Detoxification and Substance Abuse Treatment

269 Pages·2006·0.84 MB·English

Detoxification and
Substance Abuse Treatment
A Treatment
Improvement
Protocol
TIP
45
U.S. DEPARTMENT OFHEALTH 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.,
Electronic Access and Copies
Karl D. White, Ed.D., and Christina Currier
of Publication
served as the Center for Substance Abuse
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 [phone]; TDD (for hearing
Marsh Cupino served as CDM KAP Managing
impaired), [phone], 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
Figure 1-2 Guiding Principles Recognized by the Consensus Panel.........................................7
Figure 2-1 Issues To Consider in Determining Whether Inpatient or Outpatient
Detoxification Is Preferred.......................................................................................21
Figure 3-1 Initial Biomedical and Psychosocial Evaluation Domains......................................25
Figure 3-2 Symptoms and Signs of Conditions That Require Immediate Medical Attention..........26
Figure 3-3 Strategies for De-escalating Aggressive Behaviors ...............................................28
Figure 3-4 Questions To Guide Practitioners To Better Understand the Patient’s Cultural
Framework...........................................................................................................32
Figure 3-5 The Transtheoretical Model (Stages of Change)..................................................36
Figure 3-6 Clinician’s Characteristics Most Important to the Therapeutic Alliance....................38
Figure 3-7 Recommended Areas for Assessment To Determine Appropriate
Rehabilitation Plans...............................................................................................40
Figure 3-8 Strategies To Promote Initiation of Treatment and Maintenance Activities................42
Figure 4-1 Assessment Instruments for Dependence and Withdrawal From Alcohol and
Specific Illicit Drugs................................................................................................49
Figure 4-2 Symptoms of Alcohol Intoxication...................................................................53
Figure 4-3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal..61
Figure 4-4 Signs and Symptoms of Opioid Intoxication and Withdrawal.................................67
Figure 4-5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents........................77
iv Contents
Figure 4-6 Other Sedative-Hypnotics and Their Phenobarbital Withdrawal Equivalents............78
Figure 4-7 Stimulant Withdrawal Symptoms....................................................................79
Figure 4-8 Commonly Abused Inhalants/Solvents..............................................................83
Figure 4-9 DSM-IV-TR on Nicotine Withdrawal ...............................................................86
Figure 4-10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence......................87
Figure 4-11 The Glover-Nilsson Smoking Behavioral Questionnaire (GN-SBQ) ........................88
Figure 4-12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With
Other Psychiatric Conditions....................................................................................89
Figure 4-13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications......90
Figure 4-14 The “5 A’s” for Brief Intervention.................................................................91
Figure 4-15 Some Definitions Regarding Disabilities ........................................................111
Figure 4-16 Impairment and Disability Chart.................................................................112
Figure 4-17 Locating Expert Assistance.........................................................................114
Figure 6-1 Financial Arrangements for Providers............................................................162
Contents v

What Is a TIP?
Treatment Improvement Protocols (TIPs), 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 (DHHS), are best-practice
guidelines for the treatment of substance use disorders. CSAT draws on
the experience and knowledge of clinical, research, and administrative
experts to produce the TIPs, which are distributed to facilities and indi-
viduals across the country. The audience for the TIPs is expanding
beyond public and private treatment facilities to include practitioners in
mental health, criminal justice, primary care, and other healthcare and
social service settings.
CSAT’s Knowledge Application Program (KAP) Expert Panel, a distin-
guished group of experts on substance use disorders and professionals in
such related fields as primary care, mental health, and social services,
works with the State Alcohol and Drug Abuse Directors to generate topics
for the TIPs. Topics are based on the field’s current needs for information
and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies
and national organizations to be members of a resource panel that recom-
mends specific areas of focus as well as resources that should be consid-
ered in developing the content for the TIP. Then recommendations are
communicated to a consensus panel composed of experts on the topic who
have been nominated by their peers. This consensus panel participates in
a series of discussions. The information and recommendations on which
they reach consensus form the foundation of the TIP. The members of
each consensus panel represent substance abuse treatment programs, hos-
pitals, community health centers, counseling programs, criminal justice
and child welfare agencies, and private practitioners. A panel chair (or
co-chairs) ensures that the guidelines mirror the results of the group’s
collaboration.
vii
A large and diverse group of experts closely “front-line” information quickly but responsi-
reviews the draft document. Once the changes bly. For this reason, recommendations prof-
recommended by these field reviewers have fered in the TIP are attributed to either pan-
been incorporated, the TIP is prepared for elists’ clinical experience or the literature. If
publication, in print and online. The TIPs research supports a particular approach, cita-
can be accessed via the Internet at tions are provided.
www.kap.samhsa.gov. The online TIPs are
This TIP, Detoxification and Substance
consistently updated and provide the field
Abuse Treatment, revises TIP 19,
with state-of-the-art information.
Detoxification From Alcohol and Other
While each TIP strives to include an evidence Drugs. The revised TIP provides the clinical
base for the practices it recommends, CSAT evidence-based guidelines, tools, and
recognizes that the field of substance abuse resources necessary to help substance abuse
treatment is evolving, and research frequently counselors and clinicians treat clients who are
lags behind the innovations pioneered in the dependent on substances of abuse.
field. A major goal of each TIP is to convey
viii What Is a TIP?
Consensus Panel
Chair Anthony Radcliffe, M.D., FASAM
Chief of Addiction Medicine
Norman S. Miller, M.D., FASAM
Kaiser Permanente
Professor and Director of Addiction Medicine
Southern California Permanente Medical
Department of Psychiatry
Group
Michigan State University
Fontana, California
East Lansing, Michigan
Carl Rollynn Sullivan, III, M.D.
Co-Chair
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
Arapahoe House, Inc.
Anne M. Herron, M.S.
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