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SAMHSA News - July/August, Volume 14, Number 4


Treatment Protocol Focuses on Detoxification

SAMHSA's Center for Substance Abuse Treatment (CSAT) recently released Treatment Improvement Protocol 45 (TIP 45)—Detoxification and Substance Abuse Treatment.

Prepared by a consensus panel of experts in detoxification services, the TIP provides the clinical evidence-based guidelines, tools, and resources necessary to help substance abuse counselors and clinicians treat clients who are dependent on substances of abuse.

The new publication is a revision of TIP 19, Detoxification From Alcohol and Other Drugs, which was published by CSAT in 1995.

  • Urgent Needs. TIP 45 emphasizes the importance of detoxification as one component in the continuum of health care services for substance-related disorders. It reinforces the urgent need for non-traditional settings—such as hospital emergency departments, medical and surgical wards, and acute care clinics—to be prepared to help get patients in need of detoxification services into treatment as quickly as possible.

  • Treatment Settings. Matching patients to appropriate treatment settings presents a challenge to detoxification programs, given the wide variety of settings and the unique needs of individual patients. Matching patients' clinical needs with the appropriate care setting in the least restrictive and most cost-effective manner is a complex task.

Another challenge for detoxification programs is to provide effective linkages to substance abuse treatment services. Patients often leave detoxification without followup to the treatment needed to achieve long-term abstinence.

According to this TIP, each year, at least 300,000 patients with substance use disorders or acute intoxication obtain inpatient detoxification in general hospitals; additional numbers obtain detoxification in other settings. Only 20 percent of people discharged from acute care hospitals receive substance abuse treatment during that hospitalization. Only 15 percent of people who are admitted to a detoxification program through an emergency department, and then discharged, go on to receive treatment.

  • Medical and Non-Medical Management. The consensus panel recognizes that medically assisted withdrawal is not always necessary or desirable. A non-medical approach can be highly cost-effective and provide inexpensive access to treatment for individuals seeking aid. The panel agreed on several guidelines for non-medical detoxification programs.

Management of withdrawal without medication may well serve young people in good health with no history of previous withdrawal reactions. However, supervisory personnel in non-medical settings should be trained to identify life-threatening symptoms and to solicit help through the emergency medical system as needed.

  • Protocols. TIP 45 provides medical information on detoxification protocols for specific substances as well as considerations for individuals with co-occurring medical conditions including mental disorders. Although the TIP is not intended to take the place of medical texts, it provides practitioners with an overview of common medical complications seen in people who use substances.

The existence of co-occurring medical disorders also influences the setting in which detoxification occurs. It is highly desirable that primary care practitioners—physicians, physician assistants, and nurse practitioners—with some experience in substance abuse treatment assess people undergoing detoxification.

People with a history of severe withdrawals, multiple withdrawals, delirium tremens (a potentially fatal syndrome associated with alcohol withdrawal), or seizures are not good candidates for detoxification programs in non-medical settings.

  • Sensitivity. Physicians, nurses, substance abuse counselors, and administrators are in a unique position to ensure a safe and humane withdrawal from substance abuse as well as to cultivate patients' entry into treatment. Regardless of their role in providing detoxification services, all personnel should keep in mind that patients undergoing detoxification are in the midst of a personal and medical crisis. For many patients, this crisis represents a window of opportunity to acknowledge their substance abuse problem and become willing to seek treatment.

The primary audiences for this TIP include substance abuse treatment counselors, administrators of detoxification programs, directors of single state agencies, psychiatrists, and other physicians working in the field.

To obtain TIP 45, Detoxification and Substance Abuse Treatment, contact SAMHSA's National Clearinghouse for Alcohol and Drug Information at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686 (English and Spanish) or 1 (800) 487-4889 (TDD). Ask for NCADI No. BKD541. Online, TIP 45 will be available soon at www.kap.samhsa.gov/products/manuals/tips/
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