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Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 45.)

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Detoxification and Substance Abuse Treatment.

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1 Overview, Essential Concepts, and Definitions in Detoxification

Chapter 1 provides a brief historical overview of changes in the perceptions and provision of detoxification services. It also introduces the core concepts of the detoxification field, discusses the primary goals of detoxification services, clarifies the distinction between detoxification and treatment, and highlights some of the broader issues involved with providing detoxification within systems of care.

Overview

Purpose of the TIP

Audience

Scope

History of Detoxification Services

Definitions

Detoxification

Other Relevant Terms

Guiding Principles in Detoxification and Substance Abuse Treatment

Challenges to Providing Effective Detoxification

Purpose of the TIP

This TIP is a revision of TIP 19, Detoxification From Alcohol and Other Drugs (Center for Substance Abuse Treatment [CSAT] 1995). Significant changes in the area of detoxification services since the publication 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)

This TIP provides clinicians with up-to-date information in these areas. 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. Like its predecessor, this TIP was created by a panel of experts with diverse experience in detoxification services—physicians, psychologists, counselors, nurses, and social workers, all with particular expertise to share.

Audience

The primary audiences for this TIP include substance abuse treatment counselors; administrators of detoxification programs; Single State Agency directors; psychiatrists and other physicians working in the field; primary care providers such as physicians, nurse practitioners, physician assistants, nurses, psychologists, and other clinical staff members; staff of managed care and insurance carriers; policymakers; and others involved in planning, evaluating, and delivering services for detoxifying patients from substances of abuse. Secondary audiences include public safety/police and criminal justice personnel, educational institutions, those involved with assisting workers (e.g., Employee Assistance Programs), shelters/feeding programs, and managed care organizations. The TIP also should prove useful to providers of other services in comprehensive systems of care (vocational counseling, occupational therapy, and public housing/assisted living), administrators, and payors (public, private, and managed care).

Scope

Among other issues covered in this TIP is the importance of detoxification as one component in the continuum of healthcare services for substance-related disorders. The TIP reinforces the urgent need for nontraditional settings—such as emergency rooms, medical and surgical wards in hospitals, acute care clinics, and others that do not traditionally provide detoxification services—to be prepared to participate in the process of getting the patient who is in need of detoxification into a program as quickly as possible to potentially avoid the myriad possible negative consequences associated with substance abuse (e.g., physiological and psychological disturbances/disorders, criminal involvement, unemployment, etc.). Furthermore, it promotes the latest strategies for retaining individuals in detoxification while also encouraging the development of the therapeutic alliance to promote the patient's entrance into substance abuse treatment. This includes suggestions on addressing psychosocial issues that may affect detoxification services.

This TIP provides medical information on detoxification protocols for specific substances, as well as considerations for individuals with co-occurring medical conditions including mental disorders. While the TIP is not intended to take the place of medical texts, it provides the practitioner with an overview of medical considerations.

This TIP will also bring clinicians and administrators up-to-date on important aspects of detoxification, including how the services are to be paid for. It is unusual in a clinical treatment improvement protocol to discuss issues related to how clinical services are reimbursed. However, in the field of substance abuse and detoxification services, reimbursement issues have become so intertwined with the delivery of services that the consensus panel deemed it necessary to address the conflicts and misunderstandings that sometimes arise between the care systems and the reimbursement systems.

History of Detoxification Services

Prior to the 1970s, public intoxication was treated as a criminal offense. People arrested for it were held in the “drunk tanks” of local jails where they underwent withdrawal with little or no medical intervention (Abbott et al. 1995; Sadd and Young 1987). Shifts in the medical field, in perceptions of addiction, and in social policy changed the way that people with dependency on drugs, including alcohol, were viewed and treated. Two notable events were particularly instrumental in changing attitudes. In 1958, the American Medical Association (AMA) took the official position that alcoholism is a disease. This declaration suggested that alcoholism was a medical problem requiring medical intervention. In 1971, the National Conference of Commissioners on Uniform State Laws adopted the Uniform Alcoholism and Intoxication Treatment Act, which recommended that “alcoholics not be subjected to criminal prosecution because of their consumption of alcoholic beverages but rather should be afforded a continuum of treatment in order that they may lead normal lives as productive members of society” (Keller and Rosenberg 1973, p. 2). While this recommendation did not carry the weight of law, it made a major change in the legal implications of addiction. With these changes came more humane treatment of people with addictions.

Several methods of detoxification have evolved that reflect a more humanitarian view of people with substance use disorders. In the “medical model,” detoxification is characterized by the use of physician and nursing staff and the administration of medication to assist people through withdrawal safely (Sadd and Young 1987). The “social model” rejects the use of medication and the need for routine medical care, relying instead on a supportive nonhospital environment to ease the passage through withdrawal (Sadd and Young 1987). Today, it is rare to find a “pure” detoxification model. For example, some social model programs use medication to ease withdrawal but generally employ nonmedical staff to monitor withdrawal and conduct triage (i.e., sorting patients according to the severity of their disorders). Likewise, medical programs generally have some components to address social/personal aspects of addiction.

Just as the treatment and the conceptualization of addiction have changed, so too have the patterns of substance use and the accompanying detoxification needs. The popularity of cocaine, heroin, and other substances has led to the need for different kinds of detoxification services. At the same time, public health officials have increased investments in detoxification services and substance abuse treatment, especially after 1985, as a means to inhibit the spread of HIV infection and AIDS among people who inject drugs. More recently, people with substance use disorders are more likely to abuse more than one drug simultaneously (i.e., polydrug use) (Office of Applied Studies 2005).

The AMA continues to maintain its position that substance dependence is a disease, and it encourages physicians and other clinicians, health organizations, and policymakers to base all their activities on this premise (AMA 2002). As treatment regimens have become more sophisticated and polydrug abuse more common, detoxification has evolved into a compassionate science.

Definitions

Few clear definitions of detoxification and related concepts are in general use at this time. Criminal justice, health care, substance abuse, mental health, and many other systems all define detoxification differently. This TIP offers a clear and uniform set of definitions for the various components of detoxification and substance abuse treatment that may prove useful to the field of detoxification.

Detoxification

Detoxification is a set of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances. The acute medical management of life-threatening intoxication and related medical problems generally is not included within the term detoxification and is not covered in detail in this TIP.

The Washington Circle Group (WCG), a body of experts organized to improve the quality and effectiveness of substance abuse prevention and treatment, defines detoxification as “a medical intervention that manages an individual safely through the process of acute withdrawal” (McCorry et al. 2000a , p. 9). The WCG makes an important distinction, however, in noting that “a detoxification program is not designed to resolve the long-standing psychological, social, and behavioral problems associated with alcohol and drug abuse” (McCorry et al. 2000a, p. 9). The consensus panel supports this statement and has taken special care to note that detoxification is not substance abuse treatment and rehabilitation. For further explanation, see the text box below.

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 life-threatening complications that might appear if the patient was 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 contact 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.

The consensus panel built on existing definitions of detoxification as a broad process with three essential components that may take place concurrently or as a series of steps:

  • Evaluation entails testing for the presence of substances of abuse in the bloodstream, measuring their concentration, and screening for co-occurring mental and physical conditions. Evaluation also includes a comprehensive assessment of the patient's medical and psychological conditions and social situation to help determine the appropriate level of treatment following detoxification. Essentially, the evaluation serves as the basis for the initial substance abuse treatment plan once the patient has been withdrawn successfully.
  • Stabilization includes the medical and psychosocial processes of assisting the patient through acute intoxication and withdrawal to the attainment of a medically stable, fully supported, substance-free state. This often is done with the assistance of medications, though in some approaches to detoxification no medication is used. Stabilization includes familiarizing patients with what to expect in the treatment milieu and their role in treatment and recovery. During this time practitioners also seek the involvement of the patient's family, employers, and other significant people when appropriate and with release of confidentiality.
  • Fostering the patient's entry into treatment involves preparing the patient for entry into substance abuse treatment by stressing the importance of following through with the complete substance abuse treatment continuum of care. For patients who have demonstrated a pattern of completing detoxification services and then failing to engage in substance abuse treatment, a written treatment contract may encourage entrance into a continuum of substance abuse treatment and care. This contract, which is not legally binding, is voluntarily signed by patients when they are stable enough to do so at the beginning of treatment. In it, the patient agrees to participate in a continuing care plan, with details and contacts established prior to the completion of detoxification.

All three components (evaluation, stabilization, and fostering a patient's entry into treatment) involve treating the patient with compassion and understanding. Patients undergoing detoxification need to know that someone cares about them, respects them as individuals, and has hope for their future. Actions taken during detoxification will demonstrate to the patient that the provider's recommendations can be trusted and followed.

Other Relevant Terms

As defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) (American Psychiatric Association [APA] 2000), a substance-related disorder is a “disorder related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure” (APA 2000, p. 191). The term substance “can refer to a drug of abuse, a medication, or a toxin” (APA 2000, p. 191). In this TIP, the term substance refers to alcohol as well as other drugs of abuse.

Substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. According to the DSM-IV-TR, substance use disorders include both “substance dependence” and “substance abuse.” Substance dependence refers to “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior” (APA 2000, p. 192). Substance abuse refers to “a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances” (APA 2000, p. 198). It should be noted that for purposes of this TIP, the term “substance abuse” is sometimes used to denote both substance abuse and substance dependence as they are defined by the DSM-IV-TR.

This TIP also uses the DSM-IV-TR definitions for substance intoxication and substance withdrawal. Substance intoxication is “the development of a reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance” whereas substance withdrawal is “the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use” (APA 2000, pp. 199, 201). Figure 1-1 defines these and other relevant terms.

Figure 1-1: DSM-IV-TR Definitions of Terms

TermDefinition
SubstanceA drug of abuse, a medication, or a toxin.
Substance-related disordersDisorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure.
Substance abuse (in this TIP, also sometimes used to denote “substance dependence”)A maladaptive (i.e., harmful to a person's life) pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances.
Substance dependence (in this TIP, “substance abuse” is sometimes used to include “dependence”)A cluster of cognitive, behavioral, and physiological symptoms indicating that the individual is continuing use of the substance despite significant substance-related problems. A person experiencing substance dependence shows a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior.
Substance intoxicationThe development of a reversible substance-specific syndrome as the result of the recent ingestion of (or exposure to) a substance.
Substance withdrawalThe development of a substance-specific 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.

Treatment/rehabilitation includes an ongoing, continual assessment of the patient's physical, psychological, and social status, as well as an analysis of environmental risk factors that may be contributing to substance use and the identification of immediate relapse triggers as well as prevention strategies for coping with them. It also includes the delivery of primary medical care and psychiatric care, if necessary, to help the patient abstain from substance use and minimize the physical harm caused by it. Ultimately, the goal of treatment/rehabilitation is to attain a higher level of social functioning by reducing risk factors, enhancing protective factors, and thus decreasing the possibility of relapse.

Maintenance includes the continuation of counseling and support specified in the treatment plan, refinement and strengthening of strategies to avoid relapse, and engagement in ongoing relapse prevention, aftercare, and/or domiciliary care (Lehman et al. 2000).

As a final note, in this TIP persons in need of detoxification services and subsequent substance abuse treatment are referred to as patients to emphasize that these persons are coming into contact with physicians, nurses, physician assistants, and medical social workers in a medical setting in which the patient often is physically ill from the effects of withdrawal from specific substances. In some social setting detoxification programs, the terms “client” or “consumer” may be used in place of “patient.”

Guiding Principles in Detoxification and Substance Abuse Treatment

The consensus panel recognizes that the successful delivery of detoxification services is dependent on standards that are to some extent empirically measurable and agreed upon by all parties. The consensus panel developed guidelines (listed in Figure 1-2) that serve as the foundation for the TIP.

Figure 1-2: 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 substance-related 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 treatment 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 cost-effective. If reimbursement systems do not provide payment for the complete detoxification process, patients may be released prematurely, leading to medically or socially unattended withdrawal. Ensuing medical complications 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 comprehensive 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 [CSAT in development a]).
8. A successful detoxification process can be measured, in part, by whether an individual who is substance dependent enters, remains in, and is compliant with the treatment protocol of a substance abuse treatment/rehabilitation program after detoxification.

Challenges to Providing Effective Detoxification

It is an important challenge for detoxification service providers to find the most effective way to foster a patient's recovery. Effective detoxification includes not only the medical stabilization of the patient and the safe and humane withdrawal from drugs, including alcohol, but also entry into treatment. Successfully linking detoxification with substance abuse treatment reduces the “revolving door” phenomenon of repeated withdrawals, saves money in the medium and long run, and delivers the sound and humane level of care patients need (Kertesz et al. 2003). Studies show that detoxification and its linkage to the appropriate levels of treatment lead to increased recovery and decreased use of detoxification and treatment services in the future. In addition, recovery leads to reductions in crime, general healthcare costs, and expensive acute medical and surgical treatments consequent to untreated substance abuse (Abbot et al. 1998; Aszalos et al. 1999). While detoxification is not treatment per se, its effectiveness can be measured, in part, by the patient's continued abstinence.

Another challenge to providing effective detoxification occurs when programs try to develop linkages to treatment services. A study (Mark et al. 2002) conducted for the Substance Abuse and Mental Health Services Administration highlights the pitfalls of the service delivery system. According to the authors, each year at least 300,000 patients with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals while additional numbers obtain detoxification in other settings. Only about one-fifth of people discharged from acute care hospitals for detoxification receive substance abuse treatment during that hospitalization. Moreover, only 15 percent of people who are admitted through an emergency room for detoxification and then discharged receive any substance abuse treatment. Finally the average length of stay for people undergoing detoxification and treatment in 1997 was only 7.7 days (Mark et al. 2002). Given that “research has shown that patients who receive continuing care have better outcomes in terms of drug abstinence and readmission rates than those who do not receive continuing care,” the report authors conclude that there is a pronounced need for better linkage between detoxification services and the treatment services that are essential for full recovery (Mark et al. 2002, p. 3).

Reimbursement systems can present another challenge to providing effective detoxification services (Galanter et al. 2000). Third-party payors sometimes prefer to manage payment for detoxification separately from other phases of addiction treatment, thus treating detoxification as if it occurred in isolation from addiction treatment. This “unbundling” of services has promoted the separation of all services into somewhat scattered segments (Kasser et al. 2000). In other instances, some reimbursement and utilization policies dictate that only “detoxification” currently can be authorized, and “detoxification” for that policy or insurer does not cover the nonmedical counseling that is an integral part of substance abuse treatment. Many treatment programs have found substance abuse counselors to be of special help with resistant patients, especially for patients with severe underlying shame over the fact that their substance use is out of control. Yet some payors will not reimburse for nonmedical services such as those provided by these counselors, and therefore the use of such staff by a detoxification or treatment service may be impossible, in spite of the fact that they are widely perceived as useful for patients.

Payors are gradually beginning to understand that detoxification is only one component of a comprehensive treatment strategy. Patient placement criteria, such as those published by the American Society of Addiction Medicine (ASAM) in the Patient Placement Criteria, Second Edition, Revised (ASAM 2001), have come to the fore as clinicians and insurers try to reach agreements on the level of treatment required by a given patient, as well as the medically appropriate setting in which the treatment services are to be delivered. Accordingly, the TIP offers suggestions for resolving conflicts as well as clearly defining terms used in patient placement and treatment settings as a step toward clearer understanding among interested parties.

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