Detoxification From Alcohol and Other Drugs
Treatment Improvement Protocol (TIP) Series 19

Incarcerated Persons

Persons who are incarcerated or detained in holding cells or elsewhere should be assessed for physical dependence on alcohol, sedative-hypnotics, and/or heroin. Untreated withdrawal from alcohol or other sedative-hypnotics can be life threatening. Heroin withdrawal is not life threatening to an individual who is healthy; however, it may be difficult for the patient. Individuals who are on methadone maintenance may experience severe withdrawal symptoms if the medication is abruptly stopped.

Persons who have been on maintenance therapy before being incarcerated should continue to receive their usual dosage of medication if the expected period of incarceration is less than 2 weeks. If incarceration is longer, the maintenance therapy should be gradually discontinued.

The treatment protocols outlined in Chapter 3 are applicable for incarcerated persons who need detoxification. There may, however, be restrictions on the use of methadone or levo-alpha-acetylmethadol in a prison setting. In such cases, staff may need to create linkages with local methadone detoxification programs.

There is an underground market for psychoactive medications, drugs of abuse, or both, in most prisons. Patients may try to deceive staff about their dependence so that they can receive drugs that they then sell to other inmates. They may attempt to convince nurses that they have swallowed their medication when they have not. To ensure appropriate care of inmates, prison medical staff need special training in patient assessment and detoxification protocols.

Women

Women who enter detoxification will benefit from a comprehensive physical examination, including a gynecological and obstetrical evaluation. Sensitivity to the wishes of the patient regarding examinations and tests is imperative, and the treatment staff must be careful to obtain consent. Unless they are pregnant or nursing, women can usually be treated under the detoxification protocols described in Chapter 3.

Special attention should be given to the detoxification setting. Establishing distance from the environment in which the alcohol and other drug (AOD) abuse has been taking place may be more critical for women than for men.

Pregnant and Nursing Women

Special concerns surround detoxification during pregnancy. The Treatment Improvement Protocol (TIP) titled Pregnant, Substance-Using Women (TIP 2; Center for Substance Abuse Treatment, 1993) addresses the complex issues involved in treating this population. Conditions that ensure close observation and monitoring of maternal and fetal well-being are explored in depth. The TIP includes guidelines for withdrawal from alcohol, withdrawal from opiates, and the issues related to the use of methadone for stabilization, withdrawal from cocaine, and withdrawal from sedative-hypnotics.

Withdrawal from opiates can result in fetal distress, which can lead to miscarriage or premature labor. Opioid substitution therapy, coupled with good prenatal care, is generally associated with normal deliveries. Although these newborns tend to have a lower birth weight and smaller head circumference than drug-free newborns, no developmental differences at 6 months of age (Zweben and Payte, 1990) have been documented.

Treatment staff should not modify detoxification regimens for nursing women unless there is specific evidence that the pharmacologic product enters the milk in amounts that could be harmful to the infant. Women who are using benzodiazepines (e.g., Librium or Xanax) and antidepressant or antipsychotic agents should not breast feed.

All pregnant women and nursing mothers should be informed of the potential risks of drugs that are excreted in breast milk. For more information, see the TIP Improving Treatment for Drug-Exposed Infants (TIP 5; Center for Substance Abuse Treatment, 1993).

The availability of child care often influences a woman's ability to enter treatment. At a minimum, detoxification programs should have a linkage to child-care services; onsite services are preferable.

Adolescents

Adolescence is a period of rapid physical and psychosocial change. Issues facing adolescents in detoxification differ from those facing adults in several ways. Chief among these differences is that physical dependence is generally not as severe and response to detoxification is generally more rapid in adolescents than in adults. Adolescents are not as accustomed to pain as are adults; as a result, they may be more resistant to simple procedures, such as having blood drawn. Adolescents also are notorious for leaving treatment against medical advice.

Adolescents undergoing detoxification need nurturing, support, and structure. Treatment providers must be sensitive to their developmental stages. Adolescents should be housed separately from adults. Decisions about involving the family in treatment should be made on a case-by-case basis and based on an assessment of family functioning.

Federal regulations allow methadone detoxification of adolescents, but State regulations vary. Methadone detoxification is rare in this age group. For a complete discussion of this issue, see the TIP titled State Methadone Treatment Guidelines (TIP 1; Center for Substance Abuse Treatment, 1993).

Elderly Persons

AOD-related disorders in elderly patients tend to be more severe than those in younger persons, and there is an increased likelihood of medical comorbidity in the elderly. For these reasons, detoxification in a medical setting is often required.

Age does not affect the choice of medication for detoxification; however, dosages may need to be reduced because of slowed metabolism. A complete assessment and careful monitoring of comorbid conditions (e.g., respiratory disease, heart disease, diabetes) is essential. Because many elderly patients are taking a number of prescription and over-the-counter medications, the possibility of drug interactions cannot be ignored.

Patients Who Are HIV-Positive

AOD abuse and HIV infection often coexist in the same individual, who is usually also at risk of becoming infected with tuberculosis or sexually transmitted diseases. The capacity of AOD abuse treatment programs to address these multiple health problems has expanded greatly in recent years, but there remains a need for comprehensive guidelines for treatment of HIV-positive AOD patients. Collaborative, efficient approaches must be developed among AOD specialists, public health officials, mental health specialists, and primary health care providers in order to prevent further spread of disease and to assure delivery of high-quality care to infected individuals.

Other Medical Conditions

For patients withdrawing from alcohol, a history of seizures during previous withdrawals strengthens the case for using an anticonvulsant (such as phenytoin [Dilantin], carbamazepine [Tegretol], or phenobarbital) during detoxification. A patient who is dependent on alcohol or sedative-hypnotic agents may have a withdrawal seizure even though he or she does not have a history of seizure disorders. An alcoholic who has a seizure while drinking has an underlying seizure disorder. Treatment staff must consider both possibilities when determining detoxification treatment.

Brain-injured patients are also at risk for seizures. If an AOD-abusing patient who has sustained trauma to the head becomes delirious, one must determine the exact cause of the delirium. Slower medication tapers should be used in patients with seizure disorders. Dosages of anticonvulsant medications should be stabilized before sedative-hypnotic withdrawal begins.

Patients with cardiac disease require close monitoring. Because a withdrawal seizure, or even the physiological stress of withdrawal, may complicate the patient's cardiac condition, it may be necessary to withdraw the drug at a lower-than-normal rate. Treatment providers should also be alert to the possibility of interactions between the cardiac medications and the agents used to manage detoxification.

Severe liver or kidney disease can slow the metabolism of both the drug of abuse and the medication. Use of slower-acting medications and a slower taper are appropriate for detoxification in these patients.

Because of these patients' increased risk of developing addictions, treatment providers should exercise caution when prescribing medication for chronic pain to patients with a history of AOD abuse. Opioid maintenance may, however, be necessary for patients with chronic, nonmalignant pain. Pain patients do not require detoxification from prescribed medications unless they meet the criteria for opiate abuse or dependence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). Nonsteroidal analgesic medications play a larger role in the management of pain in AOD-abusing patients than in other patients.

Persons With Psychiatric Comorbidity

The term "dual diagnosis" or "dual disorder" is used in the addiction field to refer to patients who have both a substance use disorder and any psychiatric disorder, such as schizophrenia. Estimates of the incidence of psychiatric disorders among substance abusers vary widely. Another TIP in this series, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (TIP 9; Center for Substance Abuse, 1994), provides practical information about the treatment of patients with dual disorders.

As noted in Chapter 2 , it is difficult to accurately assess underlying psychopathology in a person undergoing detoxification. Drug toxicity, particularly with amphetamines and cocaine, hallucinogens, or phencyclidine, may mimic psychiatric disorders. For this reason, treatment providers should conduct a psychiatric evaluation after several weeks of abstinence.

At the time they are evaluated for detoxification, some patients with underlying psychiatric disorders are already taking antidepressants, neuroleptics, anxiolytics (benzodiazepines or other sedative-hypnotics), or lithium. Although staff may believe that these patients should immediately discontinue all mind-altering medication, such a course of action is not always in the best interest of the patient. Abrupt cessation of psychotherapeutic medications may cause withdrawal symptoms or reemergence of symptoms of the underlying psychopathology.

For the staff of a "drug-free" program, use of anxiolytics by a patient can pose a significant conflict with program ideology. If a patient who was abusing alcohol was also taking alprazolam (Xanax) for a panic disorder, for example, some programs would want the individual to discontinue the alprazolam. Indeed, unless the alprazolam was initiated during a period of extended alcohol abstinence, the diagnosis of panic disorder may not be correct. If panic attacks resume during alcohol detoxification because the alprazolam has been discontinued, however, the patient might leave therapy. As a general rule, therapeutic doses of medication should be continued during alcohol withdrawal if the patient has been taking it as prescribed, with respect to both amount and timing of dose. Decisions about discontinuing the medication should be temporarily deferred. If, however, the patient has been abusing the prescribed medication or the psychiatric condition was clearly caused by the alcohol abuse, the rationale for discontinuing the medication is more compelling.

During detoxification, some patients decompensate into psychosis, depression, or severe anxiety. In such cases, careful evaluation of the withdrawal medication regimen is of paramount importance. If the decompensation is a result of inadequate dosing with the withdrawal medication, the appropriate response is to increase that medication. If it appears that the withdrawal medication is adequate, other medications may be needed. Before choosing such an alternative, it is important to take into account additional considerations, such as the side effects of the added medication and the possibility of interaction with the withdrawal medication.

A patient who is psychotic may need to take neuroleptics. Medications that have a minimal effect on the seizure threshold are recommended, particularly if the patient is being withdrawn from alcohol or sedative-hypnotic medication. Small, frequent doses of haloperidol (Haldol), such as 1 mg every 2 hours, may be used until the patient's symptoms of psychosis dissipate. The case for the emergency use of antidepressants is less convincing because of the 2- to 3-week lag time between initiation of medication and therapeutic response.

After detoxification is complete, the patient's need for the medication should be reassessed. A trial period with no medications is sometimes the best way to assess the patient's need.

The Importance of Cultural Competence of Staff

Detoxification protocols such as those described in Chapter 3 may be used effectively with persons of all races, cultures, and ethnic groups. However, treatment components and procedures should be reviewed to ensure that they are culturally sensitive and culturally relevant. Staff should be trained to avoid discriminatory language and behaviors.

The diversity of the counselors should reflect that of the surrounding community. Additionally, counselors must be specially trained and selected for cultural appropriateness. They must be aware, for example, that cultural attitudes toward communication styles vary with regard to preferred space (physical distance), appropriate physical contact, eye contact, and terminology. A treatment staff who are competent in the languages spoken by the clientele help the program retain more patients. Language competency entails not only the ability of a staff person to communicate with a patient but also familiarity with trends in street terminology.

Providers should evaluate written and visual materials provided to patients and families for readability as well as for cultural appropriateness. If the population is predominantly Spanish-speaking, materials, including intake and assessment forms and educational materials, should be printed in Spanish. At least some of the staff should speak Spanish.

An individual's response to authority differs from culture to culture. The counselor's sensitivity to such differences is essential in determining the patient's response to care and in engaging the patient in the detoxification process. Treatment providers should keep in mind that diversity exists within ethnic groups as well. For example, Spanish-speaking cultures are often thought of as one group (Hispanic) and assumed to be essentially identical. However, Hispanic cultures actually consist of a variety of different cultures such as Mexican, Puerto Rican, Cuban, and Central and South American, all of which differ significantly from one another. People of all ethnic groups vary by personality, geographic origin, socioeconomic class, religious upbringing, and other factors, all of which play a role in their individual "cultures." Treatment providers should assess each patient individually. Finally, the counselor should not presume the degree to which "cultural" factors are a determinant of current behavior.