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Patient Selection and Detoxification Protocols 
from the
Smithers Addiction Treatment and Research Center, circa 1999

by Alex DeLuca, M.D.; Smithers Treatment & Research Center; circa 1999.  Originally posted circa 1999; revised 2/1/2005 [www.doctordeluca.com/Documents/opd_prot.htm].

Smithers Treatment Center offers Outpatient  Detoxification in addition to it’s inpatient detoxification services. This document will provide an overview of the Outpatient Detoxification services at Smithers.

PATIENT SELECTION and PATIENT SAFETY

Smithers Treatment Center uses the ASAM Patient Placement Criteria (PPC) to help determine appropriate Level of Care (intensity of treatment) based on a complete medical and psychosocial assessment. In this scheme, patients will be considered for a trial of outpatient detoxification if:

1. they do not meet criteria for Level IV (Medically Managed Inpatient Treatment) or Level III (Medically Supervised Inpatient Treatment), and,
   
2. they are assessed as being:
    
   • at minimal risk of severe withdrawal
     
   • as likely to complete needed detoxification and enter into continued treatment, and,
     
   • as having emotional support and a safe home environment.

Please see Appendix 1 for a more detailed discussion of selection criteria.

SETTING

Lower-intensity outpatient detoxification services will be provided on the Smithers Evaluation Unit. More severe withdrawal states are handled in a day hospital setting on our inpatient unit.  A full time RN, a full time MD and several full time counselors staff outpatient detoxifications. While the detoxification proceeds, assessment and referral services are completed such that by the time the detox is over and the patient is stable, a complete bio-psychosocial assessment is done, and an appropriate referral to ongoing treatment is made.

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OUTPATIENT DETOXIFICATION PROTOCOLS

The following sections will outline the general approach and methodology of Smithers Treatment Center to the outpatient detoxification of patients dependent on various classes of substances. An MD expert in addiction medicine will directly supervise each outpatient detoxification. Depending on the individual’s medical and psychological history, current social and occupational obligations and conditions, etc., different medications may be prescribed in different combinations, or different visit intervals employed, or different testing required or consultation requested.

The following apply to any Smithers outpatient detoxification:

1. Patients will be seen by the MD every day or as often as is warranted based on the patient’s physical and emotional condition
   
2. Group support/counseling sessions, as well as family counseling and educational services, will be provided based upon the identified needs of the patient to patients undergoing outpatient detoxification. Whenever possible, a thorough psychosocial assessment will be completed over the course of the detoxification, and referral for ongoing treatment made when indicated.
   
3. The patient and family member (if any) will be instructed both verbally and in writing regarding signs and symptoms of withdrawal, when to call for advice, when to take another dose of medication, and when to go to the nearest emergency room. An emergency phone number to contact a Smithers MD will be given to the patient and family member.
   
4. If the patient is unable to keep appointments, unable to refrain from alcohol or drug use, or has a medical or psychiatric crisis during the outpatient detoxification, arrangements will be made for immediate admission to the inpatient detoxification service at Roosevelt Hospital for acute stabilization.
   

ALCOHOL AND SEDATIVES

Benzodiazepine sedatives will be prescribed to treat the withdrawal syndrome; the amount of medication dispensed will be sufficient to last the patient until the next visit. Other medications will be prescribed as indicated; for example, antidepressants, antianxiety, and sleeping medications.

Unless contraindicated, or unless the patient refuses, the patient will be started on disulfiram (Antabuse) on the second visit and maintained on same for the duration of the outpatient detoxification after which they may discontinue it if they so desire. BAC and urine toxicology screen will be used as indicated.

In the majority of alcohol dependent patients, the outpatient detoxification and additional services including recommendation of and referral to additional treatment will be completed in three visits over seven days. Some patients will have a more difficult time and will require up to six visits over fourteen days. The duration and intensity of treatment for sedative/hypnotic dependence will vary depending on the doses involved and duration of abuse, and also on the presence or absence of any underlying psychiatric or medical illness.

OPIATES

A number of different medications might be used in outpatient narcotics detoxification either alone or in combination depending on severity of dependence or withdrawal, presence or absence of comorbid psychiatric or medical problems, the patient’s motivational state, and patient preference. Detoxification agents might include, but are not necessarily limited to, clonidine, propoxyphene, buprenorphine, and naltrexone. Adjunctive medications to treat craving, anxiety, depression, or insomnia might include beta-blockers, anti-histamines, benzodiazepines, clonidine, naltrexone, and antidepressants, and will be used when indicated. Every effort is made to make the patient as comfortable as possible while the detoxification proceeds.

Unless contraindicated, or unless the patient refuses, one goal of outpatient opiate detoxification will be naltrexone (Trexan) therapy for at least 3-6 months, in association with outpatient counseling, monitoring, and support, as an aid in maintaining abstinence during this critical high-relapse period. [cross reference pt guide]

In the majority of opioid dependent patients, the outpatient detoxification and additional services including recommendation of and referral to additional treatment will be completed in six visits over fourteen days.

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STIMULANTS

Pharmacological treatment for uncomplicated stimulant withdrawal is rarely needed; however, the majority of primary stimulant addicts use other drugs, usually of the sedative or opiate class, and therefore the patient must be questioned carefully about other substance use and observed closely for signs or symptoms of withdrawal from another class of drugs. Certain patients may benefit from adjunctive medication as outlined above.

In the majority of stimulant dependent patients, the outpatient detoxification and additional services including recommendation of and referral to additional treatment will be completed in six visits over fourteen days.

ADDITIONAL SERVICES

Over the course of the outpatient detoxification (usually 1-2 weeks), the patient will have a complete medical history and physical exam, urine toxicology screen, relevant blood tests, serial breathalyzer (BAC), serial withdrawal scales (CIWA), complete psychosocial assessment (ASI), available daily group therapy, and, ultimately, referral to the appropriate aftercare based on the ASAM PPC in consultation with the patient and his or her referral source.

APPENDIX ONE

Criteria for Outpatient vs. Inpatient Detoxification

Not all patients are appropriate candidates for outpatient detoxification. The American Society of Addiction Medicine (ASAM) have developed guidelines to help ensure that critical errors in referral are avoided. Please refer to the full text of these guidelines which are published by ASAM as the Patient Patient Criteria (PPC); here follows a brief discussion highlighting some of the criteria that suggest that the appropriate referral is to an inpatient hospital detoxification setting:

Patient is at high risk for complicated withdrawal:

Patient is at high risk for biomedical complications:

• Presence of biomedical problem(s) requiring inpatient diagnosis and treatment, such as, impending hepatic decompensation, acute pancreatitis or other condition requiring parenteral therapy, active gastrointestinal bleeding, cardiovascular disorder requiring monitoring, etc.
   
• Chemical use gravely complicating existing biomedical condition, or worsening of a condition making immediate abstinence critical to avoid severe morbidity or mortality.

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Patient is at high risk for psychiatric or behavioral complications:

• Uncontrolled behavior endangering self or others
   
• Impairment of cognitive function, mental confusion or fluctuating orientation, or extreme depression such that activities of daily living are impeded.
  

• Evidence of disorientation to self, alcoholic hallucinosis, or toxic psychosis within the past 24 hours or currently.
 
 
• Chemical use gravely complicating existing psychiatric condition, or worsening of a condition making immediate abstinence critical to avoid severe morbidity or mortality.

To look at the issue from the opposite perspective, we can say that patients are appropriate for outpatient detoxification if they do not meet criteria for inpatient detoxification:

Patient is at minimal risk of severe withdrawal:

• CIWA < 10 after 4-8 hours abstinence, or, BAC = 0.0 with minimal or no medication that might mask signs or symptoms of withdrawal.
  
  
• Reliable history that use of substances in combination does not pose a significant risk of complicated withdrawal.

Patient is likely to complete detoxification and accept referral:

• History of completion of outpatient detoxification and entry into continued treatment.
  
  
• Presence of support services to ensure commitment to complete detoxification and enter treatment.

Patient has, and responds positively to, emotional support combined with treatment:

• Evidences decreased emotional symptoms by closure of initial treatment session.
  
  
• Patient and caretaker clearly understand instructions for care.
  
  
• Home environment able to provide adequate reality, reassurance and respect.

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