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.
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.
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