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Detoxification and Substance Abuse Treatment 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 24-hour supervised setting such as a residential detoxification or Populations treatment program. For an illustration of some of the fundamental 47 Case Study A 44-year-old Caucasian male with a fifth-grade 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 (CIWA-Ar) (see below) score = 12, indicating mild withdrawal. A treatment plan was recommended that called for an outpatient 3-day fixed-dose 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 3-1, p. 25. Clinicians also can use the presentation of Figure 4-1 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, zero-order kinetics (decreas- markers are: ing a set amount per unit of time rather than a set percentage), so the concept of half-life is not 1. In the initial screening setting to support really accurate. However, first-order kinetics or refute other information that leads to and half-life do occur when BAC is low (i.e., proper diagnosis, assessment, and manage- below 10mg percent), and the half-life 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 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and Specific Illicit Drugs Drug of Dependence Instrument Reference Notes Alcohol CIWA-Ar 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 16-item 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 alcohol-dependent 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 CIWA-Ar 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 chromatography-mass 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 half-life, 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 cross-reactivity 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
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