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Diane MillerChiefScientific Communications BranchNational Institute on Alcohol Abuseand AlcoholismKensington, MarylandHarry B. Montoya, M.A.President/Chief Executive OfficerHands Across CulturesEspanola, New MexicoRichard K. Ries, M.D.Director/ProfessorOutpatient Mental Health ServicesDual Disorder ProgramsHarborview Medical CenterSeattle, WashingtonGloria M. Rodriguez, D.S.W.Research ScientistDivision of Addiction ServicesNew Jersey Department of Healthand Senior ServicesTrenton, New JerseyEverett Rogers, Ph.D.Center for Communications ProgramsJohns Hopkins UniversityBaltimore, MarylandJean R. Slutsky, P.A., M.S.P.H.Senior Health Policy AnalystAgency for Healthcare Research & QualityRockville, MarylandxiiNedra Klein Weinreich, M.S.PresidentWeinreich CommunicationsCanoga Park, CaliforniaClarissa WittenbergDirectorOffice of Communications and Public LiaisonNational Institute of Mental HealthKensington, MarylandConsulting MembersPaul Purnell, M.A.Social Solutions, L.L.C.Potomac, MarylandScott Ratzan, M.D., M.P.A., M.A.Academy for Educational DevelopmentWashington, DCThomas W. Valente, Ph.D.Director, Master of Public Health ProgramDepartment of Preventive MedicineSchool of MedicineUniversity of Southern CaliforniaAlhambra, CaliforniaPatricia A. Wright, Ed.D.Independent ConsultantBaltimore, MarylandExpert Panel

ForewordThe Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and HumanServices that leads public health efforts to advance the behavioral healthof the nation. SAMHSA’s mission is to reduce the impact of substanceabuse and mental illness on America’s communities.The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance abuse and mental illness onAmerica's communities by providing evidence-based and best practiceguidance to clinicians, program administrators, and payers. TIPs are theresult of careful consideration of all relevant clinical and health servicesresearch findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, programadministrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. Fieldreviewers then review and critique this panel’s work.The talent, dedication, and hard work that TIPs panelists and reviewersbring to this highly participatory process have helped bridge the gapbetween the promise of research and the needs of practicing clinicians andadministrators to serve, in the most scientifically sound and effective ways,people in need of behavioral health services. We are grateful to all whohave joined with us to contribute to advances in the behavioral healthfield.Pamela S. Hyde, J.D.AdministratorSubstance Abuse and Mental Health Services AdministrationDaryl W. KadeActing DirectorCenter for Substance Abuse TreatmentSubstance Abuse and Mental Health Services Administrationxiii

Executive SummaryThis Treatment Improvement Protocol (TIP) is a revision of TIP 19,Detoxification From Alcohol and Other Drugs (Center for SubstanceAbuse Treatment 1995d). It provides clinicians with updated informa tion and expands on the issues commonly encountered in the delivery ofdetoxification services. Like its predecessor, this TIP was created by apanel of experts (the consensus panel) with diverse experience in detoxi fication services—physicians, psychologists, counselors, nurses, andsocial workers, all with particular expertise to share.This diverse group agreed to the following principles, which served as abasis for the TIP:1. Detoxification, in and of itself, does not constitute complete sub stance abuse treatment.2. The detoxification process consists of three essential components,which should be available to all people seeking treatment: Evaluation Stabilization Fostering patient readiness for and entry into substance abusetreatment3. Detoxification can take place in a wide variety of settings and at a num ber of levels of intensity within these settings. Placement should beappropriate to the patient’s needs.4. All persons requiring treatment for substance use disorders shouldreceive treatment of the same quality and appropriate thoroughnessand should be put into contact with substance abuse treatmentproviders after detoxification.5. Ultimately, insurance coverage for the full range of detoxification ser vices is cost effective.6. Patients seeking detoxification services have diverse cultural and ethnicbackgrounds as well as unique health needs and life situations.Programs offering detoxification should be equipped to tailor treatmentto their client populations.7. A successful detoxification process can be measured, in part, bywhether an individual who is substance dependent enters andremains in some form of substance abuse treatment/rehabilitationafter detoxification.Among the issues covered in this TIP is the importance of detoxificationas one component in the continuum of healthcare services for sub stance related disorders. The TIP reinforces the urgent need for non xv

traditional settings—emergency rooms, medi cal and surgical wards in hospitals, acute careclinics, and others—to be prepared to partici pate in the process of getting the patient whois in need of detoxification services into treat ment as quickly as possible. Furthermore, itpromotes the latest strategies for retainingindividuals in detoxification while alsoencouraging the development of the therapeu tic alliance to promote the patient’s entranceinto substance abuse treatment. The TIP alsoincludes suggestions on addressing psychoso cial issues that may impact detoxificationtreatment, such as providing culturallyappropriate services to the patient popula tion.5. Level IV D: Medically Managed IntensiveInpatient DetoxificationMatching patients to appropriate care repre sents a challenge to detoxification programs.Given the wide variety of settings and theunique needs of the individual patient, estab lishing criteria that take into account all thepossible needs of patients receiving detoxifica tion and treatment services is an extraordi narily complex task. Addiction medicine hassought to develop an efficient system of carethat matches patients’ clinical needs with theappropriate care setting in the least restric tive and most cost effective manner. Patientplacement criteria, such as those publishedby the American Society of AddictionMedicine (ASAM) in the Patient PlacementCriteria, Second Edition, Revised, representan effort to define how care settings may bematched to patient needs and special charac teristics. These criteria—the five “AdultDetoxification” placement levels—define themost broadly accepted standard of care fordetoxification services. The five levels of carearePlacement will depend in part on the sub stance of abuse. The consensus panel suggeststhat for alcohol, sedative hypnotic, and opi oid withdrawal syndromes, hospitalization (orsome form of 24 hour medical care) is oftenthe preferred setting for detoxification, basedon principles of safety and humanitarian con cerns. When hospitalization cannot be pro vided, then a setting that provides a high levelof nursing and medical backup 24 hours aday, 7 days a week is desirable.1. Level I D: Ambulatory DetoxificationWithout Extended Onsite Monitoring2. Level II D: Ambulatory Detoxification WithExtended Onsite Monitoring3. Level II.2 D: Clinically Managed ResidentialDetoxification4. Level III.7 D: Medically MonitoredInpatient DetoxificationxviASAM criteria are being adopted extensivelyon the basis of their face validity, thoughtheir outcome validity has yet to be clinicallyproven. The ASAM guidelines are to beregarded as a work in progress, as theirauthors readily admit. They are an importantset of guidelines that are of great help to clini cians. For administrators, the standards pub lished by such groups as the JointCommission on Accreditation of HealthcareOrganizations and the Commission onAccreditation of Rehabilitation Facilities pro vide guidance for overall program operations.A further challenge for detoxification pro grams is to provide effective linkages to sub stance abuse treatment services. Patientsoften leave detoxification without followup tothe treatment needed to achieve long termabstinence. Each year at least 300,000patients with substance use disorders or acuteintoxication obtain inpatient detoxification ingeneral hospitals, while additional numbersobtain detoxification in other settings. Only20 percent of people discharged from acutecare hospitals receive substance abuse treat ment during that hospitalization. Only 15percent of people who are admitted to adetoxification program through an emergencyroom and then discharged go on to receivetreatment.The consensus panel recognizes that medical ly assisted withdrawal is not always necessaryor desirable. A nonmedical approach can behighly cost effective and provide inexpensiveExecutive Summary

access to treatment for individuals seekingaid. Young individuals in good health, with nohistory of previous withdrawal reactions, maybe well served by management of withdrawalwithout medication. However, personnelsupervising in this setting should be trained toidentify life threatening symptoms and solicithelp through the emergency medical system asneeded.The consensus panel also agreed on severalguidelines for nonmedical detoxification pro grams. Such programs should follow local gov ernmental regulations regarding their licensingand inspection. In addition, it is desirable thatall such programs have an alcohol and drug free environment as well as personnel who arefamiliar with the features of substance usewithdrawal syndromes, have training in basiclife support, and have access to an emergencymedical system that can transport patients toemergency departments and other sites for clin ical care.A major clinical question for detoxification isthe appropriateness of the use of medicationin the management of an individual in with drawal. This can be a difficult matter becauseprotocols have not been firmly establishedthrough scientific studies or evidence basedmethods. Furthermore, the course of with drawal is unpredictable and currently avail able techniques of screening and assessmentdo not predict who will experience life threat ening complications.Although it is the philosophy of some treat ment facilities to discontinue all medications,this course of action is not always in the bestinterest of the patient. Abrupt cessation ofpsychotherapeutic medications may causesevere withdrawal symptoms or the re emer gence of a psychiatric disorder. As a generalrule, therapeutic doses of medication shouldbe continued through any withdrawal if thepatient has been taking the medication as pre scribed. Decisions about discontinuing themedication should be deferred until after theindividual has completed detoxification. If,however, the patient has been abusing theExecutive Summarymedication or the psychiatric condition wasclearly caused by substance use, then therationale for discontinuing the medication isstrengthened. Finally, practitioners shouldconsider withholding medication that lowersthe seizure threshold (e.g., bupropion, con ventional antipsychotics) during the acutealcohol withdrawal period or at least pre scribing a loading dose or scheduled taper ofbenzodiazepine.Further studies are needed to confirm theclinical experience that psychiatric symptoms(including anxiety, depression, and personali ty disorders) respond to specific treatment ofthe addiction. For example, cognitive–behav ioral techniques employed in the 12 Steptreatment approach have been effective in themanagement of anxiety and depression associ ated with addiction. Although challenging,treatment of both addiction and co occurringpsychiatric conditions has proven cost effec tive in some studies.This TIP also provides medical informationon detoxification protocols for specific sub stances as well as considerations for individu als with co occurring medical conditionsincluding mental disorders. While the TIP isnot intended to take the place of medicaltexts, it provides the practitioner with anoverview of common medical complicationsseen in individuals who use substances.Disorders of several systems are discussed insome detail: gastrointestinal (including thegastrointestinal tract, liver, and pancreas),cardiovascular system, hematologic (blood)abnormalities, pulmonary (lung) diseases, dis eases of the central and peripheral nervoussystem, infectious diseases, and special mis cellaneous disorders. The TIP presents a cur sory overview of special conditions, modifica tions in protocols, and the use of detoxifica tion medications in patients with co occurringmedical conditions or mental disorders.Overall treatment of specific conditions is notaddressed unless modification of such treat ment is needed.xvii

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Joy, R.N., CD, CASAC. Manager Alcoholand Drug Abuse Unit Stateof Missouri Department of Mental Health FultonState Hospital Fulton,Missouri. x Consensus Panel. xi. KAP Expert Panel and Federal Government Participants. Barry S. Brown, Ph.D. Adj