Table Of Content

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  prepared  under  contract of  Publication numbers  270­99­7072  and  270­04­7049  by  the This  publication  may  be  ordered  from or Knowledge  Application  Program  (KAP),  a downloaded from SAMHSA’s  Publications  Joint  Venture  of  The  CDM  Group,  Inc.,  and Ordering  Web  page  at http://store.samhsa.gov.  JBS  International,  Inc.,  for  the  Substance Or,  please  call  SAMHSA  at  1­877­SAMHSA­7  Abuse  and  Mental  Health  Services (1­877­726­4727) (English  and  Español).  Administration  (SAMHSA),  U.S.  Department of  Health  and  Human  Services  (HHS).  Andrea Kopstein,  Ph.D.,  M.P.H.,  Karl  D.  White, Recommended  Citation Ed.D.,  and  Christina  Currier  served  as Substance Abuse and Mental Health Services Government  Project  Officers. Administration. Detoxification and Substance Abuse Treatment. Treatment Improvement Disclaimer Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 13­4131. Rockville, The  views,  opinions,  and  content  of  this  publi­ MD: Substance Abuse and Mental Health cation  are  those  of  the  author  and  do  not  neces­ Services Administration, 2006. sarily  reflect  the  views,  opinions,  or  policies  of SAMHSA  or  HHS. Originating  Office Public  Domain  Notice Quality  Improvement  and  Workforce Development  Branch,  Division  of  Services All  materials  appearing  in  this  volume  except Improvement,  Center  for  Substance  Abuse those  taken  directly  from  copyrighted  sources Treatment,  Substance  Abuse  and  Mental are  in  the  public  domain  and  may  be  repro­ Health  Services  Administration,  1  Choke duced  or  copied  without  permission  from Cherry  Road,  Rockville,  MD  20857. SAMHSA  or  the  authors.  Citation  of  the  source is  appreciated.  However,  this  publication  may HHS  Publication  No.  (SMA)  13­4131 not  be  reproduced  or  distributed  for  a  fee  with­ First  Printed  2006 out  the  specific,  written  authorization  of  the Revised  2008,  2012, and 2013 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 Figure 4­2 Symptoms of Alcohol Intoxication...................................................................53 Figure 4­3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61 Figure 4­4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67 Figure 4­5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77 iv Contents Figure 4­6 Other Sedative­Hypnotics and Their Phenobarbital Withdrawal Equivalents ............78 Figure 4­7 Stimulant Withdrawal Symptoms....................................................................79 Figure 4­8 Commonly Abused Inhalants/Solvents..............................................................83 Figure 4­9 DSM­IV­TR on Nicotine Withdrawal ...............................................................86 Figure 4­10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87 Figure 4­11 The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ) ........................88 Figure 4­12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With  Other Psychiatric Conditions ....................................................................................89 Figure 4­13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90 Figure 4­14 The “5 A’s” for Brief Intervention .................................................................91 Figure 4­15 Some Definitions Regarding Disabilities ........................................................111 Figure 4­16 Impairment and Disability Chart.................................................................112 Figure 4­17 Locating Expert Assistance.........................................................................114 Figure 6­1 Financial Arrangements for Providers............................................................162 Contents v What Is a TIP? Treatment  Improvement  Protocols  (TIPs)  are  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  (HHS).  Each  TIP  involves  the development  of  topic­specific  best­practice  guidelines  for  the  prevention and  treatment  of  substance  use  and  mental  disorders.  TIPs  draw  on  the experience  and  knowledge  of  clinical,  research,  and  administrative  experts of  various  forms  of  treatment  and  prevention.  TIPs  are  distributed  to facilities  and  individuals  across  the  country.  Published  TIPs  can  be accessed  via  the  Internet  at  http://store.samhsa.gov. Although  each  consensus­based  TIP  strives  to  include  an  evidence  base  for the  practices  it  recommends,  SAMHSA  recognizes  that  behavioral  health  is continually  evolving,  and  research  frequently  lags  behind  the  innovations pioneered  in  the  field.  A  major  goal  of  each  TIP  is  to  convey  "front­line" information  quickly  but  responsibly.  If  research  supports  a  particular approach,  citations  are  provided. vii 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 Co­Chair Carl  Rollynn  Sullivan,  III,  M.D. 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 Co­Managers 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 Charles  A.  Dackis,  M.D.  Hendree  E.  Jones,  M.A.,  Ph.D.  Assistant  Professor  Assistant  Professor  Department  of  Psychiatry  CAP  Research  Director  University  of  Pennsylvania  School  of  Medicine Department  of  Psychiatry  and  Behavioral Philadelphia,  Pennsylvania Sciences  Johns  Hopkins  University  Center Sylvia  J.  Dennison,  M.D.  Baltimore,  Maryland  Chief/Medical  Director  Division  of  Addiction  Services  Frances  J.  Joy,  R.N.,  CD,  CASAC  Department  of  Psychiatry  Manager  University  of  Illinois Alcohol  and  Drug  Abuse  Unit  Chicago,  Illinois State  of  Missouri  Department  of  Mental  Health  Fulton  State  Hospital  Patricia  L.  Mabry,  Ph.D.  Fulton,  Missouri Health  Scientist  Administrator/Behavioral Scientist Office  of  Behavioral  and  Social  Sciences Research Office  of  the  Director National  Institutes  of  Health Bethesda,  Maryland x Consensus Panel KAP Expert Panel and Federal Government Participants Barry  S.  Brown,  Ph.D. Michael  Galer,  D.B.A.,  M.B.A.,  M.F.A. Adjunct  Professor Independent  Consultant University  of  North  Carolina  at  Wilmington Westminster,  Massachusetts Carolina  Beach,  North  Carolina Renata  J.  Henry,  M.Ed. Jacqueline  Butler,  M.S.W.,  LISW,  LPCC, Director CCDC  III,  CJS Division  of  Substance  Abuse  and  Professor  of  Clinical  Psychiatry Mental  Health College  of  Medicine Delaware  Health  and  Social  Services University  of  Cincinnati New  Castle,  Delaware  Cincinnati,  Ohio    Joel  Hochberg,  M.A. Deion  Cash President Executive  Director Asher  &  Partners Community  Treatment  &  Correction  Los  Angeles,  California Center,  Inc. Canton,  Ohio Jack  Hollis,  Ph.D. Associate  Director Debra  A.  Claymore,  M.Ed.Adm. Center  for  Health  Research Owner/Chief  Executive  Officer Kaiser  Permanente WC  Consulting,  LLC Portland,  Oregon  Loveland,  Colorado    Mary  Beth  Johnson,  M.S.W. Carlo  C.  DiClemente,  Ph.D. Director Chair Addiction  Technology  Transfer  Center Department  of  Psychology National  Office University  of  Maryland  Baltimore  County University  of  Missouri—Kansas  City Baltimore,  Maryland    Kansas  City,  Missouri  Catherine  E.  Dube,  Ed.D. Eduardo  Lopez,  B.S. Independent  Consultant Executive  Producer Brown  University EVS  Communications Providence,  Rhode  Island Washington,  DC Jerry  P.  Flanzer,  D.S.W.,  LCSW,  CAC Holly  A.  Massett,  Ph.D. Chief  Academy  for  Educational  Development Services  Research  Branch Washington,  DC National  Institute  on  Drug  Abuse Bethesda,  Maryland xi

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Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .47. Psychosocial and . General Principles of Care for Patients With CoOccurring Medical Conditions 122 addressed unless modification of such treat ment is .. “medical model,” detoxification is characterize
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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  prepared  under  contract of  Publication numbers  270­99­7072  and  270­04­7049  by  the This  publication  may  be  ordered  from or Knowledge  Application  Program  (KAP),  a downloaded from SAMHSA’s  Publications  Joint  Venture  of  The  CDM  Group,  Inc.,  and Ordering  Web  page  at http://store.samhsa.gov.  JBS  International,  Inc.,  for  the  Substance Or,  please  call  SAMHSA  at  1­877­SAMHSA­7  Abuse  and  Mental  Health  Services (1­877­726­4727) (English  and  Español).  Administration  (SAMHSA),  U.S.  Department of  Health  and  Human  Services  (HHS).  Andrea Kopstein,  Ph.D.,  M.P.H.,  Karl  D.  White, Recommended  Citation Ed.D.,  and  Christina  Currier  served  as Substance Abuse and Mental Health Services Government  Project  Officers. Administration. Detoxification and Substance Abuse Treatment. Treatment Improvement Disclaimer Protocol (TIP) Series, No. 45. HHS Publication No. (SMA) 13­4131. Rockville, The  views,  opinions,  and  content  of  this  publi­ MD: Substance Abuse and Mental Health cation  are  those  of  the  author  and  do  not  neces­ Services Administration, 2006. sarily  reflect  the  views,  opinions,  or  policies  of SAMHSA  or  HHS. Originating  Office Public  Domain  Notice Quality  Improvement  and  Workforce Development  Branch,  Division  of  Services All  materials  appearing  in  this  volume  except Improvement,  Center  for  Substance  Abuse those  taken  directly  from  copyrighted  sources Treatment,  Substance  Abuse  and  Mental are  in  the  public  domain  and  may  be  repro­ Health  Services  Administration,  1  Choke duced  or  copied  without  permission  from Cherry  Road,  Rockville,  MD  20857. SAMHSA  or  the  authors.  Citation  of  the  source is  appreciated.  However,  this  publication  may HHS  Publication  No.  (SMA)  13­4131 not  be  reproduced  or  distributed  for  a  fee  with­ First  Printed  2006 out  the  specific,  written  authorization  of  the Revised  2008,  2012, and 2013 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 Figure 4­2 Symptoms of Alcohol Intoxication...................................................................53 Figure 4­3 Potential Contraindications To Using Benzodiazepines To Treat Alcohol Withdrawal ..61 Figure 4­4 Signs and Symptoms of Opioid Intoxication and Withdrawal .................................67 Figure 4­5 Benzodiazepines and Their Phenobarbital Withdrawal Equivalents ........................77 iv Contents Figure 4­6 Other Sedative­Hypnotics and Their Phenobarbital Withdrawal Equivalents ............78 Figure 4­7 Stimulant Withdrawal Symptoms....................................................................79 Figure 4­8 Commonly Abused Inhalants/Solvents..............................................................83 Figure 4­9 DSM­IV­TR on Nicotine Withdrawal ...............................................................86 Figure 4­10 Items and Scoring for the Fagerstrom Test for Nicotine Dependence ......................87 Figure 4­11 The Glover­Nilsson Smoking Behavioral Questionnaire (GN­SBQ) ........................88 Figure 4­12 Some Examples of Nicotine Withdrawal Symptoms That Can Be Confused With  Other Psychiatric Conditions ....................................................................................89 Figure 4­13 Effects of Abstinence From Smoking on Blood Levels of Psychiatric Medications ......90 Figure 4­14 The “5 A’s” for Brief Intervention .................................................................91 Figure 4­15 Some Definitions Regarding Disabilities ........................................................111 Figure 4­16 Impairment and Disability Chart.................................................................112 Figure 4­17 Locating Expert Assistance.........................................................................114 Figure 6­1 Financial Arrangements for Providers............................................................162 Contents v What Is a TIP? Treatment  Improvement  Protocols  (TIPs)  are  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  (HHS).  Each  TIP  involves  the development  of  topic­specific  best­practice  guidelines  for  the  prevention and  treatment  of  substance  use  and  mental  disorders.  TIPs  draw  on  the experience  and  knowledge  of  clinical,  research,  and  administrative  experts of  various  forms  of  treatment  and  prevention.  TIPs  are  distributed  to facilities  and  individuals  across  the  country.  Published  TIPs  can  be accessed  via  the  Internet  at  http://store.samhsa.gov. Although  each  consensus­based  TIP  strives  to  include  an  evidence  base  for the  practices  it  recommends,  SAMHSA  recognizes  that  behavioral  health  is continually  evolving,  and  research  frequently  lags  behind  the  innovations pioneered  in  the  field.  A  major  goal  of  each  TIP  is  to  convey  "front­line" information  quickly  but  responsibly.  If  research  supports  a  particular approach,  citations  are  provided. vii 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 Co­Chair Carl  Rollynn  Sullivan,  III,  M.D. 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 Co­Managers 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 Charles  A.  Dackis,  M.D.  Hendree  E.  Jones,  M.A.,  Ph.D.  Assistant  Professor  Assistant  Professor  Department  of  Psychiatry  CAP  Research  Director  University  of  Pennsylvania  School  of  Medicine Department  of  Psychiatry  and  Behavioral Philadelphia,  Pennsylvania Sciences  Johns  Hopkins  University  Center Sylvia  J.  Dennison,  M.D.  Baltimore,  Maryland  Chief/Medical  Director  Division  of  Addiction  Services  Frances  J.  Joy,  R.N.,  CD,  CASAC  Department  of  Psychiatry  Manager  University  of  Illinois Alcohol  and  Drug  Abuse  Unit  Chicago,  Illinois State  of  Missouri  Department  of  Mental  Health  Fulton  State  Hospital  Patricia  L.  Mabry,  Ph.D.  Fulton,  Missouri Health  Scientist  Administrator/Behavioral Scientist Office  of  Behavioral  and  Social  Sciences Research Office  of  the  Director National  Institutes  of  Health Bethesda,  Maryland x Consensus Panel KAP Expert Panel and Federal Government Participants Barry  S.  Brown,  Ph.D. Michael  Galer,  D.B.A.,  M.B.A.,  M.F.A. Adjunct  Professor Independent  Consultant University  of  North  Carolina  at  Wilmington Westminster,  Massachusetts Carolina  Beach,  North  Carolina Renata  J.  Henry,  M.Ed. Jacqueline  Butler,  M.S.W.,  LISW,  LPCC, Director CCDC  III,  CJS Division  of  Substance  Abuse  and  Professor  of  Clinical  Psychiatry Mental  Health College  of  Medicine Delaware  Health  and  Social  Services University  of  Cincinnati New  Castle,  Delaware  Cincinnati,  Ohio    Joel  Hochberg,  M.A. Deion  Cash President Executive  Director Asher  &  Partners Community  Treatment  &  Correction  Los  Angeles,  California Center,  Inc. Canton,  Ohio Jack  Hollis,  Ph.D. Associate  Director Debra  A.  Claymore,  M.Ed.Adm. Center  for  Health  Research Owner/Chief  Executive  Officer Kaiser  Permanente WC  Consulting,  LLC Portland,  Oregon  Loveland,  Colorado    Mary  Beth  Johnson,  M.S.W. Carlo  C.  DiClemente,  Ph.D. Director Chair Addiction  Technology  Transfer  Center Department  of  Psychology National  Office University  of  Maryland  Baltimore  County University  of  Missouri—Kansas  City Baltimore,  Maryland    Kansas  City,  Missouri  Catherine  E.  Dube,  Ed.D. Eduardo  Lopez,  B.S. Independent  Consultant Executive  Producer Brown  University EVS  Communications Providence,  Rhode  Island Washington,  DC Jerry  P.  Flanzer,  D.S.W.,  LCSW,  CAC Holly  A.  Massett,  Ph.D. Chief  Academy  for  Educational  Development Services  Research  Branch Washington,  DC National  Institute  on  Drug  Abuse Bethesda,  Maryland xi

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Chapter 4—Physical Detoxification Services for Withdrawal From Specific Substances .47. Psychosocial and . General Principles of Care for Patients With CoOccurring Medical Conditions 122 addressed unless modification of such treat ment is .. “medical model,” detoxification is characterize
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