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DETOXIFICATION AND SUBSTANCE ABUSE TREATMENT FUNDAMENTALS

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					                                                                               occurring mental and physical conditions. Evaluation also includes a
  DETOXIFICATION AND SUBSTANCE ABUSE TREATMENT                                 comprehensive assessment of the patient’s medical, psychological, and
                                                                               social situation.
                  FUNDAMENTALS
                               (3 CE Hours)                                    Stabilization includes the medical and psychosocial process of assisting
By: Services Administration (SAMHSA)                                           the patient through acute intoxication and withdrawal to the attainment
Additional Material and Editing By: Marvin C. Chaffin, II, M.S., LMHC          of a medically stable, fully supported, substance-free state.
Course objectives                                                              Fostering the patient’s entry into treatment involves preparing the
! To facilitate an understanding of the history of detoxification              patient by stressing the importance of following through with a complete
   services in the United States.                                              continuum of care.
! To develop an understanding of the definition of detoxification.
                                                                               Guiding principles/assumptions
! To develop an understanding of the definitions of evaluation and
                                                                                Detoxification alone is not sufficient treatment for substance
   stabilization in terms of modern detoxification efforts.                       dependence but it is one part of a continuum of care for substance-
! To convey the basic guiding principles and assumptions regarding                related disorders.
   modern detoxification efforts.                                               The detoxification process consists of the following three
! To facilitate an understanding of the generally accepted levels of              components:
   care and patient placement promulgated via the Patient Placement               Š Evaluation.
   Criteria, Second Edition, Revised (PPC-2R) of the American Society             Š Stabilization.
   of Addiction Medicine (ASAM).                                                  Š Fostering patient readiness for and entry into treatment.
! To facilitate an understanding of the biomedical and psychosocial               A detoxification process that does not incorporate all three critical
   issues relevant to substance abuse detoxification.                             components is considered incomplete and inadequate.
! To facilitate an understanding of the strategies relevant to client           Detoxification can take place in a wide variety of settings and at a
   engagement and recovery.                                                       number of levels of intensity within these settings.
! To facilitate an understanding of the elements of a biopsychosocial           Persons seeking detoxification should have access to the components
   screening and assessment for purposes of detoxification.                       of the detoxification process described above, no matter what the
! To facilitate an understanding of the detoxification services required          setting or the level of treatment intensity.
   for specific substances of abuse.                                            All persons requiring treatment for substance use disorders should
                                                                                  receive treatment of the same quality and appropriate thoroughness
Introduction                                                                      and should be put into contact with a treatment program for
Substance abuse detoxification first became available to the general              substance use disorders after detoxification.
public about 30 years ago. Prior to that time, persons wanting to cease         Ultimately, insurance coverage for the full range of detoxification
the use of alcohol or other mood-altering substances were forced to               and follow-up treatment services is cost-effective. If reimbursement
undergo withdrawal with little or no medical intervention. Changes in             systems do not provide payment for the complete detoxification
the medical field, in perceptions of substance abuse and addiction, and           process, patients may be released prematurely, leading to medically
in social policy transformed the way that people with dependency on               or socially unattended withdrawal.
drugs, including alcohol, were viewed and treated. Two events were              Patients seeking detoxification services have diverse cultural and
particularly instrumental in helping change attitudes. In 1958, the               ethnic backgrounds as well as unique health needs and life situations.
American Medical Association (AMA) took the official position that                Organizations that provide detoxification services need to ensure that
alcoholism is a disease. This suggested that alcoholism was a medical             they have standard practices in place to address cultural diversity.
problem that required some level of medical intervention. In 1971,              A successful detoxification process can be measured, in part, by
the National Conference of Commissioners on Uniform State Laws                    whether an individual who is substance dependent enters, remains
adopted the Uniform Alcoholism and Intoxication Treatment Act, which              in, and is compliant with the treatment protocol of a substance abuse
recommended that “alcoholics not be subjected to criminal prosecution             treatment/rehabilitation program after detoxification.
because of their consumption of alcoholic beverages but rather should be
afforded a continuum of treatment.”                                            Overarching principles for care during detoxification services
                                                                                Detoxification services do not offer a “cure” for substance use
History of detoxification services                                                disorders, but are often a first step toward recovery and a “first door”
Prior to the 1970s, public intoxication was commonly treated as a                 through which patients pass to treatment. Substance use disorders
criminal offense. People arrested for it were held in “drunk tanks”               are treatable, and there is hope for recovery. Substance use disorders
where they often underwent withdrawal with no medical intervention.               are brain disorders and not evidence of moral weakness.
As society moved toward a more humanitarian view of people with                 Patients should be treated with respect and dignity at all times.
substance use disorders, several methods of detoxification evolved.               Patients should be treated in a nonjudgmental and supportive
The “medical model” of detoxification is characterized by the use of              manner. Services planning should be completed in partnership with
physicians and nursing staff and the administration of medication to              the patient and his or her social support network, including family,
assist people safely through withdrawal. The “social model” relies more           significant others, or employers.
on a supportive non-hospital environment than on medication to ease the         All health professionals involved in the care of the patient should
passage through withdrawal.                                                       maximize opportunities to promote rehabilitation and maintenance
Definitions                                                                       activities and to link the patient to appropriate substance abuse
Detoxification is a set of interventions aimed at managing acute                  treatment immediately after the detoxification phase.
intoxication and withdrawal. It denotes a clearing of toxins from the           Active involvement of the family and other support systems, while
body of the patient who is acutely intoxicated and/or dependent on                respecting the patient’s right to privacy and confidentiality, are to be
substances of abuse. Detoxification seeks to minimize the physical harm           encouraged.
caused by the abuse of substances.                                              Patients should be treated with due consideration for individual
                                                                                  background, culture, preferences, sexual orientation, disability,
Evaluation entails testing for the presence of substances of abuse in             vulnerabilities, and strengths.
the bloodstream, measuring their concentration, and screening for co-
                                                                               Levels of care and patient placement
                                                                           1
In addition to the general placement criteria for the treatment of                   Anger and aggression.
substance-related disorders, the Patient Placement Criteria, Second                   Š All patients who are intoxicated should be considered potentially
Edition, Revised (PPC-2R) of the American Society of Addiction                           violent.
Medicine (ASAM) also indicates a second set of placement criteria, are                Š Symptoms associated with increased risk for violence include
more important for the purposes of TIP 45 and this Quick Guide – the                     hallucinations, paranoia, anxiety, and depression.
five “adult detoxification” placement levels of care within Dimension 1               Š Physical restraint should be used as a last resort.
(ASAM 2001). These “adult detoxification” levels of care are:
                                                                                  Initial biomedical and psychosocial evaluation domains
 Level I-D: Ambulatory detoxification without extended onsite
                                                                                  An initial evaluation will help detoxification staff foresee any variables
    monitoring (e.g., physician’s office, home health care agency).
                                                                                  that might complicate withdrawal. The following is a list of biomedical
    This level of care is an organized outpatient service monitored at
                                                                                  and psychosocial domains that can affect the stabilization of the patient.
    predetermined intervals.
                                                                                   Biomedical domains.
 Level II-D: Ambulatory detoxification with extended onsite
                                                                                      Š General health history: What is the patient’s medical and surgical
    monitoring (e.g., day hospital service). This level of care is
                                                                                           history? Are there any psychiatric or medical conditions? Any
    monitored by appropriately credentialed and licensed nurses.
                                                                                           known medication allergies? A history of seizures?
 Level III.2-D: Clinically managed residential detoxification (e.g.,
                                                                                      Š Mental status: Is the patient oriented, alert, and cooperative? Are
    non-medical or social detoxification setting). This level emphasizes
                                                                                           thoughts coherent? Are there signs of psychosis or destructive
    peer and social support and is intended for patients whose
                                                                                           thoughts?
    intoxication and/or withdrawal is sufficient to warrant 24-hour
                                                                                      Š General physical assessment with neurological exam: This will
    support.
                                                                                           ascertain the patient’s general health and identify medical or
 Level III.7-D: Medically monitored inpatient detoxification (e.g.,
                                                                                           psychiatric disorders of immediate concern.
    freestanding detoxification center). Unlike Level III.2.D, this level
                                                                                      Š Temperature, pulse, blood pressure (should be monitored
    provides 24-hour medically supervised detoxification services.
                                                                                           throughout detoxification).
 Level IV-D: Medically managed intensive inpatient detoxification
                                                                                      Š Patterns of substance abuse: When did the patient last use? What
    (e.g., psychiatric hospital inpatient center). This level provides 24-
                                                                                           were the substances of abuse? How much of these substances
    hour care in acute-care inpatient settings.
                                                                                           were used and how frequently?
It is important to note that ASAM PPC-2R criteria are only guidelines,                Š Urine and toxicology screen for commonly abused substances.
and that there are no uniform protocols for determining which patients                Š Past substance abuse treatments or detoxification.
are placed in which level of care. For further information on patient              Psychosocial domains.
placement, readers are advised to consult TIP 13, The Role and Current                Š Demographic features: Gather information on gender, age,
Status of Patient Placement Criteria in the Treatment of Substance Use                     ethnicity, culture, language and education level.
Disorders (Center for Substance Abuse Treatment 1995).                                Š Living conditions: Is the patient homeless or living in a shelter?
                                                                                           Are significant others in the home (and, if so, can they safely
Biomedical and psychosocial issues
                                                                                           supervise)?
Detoxification presents an opportunity to intervene during a period of
                                                                                      Š Violence, suicide risk: Is the patient aggressive, depressed, or
crisis and to encourage a client to make changes in the direction of health
                                                                                           hopeless? Is there a history of violence?
and recovery. Hence, a primary goal of the detoxification staff should be
                                                                                      Š Transportation: Does the patient have adequate means to get to
to build a therapeutic alliance and motivate patients to enter treatment.
                                                                                           appointments? Do other arrangements need to be made?
This process should begin as the patient is being medically stabilized.
                                                                                      Š Financial situation: Is the patient able to purchase medication
Symptoms and signs of conditions that require immediate medical                            and food? Does the patient have adequate employment and
attention:                                                                                 income?
 Change in mental status.                                                            Š Dependent children: Is the patient able to care for children,
 Increasing anxiety.                                                                      provide adequate childcare, and ensure the safety of children?
 Hallucinations.                                                                     Š Legal status: Is the patient a legal resident? Are there pending
 Temperature greater than 100 degrees F (these patients should be                         legal matters? Is treatment court ordered?
    considered potentially infectious).                                               Š Physical, sensory, or cognitive disabilities: Does the client have
 Significant increases and/or decreases in blood pressure and heart                       disabilities that require consideration?
    rate.
                                                                                  Considerations for specific populations
 Insomnia.
                                                                                   Adolescents.
 Abdominal pain.
                                                                                     Š Adolescents are more likely to drink large quantities of alcohol
 Upper and lower gastrointestinal bleeding.
                                                                                        in a short period of time, making it important that staff be alert to
 Changes in responsiveness of pupils.
                                                                                        escalating blood alcohol levels.
 Heightened deep tendon reflexes and ankle clonus, a reflex beating
                                                                                     Š Adolescents are more likely to use drugs they cannot identify, to
    of the foot when pressed rostrally, indicating profound central
                                                                                        combine multiple substances with alcohol, to ingest unidentified
    nervous system irritability and the potential for seizures.
                                                                                        substances, and to be unwilling to disclose drug use.
Immediate mental health needs                                                        Š Asking open-ended questions and using street terminology for
The following are mental health issues that require immediate attention:                drugs can be helpful in both establishing rapport and in obtaining
 Suicidality.                                                                          an accurate substance use history.
   Š Patients receiving detoxification services should be evaluated for            Parents with dependent children.
        suicide risk.                                                                Š It is of vital importance to ensure that the children of someone
   Š During acute intoxication and withdrawal, it is important to                       receiving detoxification services have a safe place to stay.
        provide an environment that minimizes opportunities for suicide              Š Working with patients to identify supportive family or friends
        attempts.                                                                       may uncover temporary childcare resources.
   Š Frequent safety checks should be implemented.                                   Š A consult or referral to the treatment facility’s social services
   Š Patients at risk for suicide should be placed in areas monitored                   while the patient is being detoxified is indicated when the care of
        by staff.                                                                       children is uncertain.

                                                                              2
   Victims of domestic violence.                                                  Foster a therapeutic alliance
    Š Staff should know the signs of domestic violence and be                       A relationship between the clinician and patient that is supportive,
        prepared to follow procedures to ensure the safety of a patient.              empathic, and nonjudgmental is the hallmark of a strong therapeutic
    Š Trained staff can help the victim create a long-term safety plan                alliance.
        or at least make a proper referral.                                         Efforts to establish a therapeutic alliance should begin upon
    Š All printed information about domestic violence should be                       admission.
        disguised and none should be kept by the patient when leaving
                                                                                   Referrals and linkages
        the safe facility.
                                                                                   Once an individual passes through the most severe withdrawal
    Š It may be important that the abused person not be allowed to talk
                                                                                   symptoms and is safe and medically stable, the focus of the psychosocial
        to the abuser while in detoxification.
                                                                                   intervention shifts toward preparing the patient for substance abuse
   Culturally diverse patients.
                                                                                   treatment. These interventions include:
    Š Cultural sensitivity is tremendously important.
                                                                                    Assessment of the patient’s characteristics, strengths, and
    Š Expectations of detoxification, feelings about the healthcare
                                                                                       vulnerabilities that will influence recommendations for substance
        system in general, and social and community structures vary
                                                                                       abuse treatment.
        according to cultural backgrounds.
                                                                                    Preparing the patient to participate in treatment.
    Š The practitioner should avoid defining the patient in terms of his
                                                                                    Successfully linking the patient to treatment as well as other needed
        culture; over- or underemphasizing the patient’s race or ethnicity
                                                                                       services and resources.
        can be detrimental.
    Š For a list of questions that can guide a practitioner to better              Evaluation of the patient’s rehabilitation needs
        understand a patient’s cultural framework, see Figure 3-4 in               The American Society of Addiction Medicine’s Patient Placement
        SAMSHA’s TIP 45.                                                           Criteria, Second Edition, Revised (2001) provides a widely used model
                                                                                   for determining the level of services needed to address substance-related
Strategies for engagement and recovery
                                                                                   disorders. The criteria used to determine the most appropriate level of
It is essential that all clinicians offer hope and the expectation of
                                                                                   rehabilitation are based on six dimensions:
recovery. Throughout detoxification, staff should be unified in their
                                                                                    Acute intoxication and/or withdrawal potential.
message that detoxification is only the beginning of the treatment
                                                                                    Biomedical conditions and complications.
process and that rehabilitation and maintenance activities are critical to
                                                                                    Emotional, behavioral, or cognitive conditions or complications.
sustained recovery.
                                                                                    Readiness to change.
Educate the patient on the withdrawal process                                       Relapse, continued use, or continued problem potential.
During intoxication and withdrawal, it is useful to provide information             Recovery/living environment.
on the typical withdrawal process based on the particular drug of abuse.
                                                                                   Detoxification programs should focus their evaluation on areas that are
 Providing information concerning withdrawal symptoms may reduce
                                                                                   essential to make an appropriate linkage to substance abuse treatment.
    discomfort and the likelihood the individual will leave detoxification
                                                                                   The following are recommended:
    prematurely.
                                                                                    Medical conditions and complications.
 Settings that individuals in withdrawal routinely encounter should
                                                                                    Motivation/readiness to change.
    have written materials available on drug effects and withdrawal
                                                                                    Physical, sensory, or mobility limitations.
    from specific drugs. This material should also be available for non-
                                                                                    Relapse history and potential.
    English-speaking patients.
                                                                                    Substance abuse/dependence.
 Interventions that assist the client in identifying and managing urges
                                                                                    Development and cognitive issues.
    to use also may be helpful in retaining the client in detoxification and
                                                                                    Family and social support.
    ensuring the initiation of rehabilitation.
                                                                                    Co-occurring psychiatric disorders.
Use support systems                                                                 Dependent children.
 The use of client advocates to intervene with clients wishing to leave            Trauma and violence.
   early is often an effective strategy for promoting retention.                    Treatment history.
 Visitors should be instructed about the importance of supporting the              Cultural background.
   individual in both detoxification and substance abuse treatment.                 Strengths and resources.
 If available and if the patient is stable, he or she can attend onsite 12-        Language.
   step or other support group meetings while receiving detoxification
                                                                                   Providing linkages to treatment and maintenance activities
   services.
                                                                                   Research indicates that patients are more likely to initiate and remain
Maintain a drug-free environment                                                   in treatment if they believe the services will help them with specific life
 Maintaining a safe and drug-free environment is essential to                     problems. The following are strategies that detoxification personnel can
   retaining clients in detoxification.                                            use with their patients to promote the initiation of treatment:
 Providers should be alert to drug-seeking behaviors.                              Perform an assessment of urgency for treatment.
 Visiting areas should be easy for staff to monitor.                               Reduce time between initial call and appointment.
 Explain to patients and visitors why substances are not allowed in                Call to reschedule missed appointments.
   the facility.                                                                    Provide information about what to expect at the first session.
                                                                                    Provide information about confidentiality.
Consider alternative approaches and motivational enhancement
                                                                                    Offer tangible incentives such as the prospect of improved relations
 Although the effectiveness of alternative treatments in detoxification
                                                                                        with family and friends and improved self-image.
   has not been validated in well-controlled clinical trials, alternative
                                                                                    Engage the support of family members.
   therapies that bring patients into detoxification and keep them there
                                                                                    Introduce the client to the counselor who will deliver rehabilitation
   may have utility beyond any therapeutic value offered.
                                                                                        services.
 Motivational enhancements are particularly well suited to promoting
                                                                                    Offer services that address basic needs, such as housing,
   initiation in rehabilitation and maintenance activities. For more
                                                                                        employment, and childcare.
   information on enhancing motivation for change, see TIP 35,
   Enhancing Motivation for Change in Substance Abuse Treatment.
                                                                               3
Biopsychosocial screening and assessment                                         The following symptoms of alcohol intoxication can vary greatly with
This section covers more complex psychosocial and biomedical                     the patient’s level of tolerance:
assessments that may occur after initial contact as an individual                 Blood alcohol level is 20-100mg percent:
undergoes detoxification. The following is a list of instruments useful in           Š Mood and behavioral changes.
characterizing the intensity of specific withdrawal states.                          Š Reduced coordination.
                                                                                     Š Impairment of ability to drive a car or operate machinery.
 Drug of dependence            Instrument                  Notes                  Blood alcohol level is 101-200mg percent:
 Alcohol                  CIWA-Ar (not             10 items, 2-5 minutes             Š Reduced coordination of most activities.
                          valid for decision       to complete.                      Š Speech impairment.
                          making with history                                        Š Trouble walking.
                          of serious alcohol                                         Š General impairment of thinking and judgment.
                          withdrawal or when                                         Š Somnolence, combative or “psychotic” behavior.
                          benzodiazepine                                             Š “Normal” mental status.
                          dependent).                                             Blood alcohol level is 201-300mg percent:
                                                                                     Š Marked impairment of thinking, memory, and coordination.
 Cocaine                  CSSA                     18 items, 10 minutes
                                                                                     Š Marked reduction in level of alertness.
                                                   to complete.
                                                                                     Š Memory blackouts.
 Opioids                  SOWS                     16-item                           Š Nausea and vomiting/aspiration.
                                                   questionnaire.                 Blood alcohol level is 301-400mg percent:
 Opioids                  OOWS                     Rater observes patient            Š Worsening of above symptoms with reduction of body
                                                   for 10 minutes,                        temperature and blood pressure.
                                                   indicates if any of               Š Excessive sleepiness/comatose.
                                                   13 manifestations                 Š Amnesia.
                                                   of withdrawal are                 Š Nausea and vomiting/aspiration.
                                                   present.                          Š Death.
                                                                                  Blood alcohol level is 401–800mg percent:
The CIWA-Ar is available for free from CSAT and is reprinted in TIP                  Š Difficulty waking the patient (coma).
24, A Guide to Substance Abuse Services for Primary Care Physicians.                 Š Serious decreases in pulse, temperature, blood pressure, and rate
Appendix C of TIP 45 provides further information on how to acquire                       of breathing.
and use the CSSA, SOWS, and OOWS.                                                    Š Urinary and bowel incontinence.
Biochemical markers and drug testing                                                 Š Death.
Biochemical markers are laboratory tests that detect the changes in              The signs and symptoms of acute alcohol withdrawal generally start 6
biochemistry and physiology related to the presence or absence of                to 24 hours after the patient takes his last drink. Acute withdrawal may
alcohol or other substances of abuse. Comprehensive medical drug                 begin when the patient still has significant blood alcohol concentrations.
testing for specific substances may be able to identify recent use,              The signs and symptoms may include the following and are highly
quantify the level of recent use, or may be able to quantify recent              variable:
cumulative use. Forensic or worksite drug testing should not be equated           Restlessness, irritability, anxiety, agitation.
to or confused with the more comprehensive range of sensitive tests               Anorexia, nausea, vomiting.
available for medical drug testing. Medical drug testing and testing              Tremor, elevated heart rate, increased blood pressure.
for biochemical markers are essential components of a comprehensive               Insomnia, intense dreaming, nightmares.
clinical assessment.                                                              Poor concentration, impaired memory and judgment.
Common use of biochemical markers and drug tests are:                             Increased sensitivity to sound, light, and tactile sensations.
 In the initial screening setting to support or refute other information         Hallucinations (auditory, visual, or tactile).
   that leads to proper diagnosis, assessment, and management.                    Delusions, usually of paranoid or persecutory varieties.
 For forensic purposes.                                                          Grand mal seizures.
 In detecting secret or hidden use of alcohol and other substances in            Hyperthermia.
   therapeutic settings where abstinence, rehabilitation, and treatment           Delirium/disorientation with regard to time, place, person, and
   are being promoted. There are several different types of drug tests               situation; fluctuation in level of consciousness.
   and biochemical markers:                                                      Management of alcohol withdrawal without medication note:
   Š Blood alcohol content.                                                       Indications for the management of alcohol withdrawal without
   Š Breath alcohol levels.                                                        medication have not been established through scientific studies or
   Š Urine drug screens (in addition to alcohol, urine drug screens can            evidence-based methods.
       be effective for detecting benzodiazepines, barbiturates, cocaine,         The course of alcohol withdrawal is unpredictable; it is impossible to
       amphetamines, opioids, and PCP).                                            tell who will or will not experience life-threatening complications.
   Š Gamma-glutamyltransferase (GGT).                                             Positive aspects of the nonmedication approach are that it is highly
   Š Carbohydrate-deficient transferrin.                                           cost-effective and provides inexpensive access to detoxification for
   Š Mean corpuscular volume (MCV).                                                individuals seeking aid.
   Š Alcohol metabolites.
   Š Toxicological drug tests for general and specific opiates,                  Social detoxification
       stimulants, hallucinogens, benzodiazepines, barbiturates,                 Social detoxification programs are short-term, non-medical treatment
       marijuana, other controlled substances, and other drugs that              service for individuals with substance use disorders. A social
       are compounded with controlled substances (e.g., aspirin and              detoxification program offers room, board, and interpersonal support
       acetaminophen).                                                           to intoxicated individuals and individuals in substance use withdrawal.
                                                                                 Social detoxifications programs vary widely in services offered, but there
Detoxification services for specific substances abuse                            should always be medical surveillance, including monitoring of vital
Alcohol intoxication and withdrawal                                              signs.
                                                                             4
The TIP provides several guidelines for social detoxification programs:                Gradual, tapering doses
 Such programs should follow local governmental regulations                            Once the patient has been stabilized, oral benzodiazepines can be
   regarding licensing and inspection.                                                  administered on a predetermined dosing schedule for several days
 It is highly desirable that individuals entering social detoxification                and gradually tapered over time. One example of this regimen is
   be assessed by primary care practitioners with some substance abuse                  that patients might receive 50mg of chlordiazepoxide or 10mg
   treatment experience.                                                                diazepam every six hours during the first day of treatment and 25mg
 An assessment should determine whether the patient is currently                       of chlordiazepoxide or 5mg diazepam every six hours on the second
   intoxicated and the degree of intoxication, the type of withdrawal                   and third days.
   syndrome, severity of the withdrawal, information regarding past                    Single daily dosing protocol
   withdrawals, and the presence of co-occurring psychiatric, medical,                  According to studies, this regimen may be attractive in community
   and surgical conditions that might require specialized care.                         or social detoxification settings, particularly if patients could be
 Particular attention should be paid to individuals who have                           monitored between doses.
   undergone multiple withdrawals in the past and for whom each
                                                                                    Limitations of benzodiazepines in outpatient treatment
   withdrawal appears to be worse than previous ones (the so-called
                                                                                    The interaction of benzodiazepines with alcohol can lead to coma
   “kindling effect”). Patients with a history of severe withdrawals are
                                                                                    and respiratory suppression, motor incoordination, and abuse. Abuse
   not good candidates for social detoxification.
                                                                                    is usually in the context of the concurrent use of alcohol, opioids, or
 All social detoxification programs should have personnel who are
                                                                                    stimulants. There are two limitations as well:
   familiar with the features of substance use withdrawal, have training
                                                                                     Although benzodiazepines have been studied for 30 years and
   in basic life support, and have access to an emergency medical
                                                                                        are effective for suppressing alcohol withdrawal symptoms, their
   system that can provide transportation to emergency departments.
                                                                                        ability to halt the progressive worsening of each successive alcohol
Management of alcohol withdrawal with medications                                       withdrawal is in question.
It is believed that only a minority of patients with alcoholism will go              Benzodiazepine use to treat outpatients in alcohol withdrawal may
into significant alcohol withdrawal requiring medication. Identifying                   “prime” or reinstate alcohol use during their administration.
                                                                                    .
that small minority is sometimes problematic, but there are signs and
                                                                                    Other medications
symptoms of impending problems that can alert the caretaker to seek
                                                                                    The following is a list of other medications sometimes used in
medical attention. Deciding whether or not to use medical management
                                                                                    detoxification from alcohol:
for alcohol withdrawal requires that patients be separated into three
                                                                                     Barbiturates.
groups:
                                                                                     Anticonvulsants.
 Clients who have a history of the most extreme forms of withdrawal,
                                                                                     Beta blockers/alpha adrenergic agonists.
     that of seizures and/or delirium. The medication treatment of this
                                                                                     Antipsychotics.
     group should proceed as quickly as possible.
                                                                                     Relapse prevention agents.
 Patients who are already in withdrawal and demonstrating moderate
     symptoms of withdrawal also require immediate medication.                      Management of delirium and seizures
 The third group includes patients who may still be intoxicated, or                The major goal of medical detoxification is to avoid seizures and a
     who have, at the time of admission, been abstinent for only a few              special state of delirium called delirium tremens (DTs) with aggressive
     hours and have not developed signs or symptoms of withdrawal. A                use of the primary detoxification drug. Death and disability may result
     decision regarding medication treatment for this group should be               from DTs or seizures without medical care.
     based on advancing age, number of years with alcohol dependence,
     and the number of previously treated or untreated severe                       For patients with a history of DTs or seizures, early benzodiazepine
     withdrawals. If there is an opportunity to observe the patient over            treatment is indicated at the first clinical setting. Patients with severe
     the next 6 to 8 hours, then it is possible to delay a decision regarding       withdrawal symptoms, multiple past detoxifications (more than three),
     treatment and periodically reevaluate a client in this category.               and co-occurring unstable medical and psychiatric conditions should be
                                                                                    managed similarly.
Benzodiazepine treatment for alcohol withdrawal
These drugs remain the medication of choice in treating withdrawal                  DTs
from alcohol. The early recognition of alcohol withdrawal and prompt                 Giving the patient a benzodiazepine should not be delayed by
administration of a suitable benzodiazepine will prevent further                       waiting for the return of laboratory studies, transportation problems,
withdrawal reaction from proceeding to serious consequences.                           or the availability of a hospital bed.
 Loading dose of a benzodiazepine                                                   Once full DTs have developed, they tend to run their course despite
    Administration of a metabolized benzodiazepine may be carried                      medication management.
    out every one to two hours until significant clinical improvement                Patients presenting in severe DTs should have emergency medical
    occurs or the patient becomes sedated. In general, patients with                   transport to a qualified emergency department and generally will
    severe withdrawal may receive 20mg of diazepam or 100mg of                         require hospitalization.
    chlordiazepoxide every two to three hours until improvement or                  Seizures
    sedation prevails. The treatment staff should closely monitor blood              Seizures usually occur within the first 48 hours after cessation or
    pressure, pulse, and respiratory features.                                          reduction of alcohol, with peak incidence around 24 hours.
 Symptom-triggered therapy                                                          Someone experiencing a seizure is at greater risk for progressing to
    Using the CIWA-Ar or similar alcohol withdrawal rating scales,                      DTs, whereas it is extremely unlikely that a patient already in DTs
    medical personnel can be trained to recognize symptoms of alcohol                   will also then experience a seizure.
    withdrawal, make a rating, and based on the rating administer                    The occurrence of an alcohol withdrawal seizure happens quickly,
    benzodiazepines to their patient only when signs and symptoms                       usually without warning to the individual experiencing the seizure or
    reach a particular threshold. A typical routine of administration is as             anyone around him.
    follows:                                                                         Predicting who will have a seizure during alcohol withdrawal cannot
        Administer 50mg of chlordiazepoxide for CIWA-Ar>9                               be accomplished with any great certainty.
        and reassess in one hour. Continue administering 50mg
        chlordiazepoxide every hour until CIWA-Ar is <10.

                                                                                5
   Patients having a seizure can be treated with intravenous (IV)                Vomiting.
    diazepam or lorazepam and advanced cardiac life support protocol              Diarrhea.
    procedures.                                                                   Bone and muscle pain.
   Patients who have had a single witnessed or suspected alcohol                 Anxiety.
    withdrawal seizure should be immediately given a benzodiazepine,
                                                                               Medical complications associated with opioid withdrawal can develop
    preferably with IV administration.
                                                                               and should be quickly identified and treated. Unlike alcohol and sedative
   Benzodiazepine and/or barbiturate intoxication needs to be treated
                                                                               withdrawal, uncomplicated opioid withdrawal is not life-threatening.
    and assessed differently, given the potentially life-threatening
    implications of withdrawal from either substance in combination            Management of withdrawal without medication
    with each other and/or alcohol (See section titled Intoxication and        It is not recommended that clinicians attempt to manage significant
    withdrawal from benzodiazepines and other sedative-hypnotics later         opioid withdrawal symptoms without the effective detoxification
    in this guide for more information.)                                       agents discussed below. Even mild levels of opioid use commonly
                                                                               produce uncomfortable levels of withdrawal symptoms. Management
Wernicke-Korsakoff’s syndrome
                                                                               of withdrawal without medications can produce needless suffering in a
 Wernicke-Korsakoff’s syndrome is composed of Wernicke’s
                                                                               population that tends to have limited tolerance for physical pain.
  encephalopathy and Korsakoff’s psychosis.
 Wernicke’s encephalopathy is an acute neurological disorder                  Management of opioid withdrawal with medications
  featuring oculomotor dysfunction (bilateral abducens nerve                   The management of opioid withdrawal with medication is most
  palsy-eye muscle paralysis), ataxia (loss of muscle coordination),           commonly achieved through the use of methadone, buprenorphine, or
  confusion, and weakness.                                                     clonidine.
 Korsakoff’s psychosis is a chronic neurological condition that
  includes retrograde and antegrade amnesia (profound deficit in new           Methadone
  learning and remote memory) with confabulation (patients make up             Methadone is a long-acting agonist at the µ-opioid site that displaces
  stories to cover memory gaps).                                               heroin (or other abused opioids) and restabilizes the site, thereby
 Both syndromes are related to thiamine deficiency.                           reversing opioid withdrawal symptoms.
 Thiamine initially is given parenterally (in a manner other than              If maintained for long enough, this stabilizing effect can reverse
  through the digestive tract, as by intravenous or intramuscular                  the immunological and endocrinologic defects caused by long-term
  injection). Afterward, oral administration is the treatment of choice.           heroin use.
 Always give thiamine prior to glucose administration.                         The initial dose requirements of methadone are determined by
                                                                                   estimating the amount of opioid use and gauging the patient’s
Opioid intoxication and withdrawal                                                 response to administered methadone.
Opioids are highly addicting, and their chronic use leads to withdrawal         Methadone can be given once daily and generally tapered over 3 to 5
symptoms that, although not medically dangerous, can be highly                     days in 5 to 10mg daily reductions.
unpleasant and produce intense discomfort.                                      For detailed information on methadone maintenance, readers are
Signs and symptoms of opioid intoxication and withdrawal                           referred to TIP 43, Medication-Assisted Treatment for Opioid
Opioid intoxication signs:                                                         Addiction in Opioid Treatment Programs.
 Slow pulse.                                                                  Clonidine (Catapres)
 Low blood pressure.                                                          There are several advantages to treating opioid withdrawal using
 Low body temperature.                                                        clonidine rather than methadone:
 Sedation.                                                                     Clonidine does not produce opioid intoxification and is not
 Pinpoint pupils.                                                                 reinforcing.
 Slowed movement.                                                              The FDA does not classify clonidine as having abuse potential,
 Slurred speech.                                                                  though some abuse has been reported.
 Head nodding.                                                                 Detoxification with clonidine occurs without opioids.
Opioid intoxication symptoms                                                    No special licensing is required for the dispensing of this medication.
 Euphoria.                                                                        Although clonidine alleviates some symptoms of opioid withdrawal,
 Pain-killing effects.                                                            it usually is relatively ineffective for insomnia, muscle aches, and
 Calmness.                                                                        drug craving.

Opioid withdrawal signs                                                        An appropriate protocol for clonidine is 0.1mg administered orally as
 Fast pulse.                                                                  a test dose. A dose of 0.2mg might be used initially for patients with
 High blood pressure.                                                         severe signs of opioid withdrawal or for those patients weighing more
 High body temperature.                                                       than 200 pounds. The sublingual route of administration may also be
 Insomnia.                                                                    used. Clinicians should check the patient’s blood pressure prior to
 Enlarged pupils.                                                             administration and should withhold clonidine if systolic blood pressure
 Abnormally heightened reflexes.                                              is lower than 90 or diastolic blood pressure is below 60.
 Sweating.                                                                    Clonidine (0.1 to 0.2mg orally) can be given every 4 to 6 hours on an as-
 Gooseflesh.                                                                  needed basis. Clonidine detoxification is best conducted in an inpatient
 Increased respiratory rate.                                                  setting, as vital signs and side effects can be monitored more closely in
 Tearing (as in crying).                                                      this environment.
 Yawning.
 Runny nose.                                                                  Buprenorphine
 Muscle spasms.                                                                Buprenorphine is a partial µ-opioid agonist that has recently been
                                                                                  approved by the FDA in injectable form as a detoxification agent and
Opioid withdrawal symptoms                                                        for opioid maintenance treatment.
 Abdominal cramps.                                                             Buprenorphine is available in an oral form called Subutex; it is
 Nausea.                                                                         meant for patients who are starting treatment for drug dependence.
                                                                           6
   Suboxone, another oral form of buprenorphine, contains                       Stimulant withdrawal symptoms
    buprenorphine and naltrexone; it is intended for persons dependent            Depression.
    on opioids who have already started and are continuing medication             Hypersomnia or insomnia.
    therapy.                                                                      Fatigue.
   An advantage to buprenorphine is safety. Because of the partial               Anxiety.
    agonist action, buprenorphine has a ceiling effect with regard to             Irritability.
    overdose potential. Also, it can be administered in a doctor’s office.        Poor concentration.
   For more information on buprenorphine, see TIP 40, Clinical                   Psychomotor retardation.
    Guidelines for the Use of Buprenorphine in the Treatment of Opioid            Paranoia.
    Addiction.                                                                    Drug craving.
Intoxication and withdrawal from benzodiazepines and other                       While most clinicians believe that alcohol, benzodiazepine, barbiturate,
sedative-hypnotics                                                               and opiate withdrawal should be treated aggressively with detoxification,
Patients intoxicated with sedative-hypnotics appear similar to individuals       there has been little emphasis on treating symptoms of stimulant
intoxicated with alcohol: slurred speech, ataxia, and poor physical              withdrawal. No medication has been developed for this purpose.
coordination are prominent. When benzodiazepines are ingested alone,             The most effective means of treating stimulant withdrawal involves
intentionally, or accidentally in overdose, they rarely lead to death by         establishing a period of abstinence from these agents.
themselves. Unfortunately most individuals who ingest benzodiazepines
                                                                                 Medical complications of stimulant withdrawal
also may be using alcohol, other sedative-hypnotics, or other drugs of
                                                                                  Stimulant withdrawal is not usually associated with medical
abuse, which in combination with benzodiazepines could be fatal if not
                                                                                   complications.
managed appropriately.
                                                                                  While both cocaine and amphetamines (such as methamphetamine)
General points about withdrawal                                                    often produce depression in users during withdrawal, the period of
 Management of benzodiazepines and other sedative-hypnotics in                    depression experienced by amphetamine users is more prolonged
   overdose is in part supported following principles of advanced                  and may be more intense. Consequently, amphetamine users should
   cardiac life support, with attention to ventilation.                            be monitored closely during detoxification for signs of suicidality
 Removal of benzodiazepines from the gastrointestinal tract using                 and treated for depression if appropriate.
   lavage and a cathartic is generally carried out, particularly if the           Some patients with recent cocaine and alcohol use can experience
   overdose is recent.                                                             persistent cardiac complications, including prolonged QTc interval
 Flumazenil (Romazicon) is a competitive antagonist that acts as a                and vulnerability for arrhythmia and myocardial infarction through
   benzodiazepine receptor. It can reverse the sedative and overdose               the production of cocoethylene.
   effects of benzodiazepines but not of alcohol or other sedative-               Seizures may also be a complication of stimulant abuse and can
   hypnotics.                                                                      occur during detoxification.
 Assessing the severity of benzodiazepine and other sedative-
                                                                                 Management of withdrawal with medications
   hypnotic abstinence syndrome is based primarily on information
                                                                                 Although there are no medications proven to treat stimulant withdrawal,
   from the patient, significant others, and physical assessment.
                                                                                 researchers have investigated medications for cocaine detoxification:
Management of withdrawal with medication                                          Disulfiram and Amantadine may help reduce cocaine use in patients
 One strategy that is appropriate is to begin with a slow taper of the              with more severe withdrawal symptoms.
  benzodiazepine that the patient is already taking. This taper may be            Modafinil, an anti-narcolepsy agent with stimulant-like action, is
  conducted over several weeks or perhaps even months.                               currently under investigation by one research group as a cocaine
 Switching to another benzodiazepine in a patient who has had a                     detoxification agent.
  serious abuse problem with his primary agent may be therapeutic.                Antidepressants can be prescribed for the depression that often
 Switching to another benzodiazepine with a long half-life can be                   accompanies methamphetamine or other amphetamine withdrawal.
  effective; chlorodiazepoxide and clonazepam are recommended.
                                                                                 Intoxication and withdrawal from inhalants and solvents
 Switching to a long-acting barbiturate like phenobarbital can be
                                                                                 The term “inhalants” is used to describe a large and varied group of
  effective.
                                                                                 psychoactive substances that all share common characteristics of being
 A variety of cognitive and behavioral techniques have been proposed
                                                                                 inhaled for their effects.
  to assist a medication taper.
 Anticonvulsants such as carbamazepine and valproate, as well as                Commonly abused inhalants
  sedating antidepressants such as trazodone and imipramine, have                The following is a list of commonly abused inhalants and examples of
  been advocated for use in withdrawal.                                          each.
 Preparing patients for starting detoxification during a period of               Adhesives.
  low external stressors, with patient commitment to tapering and a                  Š Airplane glue.
  plan to manage underlying anxiety disorders, are also important in                 Š Special cements.
  detoxification.                                                                 Aerosols.
                                                                                     Š Spray paint.
Intoxication and withdrawal from cocaine, methamphetamine, and
                                                                                     Š Hair spray.
other stimulants
                                                                                     Š Deodorant/air freshener.
Cocaine and amphetamines (such as methamphetamine) are the most
                                                                                     Š Analgesic spray.
frequently abused central nervous system stimulants. Individuals
                                                                                     Š Asthma spray.
dependent on stimulants experience profound loss of control over
                                                                                  Anesthetics.
stimulant intake, presumably in response to the stimulation and
                                                                                     Š Gaseous.
disruption of endogenous reward centers. Alcohol and cocaine together
                                                                                     Š Liquid.
can result in cardiac arrest secondary to cocoethylene. Patients
                                                                                     Š Local.
intoxicated on both cocaine and ethanol may need to be monitored for
                                                                                  Cleaning agents.
changes in QT interval.
                                                                                     Š Dry cleaning.

                                                                             7
    Š Spot remover.                                                              (FTQ). A later revision known as the Fagerstrom Test for Nicotine
    Š Degreasers.                                                                Dependence (FTND) has been reduced to six questions. The six-question
   Solvents and gases.                                                          version appears in Figure 4-10 of TIP 45. The Glover-Nilsson Smoking
    Š Nail polish remover.                                                       Behavioral Questionnaire (GN-SBQ) is a 1-question, self-administered
    Š Paint remover.                                                             test that evaluates the impact of behaviors and rituals associated with
    Š Paint thinner.                                                             smoking. It was designed to assist in identifying and quantifying
    Š Correction fluid and thinner.                                              behavioral aspects of smoking that play a role in maintaining nicotine
    Š Fuel gas.                                                                  dependence, which can then help the clinician develop a cessation
    Š Lighter.                                                                   strategy. The GN-SBQ appears in Figure 4-11 of TIP 45.
    Š Fire extinguisher.
                                                                                 Medical complications of withdrawal from nicotine
   Food products.
                                                                                 There are no major medical complications precipitated by nicotine
    Š Whipped cream.
                                                                                 withdrawal itself. However, patients frequently experience
    Š Whippets.
                                                                                 uncomfortable withdrawal symptoms within a few hours of cessation.
   Withdrawal from inhalants.
                                                                                 Some of these symptoms – anxiety, irritability, depression, and others –
    Š Dependence on inhalants and subsequent withdrawal symptoms
                                                                                 can be confused as other psychiatric conditions. During detoxification
        are both relatively uncommon phenomena.
                                                                                 from nicotine, some medications will have their metabolism altered,
    Š There are no specific or characteristic withdrawal symptoms that
                                                                                 including:
        would include all drugs in the inhalant class.
                                                                                  Theophylline.
    Š There are no specific assessment instruments available to
                                                                                  Caffeine.
        measure inhalant withdrawal symptoms.
                                                                                  Tacrine.
    Š Most inhalants produce some neurotoxicity with cognitive,
                                                                                  Imipramine.
        motor, and sensory involvement.
                                                                                  Haloperidol.
    Š Damage to internal organs including the heart, lungs, kidneys,
                                                                                  Pentazocine.
        liver, pancreas, and bone marrow has been reported.
                                                                                  Propranolol.
   Management of withdrawal
                                                                                  Flecainide.
    Š It is crucial to provide the patient with an environment of safety
                                                                                  Estradiol.
        that removes him or her from access to inhalants.
    Š Patients presenting with only inhalant withdrawal are unusual;             Management of withdrawal without medication
        clinicians should promptly ascertain whether the patient has             The U.S. Public Health Service’s Treating Tobacco Use and
        been abusing other substances and proceed with appropriate               Dependence: Clinical Practice Guideline (2000) is a comprehensive
        detoxification as clinically indicated.                                  review of smoking cessation literature. The nonpharmacological
    Š No systemic detoxification protocol has been established for               interventions it discusses can be broken down into two categories: self-
        inhalant abuse.                                                          help interventions and behavioral interventions.
Detoxification and withdrawal from nicotine                                      Management of withdrawal with medications
Nicotine dependence in the form of cigarette smoking accounts for                A U.S. Public Health Service panel recommends that all primary care
approximately 450,000 deaths/year; or more deaths than AIDS, alcohol,            physicians offer active medication that has been approved for assisting
cocaine, heroin, homicide, suicide, motor vehicle crashes, and fire              in smoking cessation to all smokers who want to quit. The following are
combined. Smokers are at increased risk for several medical problems,            different types of medication that can be used with patients who wish to
including cancer, emphysema, chronic obstructive lung disease, chronic           quit smoking.
bronchitis, myocardial infarction, coronary artery diseases, hypertension,
stroke, and peripheral vascular disease.                                         Nicotine replacement therapy (NRT)
                                                                                 Nicotine polacrilex gum was approved by the FDA in 1984. In the 1990s,
Withdrawal symptoms associated with nicotine                                     other NRTs received FDA approval, including the nicotine transdermal
The following are the symptoms of nicotine withdrawal as delineated              patch, the nicotine nasal spray, and the nicotine inhaler. After the acute
by the Diagnostic and Statistical Manual of Mental Disorders 4th Text            withdrawal period, patients are weaned off the medication until they
Revision(DSM-IV-TR) (2000):                                                      become nicotine free. It is clear that constituents of tobacco other than
 Abrupt cessation of nicotine use, or reduction in the amount of                nicotine are responsible for causing cancer, and no ill effects have been
    nicotine used, followed within 24 hours by four or more of the               attributed to long-term use of nicotine replacement therapy.
    following signs:
    Š Dysphoric or depressed mood.                                               Medications
    Š Insomnia.                                                                  Bupropion SR’s exact method of action is unknown, but it is not a
    Š Irritability, frustration, or anger.                                       nicotine substitute or replacement like the NRTs. The recommended dose
    Š Anxiety. Difficulty concentrating.                                         is 150mg daily for 3 days and then 150mg twice daily for 7 to 12 weeks.
    Š Restlessness.                                                              Typically patients set their quit date 1 to 2 weeks from the time they start
    Š Decreased heart rate.                                                      the medication. This is an ideal time for the patient to focus on making
    Š Increased appetite or weight gain.                                         behavioral changes and enlisting social support to augment the quit
 These symptoms cause clinically significant distress or impairment             attempt. It is sold under the brand names Wellbutrin and Zyban.
    in social, occupational, or other important areas of functioning.            Another prescription medication now available to aid in smoking
 The symptoms are not due to a general medical condition and are not            cessation is Chantix (varenicline tartrate). Approved in 2006, the drug
    better accounted for by another mental disorder.                             blocks receptors that help perpetuate addiction and lowers the cravings
For diagnostic considerations based on the DSM-IV-TR, please see                 for nicotine.
Figure 4-9 in TIP 45.                                                            Other non-nicotine pharmacotherapy
Assessing severity                                                               There are several other medications currently being looked at for their
Since 1978, a standard instrument used to measure physical dependence            effectiveness in assisting with smoking cessation. They include:
on nicotine has been the eight-item Fagerstrom Tolerance Questionnaire            The alpha-2 agonist antihypertensive, clonidine.
                                                                                  The tricyclic antidepressant, nortriptyline.
                                                                             8
   The monoamine oxidase inhibitor (MAOI) antidepressant,                         Patients using ecstasy (MDMA) or related compounds frequently are
    moclobemide.                                                                    hyperactive and hyper-verbal, reporting heightened tactile and visual
   The serotonin 5-HT1A agonist anxiolytic, buspirone.                             sensations.
   The antihypertensive CNS nicotine receptor blocker, mecamylamine.              Hyperthermia, dehydration, water intoxication, with low sodium
   Oral dextrose tablets.                                                          rhabdomyolysis, renal failure, cardiac arrhythmia, and coma have
                                                                                    been reported.
Although none of these agents have been approved by the FDA for
                                                                                   Clinicians are likely to have to manage complications of intoxication
smoking cessation, clonidine, nortriptyline, and moclobemide have been
                                                                                    and overdose but not withdrawal.
found to be effective treatments.
                                                                                Ketamine and PCP (Phencyclidine)
Combination drug therapies
                                                                                 Withdrawal symptoms from PCP include depression, drug craving,
NRT products typically provide less than half of the nicotine plasma
                                                                                   increased appetite, and hypersomnolence.
levels that cigarette users achieve through smoking. To increase nicotine
                                                                                 In clinical settings, syndromes of acute intoxication with
levels, several clinical trials have evaluated combinations of different
                                                                                   hallucinations, delusions, agitation, and violence are the most
NRTs. There is moderately strong evidence to conclude that combining
                                                                                   pressing problems.
various NRTs is more efficacious than a single form of nicotine
                                                                                 In clinical settings, ketamine and PCP require management for
replacement.
                                                                                   the agitation and psychotic features produced during acute use;
Intoxication and withdrawal from anabolic steroids                                 occasionally oral or parenteral uses of sedating medications such as
Anabolic steroids are male hormones and subject to abuse as a means                benzodiazepines will be required.
of increasing muscle mass. These agents also can produce aggressive,             Occasionally patients will have such large overdoses that they will
manic-like behavior that may include delusions.                                    require airway management and ventilatory support for some hours.
Withdrawal symptoms associated with steroids                                    Conclusion
 Withdrawal symptoms include craving for more steroids, fatigue,               Substance abuse detoxification has been available to the general public
   depression, restlessness, anorexia, insomnia, reduced libido,                since the 1970s. Prior to that time, any person desiring to stop using
   headaches, and nausea.                                                       alcohol or other drugs was forced to undergo withdrawal with minimal
 It is not known how commonly this syndrome occurs, but steroid                medical intervention. Changes in the medical field, in perceptions of
   withdrawal appears more likely in heavy users.                               substance abuse and addiction, and in social policy have changed the
                                                                                way that people with dependency on drugs are treated.
Medical complications and management of steroid withdrawal
 Due to long duration of action with anabolic steroids, side effects           Several methods of detoxification have developed over the past 30 years.
  that might emerge cannot be quickly reversed by discontinuing                 Today, detoxification is part of a continuum of care and involves both
  substance use.                                                                evaluation and stabilization, but also referral to other levels of care for
 Other side effects may require management beyond the simple                   treatment. The PPC-2R developed by the American Society of Addiction
  recommendations that steroids be immediately discontinued; there              Medicine (ASAM) is often used to determine patient placement and care
  is no recommended detoxification protocol – the key medical goal is           during the detoxification period.
  cessation of steroid use.
                                                                                Numerous biomedical and psychosocial issues must be addressed
Intoxication and withdrawal from club drugs                                     during the detoxification process, and various strategies for engagement
Club drugs are illicit drugs used in the settings of nightclubs, dance          and recovery should be implemented to improve the client’s
clubs, parties, and raves. Use of these drugs among adolescents and             chances for a successful recovery. Lastly, a number of interventions
young adults has risen significantly in recent years. Although withdrawal       have been developed for detoxification from specific substances
syndromes have been reported with some of these drugs, this is not the          of abuse, including: alcohol, opioids, benzodiazepines, cocaine,
most common clinical problem. Intoxication and severe intoxication              methamphetamines, and nicotine.
with overdose are more frequent.
                                                                                With proper interventions and therapeutic engagement, detoxification
Hallucinogens                                                                   can be the first step of the recovery process for a person who is abusing
 Hallucinogens are a broad group of substances that can produce                mood-altering substances.
   sensory abnormalities and hallucinations.
 Hallucinogens are also referred to as psychedelics and
   psychomimetics; they include LSD, mescaline, MDMA, MDA, and
   DOM.
 The prominent effects during intoxication are sensory distortions                            (Final examination questions on next page)
   with illusions and hallucinations; visual distortions are more
   common than auditory or tactile ones.
 “Bad trips” involve anxiety including panic attacks, paranoid
   reactions, anger, violence, and impulsivity.
 Withdrawal syndromes have not been reported with hallucinogens.
 Acute intoxication and bad trips usually can be managed with
   placement of the individual in a quiet, nonstimulating environment
   with immediate and direct supervision so that the patient does not
   cause harm to himself or to others
Gamma-hydroxybutyrate (GHB)
 GHB intoxication may look like alcohol or sedative-hypnotic
  intoxication, and case reports of GHB withdrawal have occurred.
 Management of withdrawal has been with supportive care and
  benzodiazepines such as lorazepam.
Ecstasy
                                                                            9
     DETOXIFICATION AND SUBSTANCE ABUSE TREATMENT                                  NOTES
                     FUNDAMENTALS
                    Final Examination Questions
(Course meets the qualifications for 3 hours of continuing education
 credit for MFCs and/or LCSs as required by the California Board of
                        Behavioral Sciences)

     Choose True or False for questions 1 through 10 and then proceed to
             www.elitecme.com to complete your final exam.

1.     The “medical model” of detoxification is characterized by the use of
       physicians and nursing staff and the administration of medication to
       assist people through withdrawal safely.
            True                         False

2. Detoxification alone is sufficient treatment for substance
   dependence.
            True                         False

3. The signs and symptoms of acute alcohol withdrawal generally start
   10 to 12 days after the patient takes his last drink.
            True                         False

4. Social detoxification programs are long-term, medical treatment
   service for individuals with substance use disorders.
            True                         False

5. The early recognition of alcohol withdrawal and prompt
   administration of a suitable benzodiazepine will prevent further
   withdrawal reaction from proceeding to serious consequences.
            True                         False

6. The interaction of benzodiazepines with alcohol can lead to coma
   and respiratory suppression, motor incoordination, and abuse.
            True                         False

7. Once full DTs have developed, they tend to stop completely with
   medication management.
            True                         False

8. Seizures usually occur within the first 48 hours after cessation or
   reduction of alcohol, with peak incidence around 24 hours.
            True                         False

9. Unlike alcohol and sedative withdrawal, uncomplicated opioid
   withdrawal is life-threatening.
            True                         False

10. Patients intoxicated with sedative-hypnotics appear similar to
    individuals intoxicated with alcohol: slurred speech, ataxia, and poor
    physical coordination are prominent.
            True                         False




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