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Detoxification and Substance Abuse Treatment [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2006. (Treatment Improvement Protocol (TIP) Series, No. 45.)
In This Chapter….
Regardless of setting or level of care, the goals of detoxification are to provide safe and humane withdrawal from substances and to foster the patient's entry into long-term treatment and recovery. Detoxification presents a unique opportunity to intervene during a period of crisis and move a client to make changes in the direction of health and recovery. Hence, a primary goal of the detoxification staff should be to build the therapeutic alliance and motivate the patient to enter treatment. This process should begin even as the patient is being medically stabilized (Onken et al. 1997).
Psychological dependence, co-occurring psychiatric and medical conditions, social supports, and environmental conditions critically influence the probability of successful and sustained abstinence from substances. Research indicates that addressing psychosocial issues during detoxification significantly increases the likelihood that the patient will experience a safe detoxification and go on to participate in substance abuse treatment. Staff members' ability to respond to patients' needs in a compassionate manner can make the difference between a return to substance abuse and the beginning of a new (and more positive) way of life.
This chapter addresses the psychosocial and biomedical issues that may affect detoxification and ensuing treatment. It highlights evaluation procedures for patients undergoing detoxification, discusses strategies for engaging and retaining patients in detoxification and preparing them for treatment, and presents an overview for providing linkages to other services.
Overarching Principles for Care During Detoxification Services.
Patients entering detoxification are undergoing profound personal and medical crisis. Withdrawal itself can cause or exacerbate current emotional, psychological, or mental problems. The detoxification staff needs to be equipped to identify and address potential problems.
An initial evaluation will help detoxification staff foresee any variables that might complicate a safe and effective withdrawal. Figure 3-1 lists the biomedical and psychosocial domains that can affect the stabilization of the patient.
Initial Biomedical and Psychosocial Evaluation Domains.
The following sections include some general guidelines and important considerations to follow when providing detoxification services.
Because substance abuse affects all systems of the body and is associated with lack of self-care, it is not unusual for detoxification to be complicated by medical problems. Health professionals should screen for medical problems that may put the client at risk for a medical crisis or expose other clients or staff to contagious diseases. This section outlines important considerations for both nonmedical and medical staff. Chapter 5 provides a clinical overview of co-occurring medical conditions and is geared primarily toward medical personnel.
The initial consultation should include an evaluation of the expected signs, symptoms, and severity of the withdrawal. Detoxification is not an exact science, but any significant deviation from the expected course of withdrawal should be observed closely. Figure 3-2 (p. 26) provides a list of signs and symptoms of conditions that require immediate medical attention. All staff members who work with patients should be aware of these and seek medical consultation for the patients as necessary.
Symptoms and Signs of Conditions That Require Immediate Medical Attention.
Seizures are of special concern. Practitioners should interview the patient and family about seizure disorders and seizure history. In addition, nonmedical staff should be aware of signs of impending seizures such as tremors, increased blood pressure, overactive reflexes, and high temperature and pulse. It is essential that nonmedical staff be trained in protocols to prevent injury in the event of a seizure. Competence in carrying out these protocols should be evaluated by a physician or nurse clinician. For more information on seizures, see Chapter 4.
All staff working with patients should be familiar with medical disorders that are associated with various addictive substances or routes of administration. Alcoholism has multiple organ effects involving the liver, pancreas, central nervous system, cardiovascular system, and endocrine system. Cocaine produces many of its medical complications through vasoconstriction (i.e., narrowing of the blood vessels), including myocardial infarction (heart attack), stroke, renal disease, spontaneous abortion, and even bowel infarction (death of tissue). Cocaine also can cause seizures and cardiac arrhythmia (irregular heartbeat). A heroin overdose can lead to a fatal respiratory depression. Intravenous drug use is particularly likely to increase the risk of infectious complications, including HIV, viral hepatitis, abscesses, and sepsis (the spreading of infection from its original site in the body). Intrapulmonary (within the lungs) administration can cause lung disorders (Dackis and Gold 1991). Nonmedical detoxification staff also should be aware of the medications used in detoxification, medications for common medical and psychiatric disorders, and signs of common medication reactions and interactions.
Standard precautions should be used with all patients to protect the staff and patients against the transmission of infectious diseases, including HIV and hepatitis A, B, and C. All open wounds should be cultured and treated to prevent the spread of infections. Providers should use HIV/blood and respiratory infection precautions until HIV and respiratory infectious status are known. Patients with respiratory infections should be carefully evaluated. The panel suggests that tuberculin testing be performed or recent test results obtained on all patients to screen for active tuberculosis. A chest x-ray is recommended if indicated by the patient's history and physical assessments. Nonmedical detoxification staff should be trained to watch for the signs of common infectious diseases passed through casual contact, including infestation with scabies and lice.
The following section provides general guidelines for treating patients who have immediate mental health needs. For more detailed information on the treatment of patients with co-occurring psychiatric conditions see TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (Center for Substance Abuse Treatment [CSAT] 2005c).
Those who are users of multiple illicit substance are more likely to experience psychiatric disorders, and the risk is highest among those who use both opiates and benzodiazepines and/or alcohol (Marsden et al. 2000). Depression is more common among those who abuse a combination of these substances, and women are at higher risk than men. Among those patients who are positive for depression, the risk of suicide is high. Marsden and colleagues' 2000 study of 1,075 clients entering treatment showed that 29 percent reported suicidal ideation in the past 3 months.
During acute intoxication and withdrawal, it is important to provide an environment that minimizes the opportunities for suicide attempts. As a precaution, locations not clearly visible to staff should be free of items that might be used for suicide attempts. Frequent safety checks should be implemented; the frequency of these checks should be increased when signs of depression, shame, guilt, helplessness, worthlessness, and hopelessness are present. When feasible, patients at risk for suicide should be placed in areas that are easily monitored by staff. Most important, when interacting with patients at risk for suicide, staff should avoid harsh confrontation and judgment and instead focus on the treatable nature of substance use disorders and the rehabilitation options available. These interactions offer an opportunity to start a dialog with the patient regarding the impact of substance use on mental illness and vice versa.
Alcohol, cocaine, amphetamine, and hallucinogen intoxication may be associated with increased risk of violence. Symptoms associated with this increased risk for violence include hallucinations, paranoia, anxiety, and depression. As a precaution, all patients who are intoxicated should be considered potentially violent (Miller et al. 1994). Programs should have in place well-developed plans to promote staff and patient safety, including protocols for response by local law enforcement agencies or security contractors. Staff working in detoxification programs should be trained in techniques to de-escalate anger and aggression. In many cases, aggressive behaviors can be defused through verbal and environmental means (Reilly and Shopshire 2002). For the protection of the staff and the patient, physical restraint should be used as a last resort and programs should be aware of local laws and regulations pertaining to physical restraint. Figure 3-3 (p. 28) lists some useful ways of managing patients who are angry and aggressive. Readers may refer to the standards published by such groups as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF) for further guidance. The Substance Abuse and Mental Health Services Administration (SAMHSA) also has published guidelines on the use of seclusion and restraint, which call for the reduction and possible elimination of their use (SAMHSA 2002).
Strategies for De-escalating Aggressive Behaviors.
With the patient's consent, a review of the patient's mental health history with the patient and family is useful in identifying co-occurring psychiatric conditions. Mental health professionals caring for the client should be consulted. If a pharmacy profile on the patient is available, it should be copied for review (within the confines of State and Federal confidentiality laws).
Diagnosis of co-occurring substance-related disorders and mental conditions is difficult during acute intoxication and withdrawal because it often is impossible to be precise until the clinical picture allows for the full assessment of both the effects of substance use and of the symptoms of mental disorders. As the individual moves from severe to moderate withdrawal symptoms, attention to differential diagnosis of substance use disorders and other psychiatric disorders becomes a priority (First et al. 2002). The American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM) guidelines recommend a period of 2 to 4 weeks of abstinence before attempting to diagnose a psychiatric disorder (APA 2000; ASAM 2001).
Malnutrition is a major concern for patients entering detoxification because the nutrient deficiencies associated with substance abuse can interfere with or even prolong the detoxification process (Nazrul Islam et al. 2001). Longstanding irregular eating habits and poor dietary intake only exacerbate the problem (Pelican et al. 1994). The detoxification process itself is stressful to the body and may result in increased nutrient requirements. Proper nutrition during recovery improves to a significant extent the adverse effects of the substance abuse (Nazrul Islam et al. 2001).
An evaluation of nutritional status should be a core component of detoxification. It should be noted, however, that for patients who abuse alcohol, the administration of fluids to address dehydration should be the first step, with nutritional evaluation occurring after the patient is adequately hydrated.
The nutritional evaluation should consist of laboratory and anthropometric indices, a detailed nutritional history, and nutrition counseling (Simko et al. 1995). The intervention begins in the initial acute phase of withdrawal and continues through detoxification and subsequent substance abuse treatment. If the patient consents, family members or significant others may be included in the nutritional evaluation and counseling.
Weight is an important consideration in determining the nutritional status of the person with a substance use disorder. Substance abuse may result in a reduction in food intake and disruption in the patient's metabolism that may in turn have caused an eating disorder, weight loss, and malnutrition. Conversely, weight gain may be related to inactivity and an excessive intake of highly refined carbohydrates (Zador et al. 1996). Patients should be asked whether there have been any recent changes in their weight. While a patient may appear to be adequately nourished, a skinfold caliper (an instrument that measures the thickness of a fold of skin with its underlying layer of fat) can determine body density (the relationship of the body's mass to its volume), though the body mass index may be a better indicator of nutritional status (Simko et al. 1995).
Other questions to ask during the initial evaluation concern appetite, eating patterns, food preferences, snacking habits, food allergies, food intolerance, special diets, and foods to be avoided because of cultural or religious beliefs. A food frequency questionnaire, food diary, or 24-hour food recall may be of use.
Many drug addictions are associated with abnormal glucose (sugar) metabolism. This abnormality means that the body is unable to maintain a stable concentration of glucose in the blood. Abnormally high or low blood sugar levels easily can be confused with the signs and symptoms of alcohol intoxication or withdrawal; consequently, a check of blood glucose level is particularly important in patients with a history of blood sugar abnormalities. Hypoglycemia (low levels of blood sugar) in the person with a substance use disorder may lead to drastic mood changes. When blood glucose levels drop below a certain threshold, these patients usually feel depressed, anxious, or moody and may experience cravings for their drug of choice.
As noted, the abuse of drugs can interfere with nutrient utilization and storage. Detoxification personnel should be familiar with the nutritional deficits associated with specific substances. Opioids are known to decrease calcium absorption and to increase cholesterol and body potassium levels. Magnesium deficiency often is seen in chronic alcohol dependence. Other nutrient deficiencies seen in alcohol abuse include protein, fat, zinc, calcium, iron, vitamins A and E, and the water-soluble vitamins pyridoxine, thiamine, folate, and vitamin B12 (Nazrul Islam et al. 2001). Alcohol also contains calories (7 kcal/gm) that when consumed in excessive amounts may displace nutrient-dense foods. Cocaine is an appetite suppressant and may interfere with the absorption of calcium and vitamin D. Laboratory tests for protein, vitamins, and iron and the other electrolytes are recommended to determine the extent of liver function as well as supplementation (Fontaine et al. 2001). Caution should be exercised when using supplements because of their potential interactions with other drugs and treatments.
Detoxification should include efforts to address nutritional deficits and to begin the patient on a course of improved eating habits. It is crucial to switch the paradigm from ingesting substances harmful to the body to taking in foods that heal the body (Nebelkopf 1981, 1987, 1988). The regularity of meal times, taste, and presentation are important considerations.
Attractively arranged, pleasant-tasting food may inspire the patient to consume vital nutrients and adequate calories. It is important that during the detoxification process, the patient avoid substituting one addiction for another. Consuming excessive amounts of caffeine or sugar can compromise the process and lead to relapse. Patients should be offered only decaffeinated beverages and healthful snacks instead of refined carbohydrates such as sugar-based sweets like candy, cookies, or donuts. Fresh fruits, vegetables, and other whole foods can contribute to the individual's health and wellness.
Gastrointestinal disturbances (i.e., nausea, vomiting, and diarrhea) may accompany the first phase of detoxification. Such disturbances can worsen dehydration and may disturb blood chemistry balance, which in turn can lead to mental status changes, neurological or heart problems, and other potentially dangerous medical conditions. Patients with gastrointestinal disturbances may only be able to tolerate clear liquids. When solid foods are tolerated, balanced meals consisting of low-fat foods, with an increased intake of protein (meat, dairy products, legumes), complex carbohydrates (whole grain bread and cereals), and dietary fiber are recommended (Duyff 1996). Patients undergoing detoxification may also experience constipation. Increasing the fiber content of the diet will help to alleviate this discomfort.
Patients with special dietary requirements need additional nutrition therapy. A person with diabetes, for example, should follow the dietary guidelines of the American Diabetes Association, which emphasizes individualized meal planning (American Diabetes Association 2004). A patient who is a vegetarian may have additional nutritional deficiencies, especially if she or he is a vegan (i.e., a person who avoids eating all foods derived from animals, including milk products and eggs). If a vegan enters detoxification with marginal or low nutrient stores, his or her diet should be augmented with legumes, meat analogs, textured vegetable protein, nuts, and seeds. Many other medical conditions (e.g., ulcers, heart disease, food allergies, etc.) may require special diets. At intake, any special dietary considerations should be noted.
Generally, detoxification is the same for adolescents as it is for adult clients. However, there are a few important and unique considerations for adolescent patients. For one, adolescents are more likely than adults to drink large quantities of alcohol in a short period of time, making it is especially important that detoxification providers be alert to escalating blood alcohol levels in these patients. Moreover, adolescents are more likely than adults to use drugs they cannot identify, to combine multiple substances with alcohol, to ingest unidentified substances, and to be unwilling to disclose drug use (Westermeyer 1997). As a result, the consensus panel recommends routinely screening adolescent patients for illicit drug intoxication. It also is important for staff to be trained in how to assess for the use of PCP, which can present with psychosis-like symptoms. Staff should ask the adolescent directly whether he has used PCP within the 12-hour period before entering the clinic or treatment center.
Adolescents should be placed in a secure, clean environment with observation and supportive care. If alcohol, heroin, or other drugs associated with vomiting are suspected, protecting the individual's airway and positioning the patient on his or her side to avoid aspiration (inhaling) of stomach contents are critical. In severe cases of ingestion of respiratory depressants, respiratory support may be needed. If the individual is severely combative or belligerent, physical restraint may be needed as a last resort when allowed and appropriate. In milder cases, observation in a quiet, secure room with compassionate reassurance may be sufficient. Additionally, adolescents served in adult settings should be separated from the adult population and observed closely to ensure that they are not victimized (i.e., verbally, physically, or sexually) by adult clients. Finally, adolescents in detoxification settings should always be screened carefully for suicide potential and co-occurring psychiatric problems.
It sometimes is challenging to establish rapport with adolescents, as their experience with adults may be marked by adverse consequences. Asking open-ended questions and using street terminology for drugs and other expressions commonly used by teenagers can be helpful both in establishing rapport and in obtaining an accurate substance use history. For more information on working with adolescents, see TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999d), and TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999f).
For parents—especially women—entering detoxification programs, the safety of children often is a concern and one of the biggest barriers to retention. Even if women do not have custody of their children they often are the ones who continue to care for them. Some children may show extreme need for their mother while separated from her, and their demands could trigger unauthorized leave from detoxification. Thus, ensuring that children have a safe place to stay while their mothers are in detoxification is of vital importance. Working with women and men to identify supportive family or friends may identify temporary childcare resources. A consult or referral to the treatment facility's social services while the patient is being detoxified is indicated when the care of children is uncertain.
While both men and women are victims of domestic abuse, women's substance use is associated with increased risk of intimate partner violence (Cunradi et al. 2002). Staff should know the signs of domestic violence and be prepared to follow procedures to ensure the safety of the patient.
Ensuring that children have a safe place to stay while their mothers are in detoxificaton is of vital importance.
If a patient discloses a history of domestic violence, trained staff can help the victim create a long-term safety plan or make a proper referral. If a safety plan is made or phone numbers for domestic violence help are provided, related information should be labeled carefully so as not to disclose its purpose (e.g., listed as women's health resources) since the abuser may go through all personal belongings. All printed information about domestic violence also should be disguised and none should be kept by the patient when she leaves the safe facility. If the victim needs to press charges or obtain a restraining order, this should be done from a safe setting (e.g., inpatient detoxification). If at all possible, the victim should be escorted to a safety shelter. It may be important that the abused person, whether male or female, not be allowed to talk to the abuser while in detoxification. Parents who are victims of domestic violence may need help with parenting skills and securing counseling and childcare. Therefore, it is important for detoxification providers to be familiar with local childcare resources. For more information see TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b).
In providing psychosocial supports for culturally diverse patients, cultural sensitivity is of tremendous importance. Clients' expectations of detoxification, their feelings about the healthcare system generally, and their social and community support structures vary according to their cultural backgrounds. In working with any specific population, the practitioner should avoid defining the patient in terms of his culture, since over- or underemphasizing the patient's race or ethnicity can be detrimental (Clark et al. 1998). Figure 3-4 provides clinicians with some helpful questions to guide their discussions.
Questions To Guide Practitioners To Better Understand the Patient's Cultural Framework.
A patient who recently relapsed after a period of extended abstinence may feel especially hopeless and vulnerable (an abstinence violation effect). In this situation, clinicians can acknowledge progress that had been made prior to relapse and reassure the patient that the internal gains from past recovery work have not all been lost (despite the feeling at the moment that they have), perhaps reframing the severity of emotional pain as an indicator of how important recovery is to the patient.
It is essential to keep patients who enter detoxification from “falling through the cracks” (Kertesz et al. 2003). Successful providers acknowledge and show respect for the patient's pain, needs, and joys, and validate the patient's fears, ambivalence, expectation of recovery, and positive life changes. It is essential that all clinicians who have contact with patients in withdrawal continually offer hope and the expectation of recovery. An atmosphere that conveys comfort, relaxation, cleanliness, availability of medical attention, and security is beneficial to patients experiencing the discomforts of the withdrawal process. Throughout the detoxification experience, detoxification staff should be unified in their message that detoxification is only the beginning of the substance abuse treatment process and that rehabilitation and maintenance activities are critical to sustained recovery.
During intoxication and withdrawal, it is useful to provide information on the typical withdrawal process based on the particular drug of abuse. Usually withdrawal includes symptoms that are the opposite of the effects of the particular drug. This rebound effect can cause anxiety and concern for patients. Providing information about the common withdrawal symptoms of the specific drugs of abuse may reduce discomfort and the likelihood that the individual will leave detoxification services prematurely (for a list of withdrawal symptoms, see Chapter 4). Settings that routinely encounter individuals in withdrawal should have written materials available on drug effects and withdrawal from specific drugs, and have staff who are well versed in the signs and symptoms of withdrawal. An additional consideration is providing such information to non–English-speaking patients and their families.
Interventions that assist the client in identifying and managing urges to use also may be helpful in retaining the client in detoxification and ensuring initiation of rehabilitation. These interventions may include cognitive–behavioral approaches that help the individual identify thoughts or urges to use, the development of an individualized plan to resist these urges, and use of medications such as naltrexone to reduce craving (Anton 1999; Miller and Gold 1994).
The use of client advocates to intervene with clients wishing to leave early often can be an effective strategy for promoting retention in detoxification. Visitors should be instructed about the importance of supporting the individual in both detoxification and substance abuse treatment. If available, and if the patient is stable, he or she can attend onsite 12-Step or other support group meetings while receiving detoxification services. These activities reinforce the need for substance abuse treatment and maintenance activities and may provide a critical recovery-oriented support system once detoxification services are completed.
Maintaining a safe and drug-free environment is essential to retaining clients in detoxification. Providers should be alert to drug-seeking behaviors, including bringing alcohol or other drugs into the facility. Visiting areas should be easy for the staff to monitor closely, and staff may want to search visiting areas and other public areas periodically to reduce the opportunities for acquiring substances. It is important to note, however, that personnel should be respectful in their efforts to maintain a drug-free environment. It is important to explain to patients (prior to treatment) and visitors why substances are not allowed in the facility.
Alternative approaches such as acupuncture are safe, inexpensive, and increasingly popular in both detoxification and substance abuse treatment. Although the effectiveness of alternative treatments in detoxification and treatment has not been validated in well-controlled clinical trials, if an alternative therapy brings patients into detoxification and keeps them there, it may have utility beyond whatever specific therapeutic value it may have (Trachtenberg 2000). Other treatments that reside outside the Western biomedical system, typically grouped together under the heading of Complementary or Alternative Medicine, also may be useful for retaining patients. Indeed, given the great cultural diversity in the United States, other culturally appropriate practices should be considered.
Motivational enhancements are particularly well-suited to accomplishing the detoxification services goal of promoting initiation in rehabilitation and maintenance activities. Use of these techniques in the detoxification setting increases the likelihood that patients will seek treatment by helping them understand the adverse consequences of continued substance use. It also establishes a supportive and nonjudgmental relationship between the substance abuse counselor and the patient—this therapeutic alliance is an important factor in the patient's choice to seek treatment services (Miller and Rollnick 2002). TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c), covers specific interventions and techniques to increase motivation to change substance-related behaviors. TIP 35 also includes some basic principles common to motivational interventions (CSAT 1999c, p. xvii):
Focus on the patient's strengths.
Show respect for a patient's decisions and autonomy; respect should be maintained at all times, even when the patient is intoxicated.
Avoid confrontation.
Individualize treatment.
Do not use labels that depersonalize the patient, such as “addict” or “alcoholic.”
Empathize with the patient, making an attempt to understand the patient's perspective and accept his or her feelings.
Accept treatment goals that involve small steps toward ultimate goals.
Assist the patient in developing an awareness of discrepancies between her or his goals or values and current behavior.
Listen reflectively to the patient's immediate concerns and ask open-ended questions.
In addition, the detoxification team can leverage the relationship the patient has with significant others. Using interventions such as Community Reinforcement and Family Training (CRAFT) (Miller et al. 1999), the detoxification team can help significant others in the patient's life capitalize on moments when the patient is ready for change and assist the patient in preparing for change in a nonthreatening, nonconfrontational manner. The consensus panel does not recommend that clinicians use direct confrontation in helping a person with a substance use disorder begin the process of detoxification and subsequent substance abuse treatment. Techniques that involve purposefully confronting patients about their substance use behavior, such as the Johnson Intervention, where significant others are taught to confront the individuals using substances (Liepman 1993), have been shown to be highly effective when significant others implement them. However, subsequent studies of clinicians, groups, and programs that rely on confrontational techniques have yielded poor outcomes (Miller et al. 1995). Moreover, the vast majority of significant others do not wish to use these techniques, and for that reason these techniques are not recommended (Miller et al. 1999).
Care should be taken to ensure that any significant other who is involved in motivating the patient for therapy is appropriate for this task. Only significant others who have been appropriately introduced to the intervention by a clinician should participate. The presence of a trained facilitator is recommended, either for coaching or for facilitating the intervention. It also is important to have the recommended treatment option readily available so if the patient agrees, admission can be swift and seamless. Those individuals selected to intervene should support the patient's abstinence from substances of abuse. Furthermore, if the patient places considerable value on her or his relationships with these significant others, success is more likely (Longabaugh et al. 1993).
Perhaps the most well-known and empirically validated model of “readiness to change” that has been applied to substance abuse is the transtheoretical model, also known as the stages of change model (DiClemente and Prochaska 1998). The interventions to increase patient motivation for substance abuse treatment described in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c) are based on this model.
According to the model, a client is considered to be at one of five stages of readiness to change his substance-abusing behavior, each stage being progressively closer to sustained recovery. Those stages are precontemplation, contemplation, preparation, action, and maintenance. The model assumes that individuals may move back and forth between different stages over time. A corollary to this assumption is that an individual's level of motivation is definitely not a permanent characteristic. Rather, motivation to change can be influenced by others, including detoxification treatment staff.
Clinicians, groups, and programs that rely on confrontational techniques have yielded poor outcomes.
In general, the basic concept is to try to move patients to the next stage of change. The clinician needs to identify any potential obstacles that might hinder the patient's progress through the stages of change. The transtheoretical model is illustrated in Figure 3-5 (p. 36) and the details of each stage are described in the text below.
The Transtheoretical Model (Stages of Change).
In the precontemplation stage, the individual is not considering any change in substance-using behavior in the foreseeable future. Typically, a patient in this stage either is unaware that his substance use is a problem or is unwilling or too discouraged to make a change. Often, a person in the precontemplation stage has not experienced serious consequences from substance use. During the precontemplation stage, the clinician should be attentive for and seize upon any ambivalence expressed by the patient toward substance-related behaviors. Such ambivalence may be more likely to emerge during initial detoxification, before the patient has returned to a relative zone of comfort and greater denial. For patients who are determined to remain in the precontemplation stage, the main goal is to get the patient to begin to consider changing. To accomplish this, the clinician might express concern, listen to the patient's perspective, and keep the door open for further communication regarding treatment options.
In the contemplation stage, the individual has some awareness that substance use presents a problem. In this stage, the patient may express a desire or willingness to change, but has no definite plans to do so in the near future, which generally is considered to be the next 2 to 6 months. Whether it is explicitly stated or not, it is thought that most individuals in this stage are ambivalent about changing. That is, side-by-side with any desire to change is a desire to continue the current behavior. For patients in the contemplation stage, clinicians are advised to use “decisional balancing strategies” to help the patient move to the action stage (Carey et al. 1999). In this approach, the clinician helps the patient to consider the positive and negative aspects of her substance abuse and has the patient weigh them against each other with the expectation that the scale of balance tips in favor of adopting new behavior. Psychoeducation on the interaction of substance abuse with other problems, including health, legal, employment, parenting, and mental illness, can be part of this procedure. Helping the patient understand that ambivalent feelings about changing substance use behaviors are normal and expected can be particularly useful at this stage.
In the preparation stage, the patient is aware that his substance use presents a significant problem and desires change. Moreover, the patient has made a conscious decision to commit himself to a behavior change. This stage is defined as one in which the individual prepares for the upcoming change in specific ways, such as deciding whether a formal treatment program is needed and, if so, which one. This stage is characterized by goal setting and making commitments to stop using, such as informing coworkers, friends, and family of treatment plans. For patients in the preparation stage, clinicians should elicit the patient's goals and strategies for change and be on the alert for signs that the patient is ready to move into the action stage. It is critical that the clinician respond quickly to any requests for treatment to capitalize on this motivation before it wanes. One of the most critically important roles the clinician can play in this stage is to assist the patient in developing a plan of action or a behavioral contract, taking into account the individual needs of the patient. As part of this process the clinician should help the patient enlist social support. Exploring the patient's expectations regarding treatment and her role in it is important. Finally, because of the commonly experienced difficulty in accessing treatment, the clinician should discuss with the patient ways of maintaining motivation for change during a possible wait for entry into a treatment program, should the patient be placed, for example, on a waiting list.
In the action stage, the patient is taking active steps to change substance use behaviors. This includes making modifications to his habits and environment, such as not spending time in places or with people associated with drug taking behavior. These changes may even continue to be made 3 to 6 months after substance abuse has ceased.
In the maintenance stage, the patient is working to maintain the changes initiated in the action phase.
The therapeutic alliance refers to the quality of the relationship between a patient and his care providers and is the “nonspecific factor” that predicts successful therapy outcomes across a variety of different therapies (Horvath and Luborsky 1993). A therapeutic alliance should be developed in the context of an ability to form an alliance to a group of helping individuals—such as a healthy support network or therapeutic community. A clinically appropriate relationship between the clinician and patient that is supportive, empathic, and nonjudgmental is the hallmark of a strong therapeutic alliance.
Readiness to change predicts a positive therapeutic alliance (Connors et al. 2000). Strong alliances, in turn, have been associated with positive outcomes in patients who are dependent on alcohol (Connors et al. 1997), as well as patients involved in methadone maintenance, on such measures as illicit drug use, employment status, and psychological functioning. In addition, the practitioner's expertise and competence instill confidence in the treatment and strengthen the therapeutic alliance. Emphasis also should be given to the alliance with a social support network, which can be a powerful predictor of whether the patient stays in treatment (Luborsky 2000).
Given the importance of the therapeutic alliance and the fact that detoxification often is the entry point for patients into substance abuse treatment services, work on establishing a therapeutic alliance ideally will begin upon admission. Many of the guidelines listed above for enhancing motivation apply to establishing this rapport. Newman (1997) makes some additional recommendations for developing the therapeutic alliance, such as discussing the issue of confidentiality with patients and acknowledging that the road to recovery is difficult. He also advises being consistent, dependable, trustworthy, and available, even when the patient is not. The clinician should remain calm and cool even if the patient becomes noticeably upset. Practitioners should be confident yet humble and should set limits in a respectful manner without engaging in a power struggle. See Figure 3-6 for a list of characteristics most valuable to a clinician in strengthening the therapeutic alliance.
Clinician's Characteristics Most Important to the Therapeutic Alliance.
Once an individual passes through the most severe of the withdrawal symptoms and is safe and medically stable, the focus of the psychosocial interventions shifts toward actively preparing her for substance abuse treatment and maintenance activities. These interventions include (1) assessment of the patient's characteristics, strengths, and vulnerabilities that will influence recommendations for substance abuse treatment; (2) preparing the patient to participate in treatment; and (3) successfully linking the patient to treatment as well as other needed services and resources.
Ensuring that patients with substance use disorders enter substance abuse treatment following detoxification often is difficult. Many patients believe that once they have eliminated the substance or substances of abuse from their bodies, they have achieved abstinence. Moreover, some insurance policies may not cover treatment, or only offer partial coverage. The patient may have to go through cumbersome channels to determine if treatment is covered, and if so, how much.
Preparation should focus on eliminating administrative barriers to entering substance abuse treatment prior to discussing treatment options with the patient. Discussions with the patient should be consistent with the patient's improving ability to process and assess information in such a way that the patient appears to be acting with his or her own interests in mind.
To make appropriate recommendations for ongoing treatment and recovery activities, detoxification staff need to determine the individual characteristics of clients and their environments that are likely to influence the level of care, setting, and specialized services needed for recovery. ASAM's Patient Placement Criteria, Second Edition, Revised (PPC-2R) (ASAM 2001) provides one widely used model for determining the level of services needed to address substance-related disorders. The levels of treatment services range from community-based early intervention groups to medically managed intensive inpatient services. As noted in Chapter 2, providers need to make a placement decision based on six dimensions:
Acute Intoxication and/or Withdrawal Potential
Biomedical Conditions and Complications
Emotional, Behavioral, or Cognitive Conditions or Complications
Readiness to Change
Relapse, Continued Use, or Continued Problem Potential
Recovery/Living Environment
Due to the limited time patients stay in detoxification settings, it is challenging for programs to conduct a complete assessment of the rehabilitation needs of the individual. With this in mind, detoxification programs should focus on those areas that are essential to make an appropriate linkage to substance abuse treatment services. The assessment of the psychosocial needs affecting the rehabilitation process itself may have to be left to the professionals providing substance abuse treatment. Other assessment considerations include
Special needs, such as co-occurring psychiatric and medical conditions that may complicate treatment or limit access to available rehabilitation services
Pregnancy, physical limitations, and cognitive impairments that limit the settings suitable for the individual
Support system issues such as family support, domestic violence, and isolation that influence recommendations about residential versus outpatient settings
The needs of dependent children
The need for gender-specific treatment (for more information see the forthcoming TIPs Substance Abuse Treatment: Addressing the Specific Needs of Women [SAMHSA in development e] and Substance Abuse Treatment: Men's Issues [SAMHSA in development g]).
Figure 3-7 (p. 40) outlines the areas the consensus panel recommends for assessment to determine the most appropriate rehabilitation plan.
Recommended Areas for Assessment To Determine Appropriate Rehabilitation Plans.
Appendix C lists a variety of instruments useful in characterizing the addiction and related disorders (for example, the Addiction Severity Index [ASI]), measuring motivational willingness to change (Stages of Change Readiness and Treatment Eagerness Scale [SOCRATES] and University of Rhode Island Change Assessment [URICA]), and evaluating co-occurring psychiatric conditions and social and family factors. Administering these instruments requires varying degrees of sophistication on the part of the clinician. All instruments should be considered for their cultural, linguistic, level of cognitive comprehension, and developmental appropriateness for each patient. For further information on patient placement see TIP 13, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (CSAT 1995h).
Just as with settings for detoxification, settings where substance abuse treatment is provided often are confused with the level of intensity of the services. It is increasingly clear that although level of intensity of services and setting are both critical to successful recovery, they are two separate dimensions to be considered when linking clients to treatment. This process has been called “delinking” or “unbundling” and generally involves determining the need for social services independently from the clinical intensity (Gastfriend and McLellan 1997; McGee and Mee-Lee 1997).
Treatment and maintenance activities are offered in a variety of settings. These include settings specifically designed to deliver substance abuse treatment, such as freestanding substance abuse treatment centers, as well as settings operating for other purposes, including mental health centers, jails and prisons, and community corrections facilities. Descriptions of these settings appear below:
Inpatient programs for treatment of substance abuse generally are delivered in hospitals and freestanding clinics and provide 24-hour nursing care in addition to intensive treatment for substance-related problems.
Residential treatment programs normally provide 24-hour supervision by nonmedical staff and the availability of medical staff may be limited. These programs deliver highly intensive substance abuse counseling and clients may participate in the upkeep of facilities. Peer support is critical to the treatment delivered. As a general rule, patients will stay at a residential treatment facility for 7 to 30 days.
Therapeutic communities (TCs) usually have 24-hour supervision by nonmedical staff or clients who have sustained recovery. They tend to provide highly intensive counseling services and rely on peer support and confrontation to shape behaviors of clients. The TC is based on concepts of self-help. Residence in a TC is longer than a patient's stay in a residential program—patients usually stay for a period of at least 30 days and often 6 months to a year. In some special situations, such as a criminal justice setting, TC residence can last 2 years or more.
Transitional residential programs and halfway houses ordinarily have 24-hour supervision from nonmedical staff or clients who have sustained recovery. Patients in these programs often are working and participate in counseling and peer support during the evening and weekend hours.
Partial hospitalization and day treatment programs use a combination of medical and nonmedical staff to deliver a high intensity of counseling services during daytime hours. Patients return home in the evenings.
Intensive outpatient programs usually are delivered by nonmedical staff in a clinic location. Patients receive 6 to 9 hours of counseling services each week in two or three contacts.
Traditional outpatient services typically are delivered by counselors in a clinic or office setting and provide fewer hours of services than the “intensive outpatient” programs.
Recovery maintenance activities are not treatment but are highly valuable for ongoing sobriety maintenance. They include 12-Step and other support groups aimed at maintaining the gains accomplished in treatment settings. Oxford House establishments and other “clean and sober” living environments are among the resources that clinicians should explore and perhaps incorporate in maintenance activities.
Approximately half of those making an appointment for treatment do not appear for their first appointment and another 20 percent or more fail to appear for the second appointment (Gottheil et al. 1997; Parker 2002). As patients near completion of detoxification, whether they take the next step and enter treatment is dependent on a number of variables. Patients who are employed, are motivated beyond the precontemplation stage, and have family and social support, as well as those with co-occurring psychiatric conditions, are more likely to initiate treatment. Conversely, those who have severe drug dependence and those who are older are less likely to follow through and enter treatment (Kirchner et al. 2000; Weisner et al. 2001). Women are more likely to initiate treatment after detoxification than men, and individuals who have health insurance that features a behavioral health carve-out and lower cost-sharing requirements are more likely to enter treatment than those who do not (Mark et al. 2003b). Kleinman and associates (2002) followed 279 opioid- and cocaine-dependent patients who had been in detoxification programs to determine how many had entered substance abuse treatment 30 days after leaving the detoxification program. They found that those who were on parole, homeless, or who had been using drugs for less than 20 years were more likely than others to have entered treatment.
Research indicates that patients are more likely to initiate and remain in rehabilitation if they believe the services will help them with specific life problems (Fiorentine et al. 1999). Figure 3-8 suggests strategies that detoxification personnel can use with their patients to promote the initiation of treatment and maintenance activities.
Strategies To Promote Initiation of Treatment and Maintenance Activities.
Patients are more likely to engage in treatment if they believe the full array of their problems will be addressed, including those needs typically addressed by wraparound services (e.g., housing, vocational assistance, childcare, transportation) (Fiorentine et al. 1999). Moreover, patients receiving needed wraparound services remain in substance abuse treatment longer and improve more than people who do not receive such services (Hser et al. 1999).
As the individual passes through acute intoxication and withdrawal, it is important to ensure that the basic needs of the patient are met after discharge. These needs include access to a safe, stable, and drug-free living environment if possible; physical safety; food and clothing; ongoing health and prenatal care; financial assistance; and childcare. Ensuring access to these basic needs may be problematic, and staff must be flexible and creative in finding the means to meet the basic needs of the patient.
Clearly, services planning should extend beyond the issues of substance dependence to other areas that may affect compliance with rehabilitation. Detoxification providers should be familiar with available resources for legal assistance, dental care, support groups, interpreters, housing assistance, trauma treatment, recovery-sensitive parenting groups, spiritual and cultural support, employment assistance, and other assistance programs for basic needs. Family and other support systems also can be helpful to the patient in accessing services and should take part in the services planning as often as possible, always with the patient's consent.
To address the needs of homeless and indigent patients, detoxification providers should be familiar with emergency shelters, cash assistance, and food programs in their communities and should have established referral relationships. Assessing women, teenagers, older adults, and other vulnerable individuals for victimization by another member of the household also is important. Patients should be linked with prenatal and primary health care for domestic violence. Ideally, linkage to these programs includes more than a phone number; detoxification staff should assist patients in scheduling initial appointments and arranging for transportation.
Linkage to primary health and prenatal care as well as to community resources is essential for individuals with substance use disorders. Linkages can be an effective mechanism to assist the patient in accessing these services if they are not available as a part of the detoxification program. Formalized referral arrangements through contracts or memoranda of understanding can be useful to specify organizational obligations (D'Aunno 1997).
An integral part of the process of linking an individual with rehabilitation and treatment resources is to address access barriers. Transportation, child care during treatment, the potential for relapse between detoxification discharge and treatment admission, housing needs, and safety issues such as possible domestic violence should be addressed through an individualized plan prior to discharge.
The problem of a patient's placement on a waiting list presents a special barrier to treatment. The solution lies in developing strategies to maintain motivation for treatment during the waiting period.
For pregnant women and patients with dependent children, the threat of Child Protective Services removing their children for abuse and neglect due to drug use can be a barrier to entering a treatment program.
Additionally, interacting with hostile or unfriendly practitioners and encountering resistance from family, partners, or friends can be barriers to treatment entry.
Detoxification staff should be knowledgeable about State laws regarding drug use during pregnancy and definitions of child abuse and neglect in order to be able to reassure and encourage women to enter treatment.
People who identify as having a physical or cognitive disability also face special barriers to treatment. The reader is referred to TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998g) and TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000d), for more information on these topics.
For racial/ethnic minorities, access barriers can be compounded by language, cultural, and financial factors. The ability of programs to develop culturally specific interventions, train staff and interpreters to respond to the specific needs of these individuals, and be aware of cultural differences in the manifestation of symptoms is critical to improving access to care. Supervision of staff and training in cross-cultural issues is equally important to all programs serving diverse patient populations. The forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (SAMHSA in development a) contains more information on this topic.
Case management presents an opportunity to tailor services to individual client needs and to minimize barriers to these services (Gastfriend and McLellan 1997). Case management is a set of services managed to assist the client in accessing needed resources. It is a useful strategy to ensure that access to wraparound services such as employment, housing, health care, and basic needs are met along with minimizing barriers to accessing substance abuse treatment. As outlined in TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a), the common functions of case management are defined as assessment, planning, linkage, monitoring, and advocacy. Case managers can facilitate the critical linkage between detoxification services and rehabilitation by providing transportation to the rehabilitation facility, arranging for childcare, or assisting with housing needs. Additionally, case management is a widely used strategy to integrate mental health and substance abuse treatment for those with co-occurring conditions (Drake and Mueser 2000).
Although it is important to make referrals for ongoing psychiatric attention, the presence of psychological symptoms should not prevent detoxification staff from referring patients to substance abuse treatment. Individuals with co-occurring psychiatric conditions appear to be able to initiate and benefit from substance abuse treatment like individuals without psychiatric conditions (Joe et al. 1995).
Since some psychiatric illnesses may affect drug cravings in patients who are substance dependent, it is important to ensure that both the psychiatric condition and the substance use disorder are addressed in rehabilitation (Anton 1999). Individuals who are taking psychotropic medications should be counseled about the importance of continuing on these medications. Whenever possible, discharge from the detoxification services should be coordinated with the patient's mental health provider in the community, and the patient should have an appointment scheduled at the time of discharge from the detoxification facility. Detoxification providers should request that the patient sign appropriate releases of information to provide assessment and other material to the mental health provider to promote continuity of care. This should only occur when the patient is medically stabilized and is in such a state of mind that he or she can make coherent decisions in this regard (e.g., while intoxicated, patients should not be permitted to sign releases).
For individuals with serious co-occurring psychiatric conditions, integrated treatment for substance use disorders and mental illness is recommended. Case management services as described above may be especially important for individuals with severe mental illness impeding their ability to access services on their own. Increasingly, substance abuse and mental health providers are implementing models using clinicians trained to deliver both substance abuse and mental health treatment concurrently (Drake and Mueser 2000). For more information, see TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).
The patient's consent should be sought to involve her or his primary healthcare provider in the coordination of care. Patients with chronic medical conditions and those in need of followup care should have an appointment made for followup medical care before leaving the detoxification setting (Luborsky et al. 1997).
For individuals with substance abuse problems who detoxify regularly but have limited periods of abstinence, traditional treatment approaches may not be effective. In some cases, addressing other needs may provide an avenue to engage the individual with chronic substance dependence in treatment. Case management approaches can be successful at addressing the need for housing, health care, and basic needs even though the individual is not yet willing to confront the issue of drinking or other drug use (Cox et al. 1998). TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a), provides additional information about delivery of case management services to homeless individuals with substance use disorders and those with other complex problems. Documentation of repetitive inappropriate use of voluntary detoxification services may help pave the way for civil commitment to involuntary treatment where this is an option, and, where detoxification resources are limited, treatment systems need to be creative in designing care plans for patients seeking frequent detoxification without evidence of any therapeutic benefit.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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