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Outpatient Detox: Is this really a good idea?
[From: Smithers Addiction News, March 2000, Vol 1, Num 1, Pages 1-2]

Alexander DeLuca, M.D.

Detoxification is a medical procedure in which death and medical/psychiatric complications are prevented or stabilized, while patient discomfort is minimized. One could also argue that detoxification is a senseless procedure in that detoxification alone accomplishes nothing–the overwhelming majority of patients who do not subsequently engage in some ongoing process of psychological and social change will find no intermediate or long term relief from their suffering. Detox is the prerequisite; the body and the brain will generally heal if the poisoning stops.

Detoxification provides an opportunity to engage, assess, motivate and refer, and it is these clinical interventions that can make a long term difference in a patient’s life. The attention of the detox staff, the daily visits with the doctor, and the relief experienced when withdrawal is adequately treated can all be powerfully engaging and motivating for patients.

Controlling the Risk in Outpatient Detox

Any detoxification procedure entails risk, but outpatient treatments involve an added dimension of potential problems. Because the patient is not in a controlled inpatient environment, behavior dangerous to self or others cannot be immediately prevented. People impaired by detox medications should not drive, so how the patient gets to and from the clinic becomes an issue in the outpatient setting. Finally, decisions must be made regarding the patient’s ability to fulfill family and occupational responsibilities, and about the safety of the home environment.

The predicted severity of withdrawal needs to be evaluated, using standardized withdrawal scales and tools whenever possible, during the medical assessment of the detox patient. Based on the entire assessment, the physician assigns the patient to the appropriate level of outpatient or inpatient care, using the ASAM Patient Placement Criteria or a similar instrument. Given the risk of serious complications in very dependent or otherwise predisposed sedative (including alcohol) addicts, special care must be taken in these cases. Medical, and psychiatric comorbidity, and increased age all independently raise risk.

Inpatient vs. Outpatient

It wasn’t too long ago that when you said something like, “Dr. Jones detoxes people,” everyone understood that the good doctor worked in an inpatient unit, probably a hospital. Nowadays Jones might be doing detoxification in his private office, in a clinic setting, in a low-intensity inpatient setting (for ex: a rehab), or in the old acute-care hospital detox ward (if it still exists).

Every study of outpatient detoxification in which medication was used to control withdrawal symptoms ends up saying the same thing. Outpatient detoxification is safe and effective in properly selected patients. A well thought out, staged assessment is imperative. First, the patient is evaluated by medical personnel, and the need for inpatient treatment ruled-out, before outpatient detox is considered and the complete biopsychosocial assessment completed.

[We will consider the elements of such an assessment, in detail, in a future Addiction News article.]

Outpatient Detox Guidelines

Detoxification providers need to have clearly stated policies, in writing, and guidelines to review with the patient. Patients need to know what the limits are and the consequences of inability or failure to abide by the policies.

Here is a stripped down version of the guidelines we use at Smithers:

1) No alcohol or drug use - urine tox on demand
2) Frequent visits (usually daily)
3) Small quantities of medications prescribed
4) Compliance is crucial
5) No driving or other hazardous activity
6) Safe, sober living environment
7) Patient understands potential complications and can use emergency number.

Most of these points are self-evident and common sense. Alcohol or drug abuse while on a outpatient detox regimen is grounds for discontinuing the treatment. The patient has to agree to frequent visits to the clinic and understands that only enough medication will be provided for adequate treatment between visits. Compliance is crucial in outpatient detox. Combining detox medication with alcohol or street drugs could be dangerous, and diversion of medication is to be mightily avoided. Pills should be counted and records kept of the dosage regimen, the number of doses prescribed or dispensed, and the number of pills returned on the next visit.

The patient must have a safe place to reside during the detox period. One cannot prescribe an abuse-able medication with a street value to a patient who lives in a crack house. Patients with significantly impaired cognitive function must have a responsible adult with them who understands the instructions and can see that the patient follows them. Patients with severe medical or psychiatric conditions are not candidates for outpatient detox. Finally, the patient should agree that if the outpatient treatment cannot be accomplished within the guidelines, he will accept referral for inpatient treatment.

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Having said all this, it needs to be emphasized that these are guidelines for the structure and functioning of medical care for substance abusers, not rules governing prisoner behavior in a maximum-security facility. There is a world of difference, in most clinicians’ minds, between the patient who impulsively uses one bag of heroin on day 3, volunteers this information and demonstrates insight into how the slip occurred and how it might have been prevented; and the patient who shows up on day 3 with a newly positive urine toxicology for cocaine, pinpoint pupils, and a story about losing his opiate detox medications. In the first case an attempt is made to analyze and learn from the experience and the outpatient detox continues, perhaps with a contract spelling out actions to be taken should further drug abuse occur. In the second case, the outpatient detox is discontinued and the patient is referred to an inpatient facility. It is the responsibility of the clinician to exercise expert judgment in interpreting and enforcing the rules.

Research has shown that many patients get more than one detox. They often report unrealistic expectations regarding remaining abstinent and are more realistic in subsequent treatments. It should also be noted that rates of compliance and relapse in addictive disease are comparable to those in other chronic, relapsing conditions such as diabetes and hypertension. We need to remember that outpatient detoxification is about stopping the pain, engaging the patient, evaluating the situation, and providing guidance and support during the patient’s next steps. It is not a test that the patient has to pass to ‘get into treatment.’ We need to provide an environment to which patients feel that they can always turn for help.

Addiction medicine patients should be entitled to the same ongoing care, based on medical need, that patients with other chronic, relapsing conditions take for granted.

—Alexander DeLuca, M.D.

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