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