Components of Treatment—Outpatient Detoxification
Outpatient detoxification begins when initial contact is made by telephone. Drug(s) of abuse, medical status and availability of one or more SSPs is ascertained. Patients are not admitted if they have an acute medical issue such as a gastrointestinal bleed. Patients are not admitted unless they bring a SSP. Every effort will be made to schedule admissions within 24 hours of a request for help; ideally on the day of the call for help. The prospective patient needs to be willing to make treatment his or her full-time activity for at least a week. They must arrive in early withdrawal (not intoxicated) and have a SSP who will take at least one full day to be with them, and then be easily available for the first week of treatment. Examples would be a parent who can take a day off from work, a sponsor who will host the patient over the first night, or a group of friends who will all take turns being with the detoxifying patient.
Within an hour of the patient's arrival they have a brief assessment and medication prescribed if needed. A full psychiatric evaluation, vital signs and a physical examination (HEENT, chest, abdomen, extremities, skin, neuro, overall impression) are done on the first day by the psychiatrist. Any acute medical conditions are addressed by the psychiatrist, or the patient is referred to University Hospital's Emergency Department. The patient, SSP and psychiatrist make a plan together; with parameters for calling the psychiatrist, who is available 24 hours per day and 7 days per week. The patient continues in treatment daily until both the withdrawal syndrome has ended, and the patient is judged stable enough to tolerate a lower level of care in safety. The initial planning meeting of the first day serves as orientation of the patient and SSP to the program; rules, procedures, activities, policies and philosophy.
Alcohol and urine drug screens are NOT done because the treatment is based on the withdrawal symptoms observed and not the history or urine results. For example, a positive urine for opiates does not lead to prescription of Suboxone for opiate withdrawal; the positive urine result could represent a single use. A patient may have been using a drug such as clonazepam that will not show up on a urine screen, yet still be at risk of seizing. The results of a breathalyzer screen for blood alcohol will not help determine the course of alcohol withdrawal. The focus of treatment is objective signs of withdrawal rather than subjective reports.
Laboratory tests are available for every patient and are done WHEN INDICATED for some useful purpose. For example, liver functions are followed for patients on valproate, CBC for any patient at risk for a GI bleed, blood glucose monitoring for patients with diabetes, PPD for patients who may be at risk for tuberculosis or needing referral to a residential program. Blood is drawn at the University Hospital laboratory, sited one block away. The goal of laboratory testing during the withdrawal period is to insure the safety of the patient during withdrawal.
Primary care evaluations (comprehensive medical care) are NOT done. Patients are referred for primary care evaluation when they are stable enough that their initial primary care evaluation appointment is likely to be kept, and is likely to result in a partnership between our treatment of the addiction, and the internist’s treatment of all medical issues .
Alcohol detoxification is accomplished with valproic acid, chlordiazepoxide and disulfiram as the main agents. Valproic acid is not addictive, is not very sedating, and minimizes the need for chlordiazepoxide. A "loading" approach is taken on the first treatment day to arrest symptoms. Concomitant use of disulfiram means that the patient is unlikely to drink while at home; they are required to take an observed dose on day one to be allowed back for day two.
Benzodiazepine detoxification is accomplished with valproic acid and chlordiazepoxide as the main agents. Benzodiazepine withdrawal comes on more slowly than alcohol withdrawal, and patients can be loaded on valproic acid prior to the emergence of withdrawal symptoms in most cases. When valproate is used, blood levels and liver function tests are monitored.
Opiate withdrawal is accomplished with Suboxone and adjunctive medications such as clonidine, dicyclomine and trazodone. Suboxone competes with abused opiates and make the addition of heroin, oxycodone, etc. ineffective. As soon as possible the patient is switched to naltrexone, the non-agonist opiate blocker.
In unusual cases of withdrawal that cannot be managed with this support system, patients are referred for 24 hour inpatient detoxification. Otherwise, the physician confers with the patient or SSP by phone if needed. In all cases the SSP involved with the treatment is informed of the need for the patient to stay on the blocker; disulfiram for alcohol and naltrexone for opiates, for the first year of sobriety. In many cases, the rule will be suggested that if the family member in recovery (patient) will not take the blocker observed by the SSP or a family member; that the addicted person not be allowed to live at home because they are likely to use the home as a base for dangerous behaviors. We anticipate that changing the setting of detoxification from an inpatient ward that isolates severely ill addicted persons from their supports, to including a SSP as a central actor in detoxification and continuing their involvement over time that outcomes will be improved. The detoxification phase of treatment is usually accomplished within a week, except in the case of long-acting benzodiazepines such as clonazepam or diazepam, where the acute symptoms of withdrawal do not remit until two weeks after the drug is stopped.