Santa Barbara County Alcohol_ Drug _ Mental Health Services by pengtt

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									Effective March 2005



      Santa Barbara County Alcohol, Drug & Mental
                    Health Services
            Alcohol & Drug Program Division




           DETOXIFICATION SOCIAL MODEL/RESIDENTIAL TREATMENT
                               GUIDELINES

            The guidelines set forth in this document shall apply to all contractors
            receiving substance abuse treatment funds or claiming reimbursement for
            drug testing procedures with the County of Santa Barbara Alcohol and
            Drug Program. The County reserves the authority to modify these
            guidelines at any time.

            These guidelines were developed in concert with local contractors funded
            by ADMHS/ADP. The Department would like to acknowledge the
            contributions made to these guidelines by the staff of Good Samaritan and
            Council on Alcoholism & Drug Abuse.


   FOREWORD:
   California Department of Alcohol and Drug Programs, Alcohol and/or other Drug
   Program Certification Standards require all certified residential and nonresidential
   alcohol and drug programs to establish guidelines:

       •    Document a referral plan appropriate for each participant from detoxification to
            community support services.

       •    Identify participants who are in need of medical services beyond the capacity of
            the program and refer or transfer such participants to more appropriate levels of
            service.



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County Alcohol & Drug Program recognizes the importance of detoxification services in
their Model of Care to the community. The goals are to assist participants in the
detoxification program to address acute withdrawal symptoms and achieve abstinence
from alcohol and/or drugs as the first step to achieving recovery from chemical
dependency and to successfully engage clients who have completed detoxification in
ongoing treatment services and referrals. Detoxification also includes a period of
psychological readjustment that prepares a patient for the next step in continuing
treatment.

Principles of Detoxification: (Based on SAMHSA TIP 19 Detoxification from Alcohol and
Other Drugs)

    •   Detoxification alone is rarely adequate treatment for AOD dependencies.

    •   When using medication regiments or other detoxification procedures, clinicians
        should use only protocols of established safety and efficacy.

    •   Providers must advise patients when procedures are used that have not been
        established as safe and effective.

    •   During detoxification, providers should control patients’ access to medication to
        the greatest extent possible.

    •   Initiation of withdrawal should be individualized.

    •   Whenever possible, clinicians should substitute a long-acting medication for
        short-acting drugs of addiction.

    •   Every means possible should be used to ameliorate the patient’s signs and
        symptoms of AOD withdrawal.

    •   The intensity of withdrawal cannot always be predicted accurately.

    •   Patients should begin participating as soon as possible in follow up support
        therapy such as peer group therapy, family therapy, individual counseling or
        therapy, 12-step recovery meetings, and AOD educational programs. Such
        services provide much-needed emotional support and provide alternative
        methods of copying with stresses that trigger AOD abuse. They provide general
        information about AOD dependence and goals for recovery. Overall health also
        can be addressed. Counseling on sexual health may include information on
        sexually transmitted diseases, HIV testing and education, and guidance on safer
        sexual practices. For injection drug users, a drug-recovery educational program
        might include a discussion of the Centers for Disease Control and Prevention
        recommendation on needle exchange and disinfection.




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    •   Upon completion of detoxification, appropriate linkages should be considered
        with local mental health services for additional assessment and screening for
        those clients presenting with a co-occurring mental health disorder.


OBJECTIVE:

The purpose of detoxification is to provide a safe withdrawal from the drug(s) of
dependence and enable the individual to become drug free. Detoxification services are
designed to administer to:

    •   The severity of the participant’s level of intoxication.

    •   Achieve a safe and supportive withdrawal from alcohol and/or other drugs.

    •   Effectively facilitate the participant’s transition into ongoing services, including
        referrals to local mental health services for those clients appearing to present
        with a co-occurring mental health condition.


Detoxification services support a smooth transition for individuals from detoxification to
community support services with the development and documentation of a referral plan
appropriate for each individual.

Detoxification services may be provided in either a residential or non-residential setting.

    •   Detoxification may be a medical model program and may require medication and
        medical monitoring.

    •   Detoxification may be a social model program involving outpatient treatment with
        structured activities to ameliorate the symptoms of withdrawal, for example
        acupuncture.

    •   Detoxification lengths of stay vary for individuals according to the degree and
        severity of addiction, drugs to which addicted, health and well being, and support
        services necessary to assist an individual in their recovery.


AGENCY GUIDELINES & STAFF

    1. Detoxification Practices

        All program guidelines shall be documented in an operation manual that is
        located at each certified site and that shall be available to staff and volunteers.
        Each program shall comply with all applicable local, state and federal laws and
        regulations. Program sites shall be clean, safe, sanitary and alcohol/drug/nicotine

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        free. This manual should also include a service plan to address the needs of the
        following special populations: perinatal, elderly, mentally ill, sedative/hypnotic
        addicts, and patients with special medical needs, HIV, STD, Hepatitis C, and TB,
        for example. Each agency shall have the following service components:

            •    Reliable access to medical services to manage withdrawal through public
                 and/or private health facilities.

            •    Standards for medical clearance before admission

            •    Standards for withdrawal management

     2. Program Staff and Development

         All program staff shall be trained to provide evaluation, detoxification, and
        referral services. Staff should meet the new counselor certification standards
        upon their final approval by the California Department of Alcohol and Drug
        Programs. Recovering staff shall have knowledge and skills gained from an
        appropriate period of successful recovery. Providers will support the
        development of staff competencies in the area of co-occurring alcohol, drug and
        mental health issues by providing release time for Detox staff to attend the co-
        occurring educational program available through the local community colleges
        and/or through ongoing workshops. Agency staff will strive toward cultural
        competency in order to recognize differences and respond effectively and
        respectfully to all clients. If the population is predominantly Spanish-speaking,
        materials, including intake and assessment forms and educational materials,
        should be printed in Spanish. At least one staff member should speak Spanish
        with a standard of bilingual ability available for every shift of coverage.

     3. Admission/Readmission

        a. Admission and Suitability Criteria

            Each agency shall have written admission criteria. Prospective clients must
            first be assessed as being dependent upon a mood or mind altering
            substance. In keeping with the spirit of the following quote from ASAM PPC
            2R, the presence or the anticipation of physical or psychological withdrawal
            symptoms is not a requirement:

                   “. . . Detoxification refers not only to the attenuation of the physical
                 and psychological features of withdrawal syndromes, but also to the
                 process of interrupting the momentum of compulsive use in
                 persons diagnosed with substance dependence. Because of the
                 force of this momentum and the inherent difficulties in overcoming it
                 even when there is no clear withdrawal syndrome, this phase of
                 treatment frequently requires a greater intensity of services initially


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                 in order to establish treatment engagement and patient role
                 induction.”

            Participants’ eligibility and suitability for services will be assessed by the
            agency. Violence or threats of violence, psychotic behavior, or bringing drugs
            into the facility are examples of unsuitability.

        b. Length of Stay

            The length of detoxification varies. In all cases, length of stay should be
            based solely upon the clinical needs of the client or patient. Mandated levels
            of care or lengths of stay should be avoided to the greatest extent possible.
            As stated in the ASAM PPC-2R:

                 “Such mandated or court-ordered referrals may not be based on
                 clinical considerations and thus may be inconsistent with a
                 placement decision arrived at through the ASAM criteria. In such a
                 case, the provider should make reasonable attempts to have the
                 order amended to reflect the assessed clinical level or length of
                 service.”

            The County will only support lengths of detoxification treatment that can be
            clinically justified. Clients needing longer stabilization periods should be
            assisted by other partner agencies that provide temporary housing, sober
            living environments, and other needed psycho-social services. The following
            are examples of objective criteria for length of drug detoxification based on
            SAMHSA. Additional stays in detox for stabilization purposes must be
            approved on a case-by-case basis.

            •    There is no withdrawal syndrome associated with either marijuana or
                 hallucinogens, and some “designer drugs”.
            •    Most clients can be detoxified from alcohol in 3-5 days
            •    Opiate withdrawal varies, for heroin or morphine, 5-7 days. Other Narcotic
                 withdrawal may require Narcotic Replacement Therapy under medical
                 supervision.
            •    Stimulant withdrawal, 2-4 days
            •    Sedatives & Benzodiazepines varies

        c. Readmission Criteria

            Participants are normally considered ineligible for readmission within 45 days
            of discharge from a successful stay. The number of detoxification attempts
            for individuals may vary according to the degree and severity of addiction,
            drugs to which addicted, health and well being, and support services
            necessary to assist an individual in their recovery. Participants who fail to
            complete a stay in detoxification are not held to the 45 day consideration. If


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            they present again for admission, they can be readmitted at the provider’s
            discretion based upon available space and clinical need.

4. Intake/Assessment

             Intake information shall include the following documentation in the client file:

            •    Identification of alcohol and illicit drugs used

            •    Consent for Participant and Release of Information that includes all social,
                 medical, and psychiatric services relevant to the individual’s care.

            •    Source of referral and documentation if court ordered

            •    Documentation of social, education, employment psychological, physical
                 and/or behavioral problems related to alcohol and/or other drugs including
                 the medical history form for medical services screening. The ASI will be
                 used as the adopted assessment tool and if the client is referred through
                 the SACPA program, the pre-placement ASI report from ADP will be
                 utilized and applied to the client’s service plan and goals.

            •    A referral plan for ancillary services in the community and housing

5. Withdrawal Management

            Every effort should be made to ease the pain and discomfort of withdrawal for
            the client. A client that receives medication to ease withdrawal symptoms will
            be allowed to take their doctor prescribed medications. All medications are to
            be kept under lock and key and can only be accessed under the close
            supervision of staff.

            Social model programs that provide detoxification should have reliable and
            routine access to medical services to manage medical and psychiatric
            complications of their patient’s withdrawal. The access may be provided by a
            physician, nurse practitioner, or physician’s assistant. Written procedures or
            appropriate checklists for accessing such service must be readily available to
            all staff.

6. Client Support Services

            When a client is ready to participate, agencies will provide support therapy
            such as peer group, individual counseling, 12-step recovery meetings, and
            recovery educational programs.

            Clients with Co-Occurring Disorders will receive services and linkages to
            ADMHS and other community providers.


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7. Drug Testing

            Drug testing is used to identify alcohol and illicit drug dependence at
            admission, to promote abstinence and validation of effort during
            detoxification, and to verify completion of withdrawal and sobriety at
            discharge. Agencies shall follow the ADMHS & ADP Drug Testing Policy &
            Procedures, effective December 2002.

8. Discharge Criteria

            Program rules indicating criteria for successful discharge will be made
            available to all clients. Criteria for early discharge and/or removal will also be
            available.

9. After Care Linkages/Referral Plan

            Each client will receive a treatment plan indicating after care linkages and
            referrals to community recovery support services to insure continuum of care
            based on the individual needs of the client and for relapse prevention.

            •    Agency will have client sign a consent for release of information to referral
                 agencies so follow up may occur at a 1 month, 3 month, and 6 month
                 interval.

            •    Every attempt should be made to make personal contact with the client
                 through referral agencies.

10. Outcomes

            •    Clients who successfully complete Detoxification will enter AOD treatment


NOTE: Authority cited:

    •   Alcohol and/or Other Drug Program Certification Standards 16000, Detoxification
        Services SAMSHA/US

    •   Government Center for Substance Abuse Treatment (CSAT) Treatment
        Improved Protocol Series (TIP) 19, 1995

    •   American Society of Addiction Medicine (ASAM) Patient Placement Criteria for
        the Treatment of Substance-Related Disorders (PPC-2R)




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