KAP Managing impaired), (800) 487-4889, or electronically Project Co-Director. Sheldon Weinberg, through the following Internet World Wide Ph.D., served as KAP Senior Web site: www.ncadi.samhsa.gov. Researcher/Applied Psychologist. Other KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Recommended Citation Editorial Director; Jonathan Max Gilbert. Center for Substance Abuse Treatment. M.A., Editor/Writer; Deborah Steinbach, Detoxification and Substance Abuse M.A., Editor/Writer; James M. Girsch, Ph.D., Treatment. Treatment Improvement Protocol Editor/Writer; Michelle Myers, Quality (TIP) Series 45. DHHS Publication No. Assurance Editor; and Sonja Easley and (SMA) 06-4131. Rockville, MD: Substance Elizabeth Plevyak, Editorial Assistants. In Abuse and Mental Health Services addition, Sandra Clunies, M.S., ICADC, Administration, 2006. served as Content Advisor. Jonathan Max Gilbert, M.A. served as a writer. Special thanks go to Suzanne Gelber, Ph.D., for her Originating Office contributions to chapter 6, and Joan Practice Improvement Branch, Division of Dilonardo, Ph.D., for her input on the TIP. Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Disclaimer Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. The opinions expressed herein are the views of the consensus panel members and do not neces- DHHS Publication No. (SMA) 06-4131 sarily reflect the official position of CSAT, Printed 2006 SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instru- ments, software, or resources described in this document are intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. 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 Sedative-Hypnotics ...............................................................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—Co-Occurring Medical and Psychiatric Conditions.......................................121 General Principles of Care for Patients With Co-Occurring Medical Conditions .....................122 Treatment of Co-Occurring Psychiatric Conditions..........................................................136 Standard of Care for Co-Occurring 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 CSAT TIPs and Publications....................................................................................243 Figures Figure 1-1 DSM-IV-TR Definitions of Terms .....................................................................6
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