Doctor DeLuca's Addiction Website

http://www.doctordeluca.com/documents/CriteriaInptVsOutptDetox.htm
Circa 1998


Inpatient vs. outpatient detox? Criteria for deciding
(see also: "Outpatient Detox -  Is This Really a Good Idea?")



Patients who should not have outpatient detox procedures     

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 see 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
  • Current overdose-in-progress compromising vital signs, mental status or cardiac function, or life-threatening stupor.
  • Head trauma, seizure, hallucinations, or symptoms of delirium tremens within the past 24 hours.
  • History of seizures, hallucinations or delirium tremens when withdrawing from similar amounts of alcohol/sedatives; or history of recurrent or multiple seizures.
  • Pregnant patient in need of detoxification.
  • Daily use of sedative medications in doses above therapeutic levels for greater than one month, or in therapeutic doses but in combination with alcohol for greater than six weeks.
  • CIWA >= 20, BAC >= 0.3, BAC >= 0.1 plus symptoms of alcohol withdrawal syndrome.
  • CIWA = 10-19 plus pulse > 110 or BP > 160/110.
  • 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.
  • 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.


Patients who are good candidates for outpatient detoxification

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, and 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.

For further discussion of inpatient and outpatient detox see: "Outpatient Detox - Is This Really a Good Idea?"

 

 

Alexander DeLuca, M.D., FASAM.
Copyright 1999, 2000, 2001. All rights reserved.                                   [Top Of Page]
Revised: March 13, 2001.