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Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies Into Medical Practice. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 49.)

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Incorporating Alcohol Pharmacotherapies Into Medical Practice.

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Appendix C—Excerpts From Quick Guide for Clinicians Based on TIP 45, Detoxification and Substance Abuse Treatment


The “medical model” of detoxification is characterized by the use of physicians and nursing staff and the administration of medication to assist people through withdrawal safely. The “social model” relies more on a supportive non-hospital environment than on medication to ease the passage through withdrawal.


Detoxification is a series of interventions aimed at managing acute intoxication and withdrawal. It denotes a clearing of toxins from the body of the patient who is acutely intoxicated and/or dependent on substances of abuse. Detoxification seeks to minimize the physical harm caused by the abuse of substances.

Evaluation entails testing for the presence of substances of abuse in the bloodstream, measuring their concentration, and screening for co-occurring mental and physical conditions. Evaluation also includes a comprehensive assessment of the patient's medical, psychological, and social situation.

Stabilization includes the medical and psychosocial process of assisting the patient through acute intoxication and withdrawal to the attainment of a medically stable, fully supported, substance-free state.

Fostering the patient's entry into treatment involves preparing a patient for entry into treatment by stressing the importance of following through with a complete continuum of care.

Guiding Principles/Assumptions

The panel of experts who created TIP 45 agreed to the following assumptions, which served as a basis for their work:


Detoxification alone is not sufficient treatment for substance dependence but is one part of a continuum of care for substance-related disorders.


The detoxification process consists of the following three components:

  • Evaluation
  • Stabilization
  • Fostering patient readiness for and entry into treatment

A detoxification process that does not incorporate all three critical components is considered incomplete and inadequate by the consensus panel.


Detoxification can take place in a wide variety of settings and at a number of levels of intensity. Placement should be appropriate to a patient's needs.


Persons seeking detoxification should have access to the components of the detoxification process described above, no matter what the setting or the level of treatment intensity.


All persons requiring treatment for substance use disorders should receive treatment of the same quality and appropriate thoroughness and should be put into contact with a treatment program for substance use disorders after detoxification.


Ultimately, insurance coverage for the full range of detoxification services and followup treatment services is cost-effective. If reimbursement systems do not provide payment for the complete detoxification process, patients may be released prematurely, leading to medically or socially unattended withdrawal.


Patients seeking detoxification services have diverse cultural and ethnic backgrounds as well as unique health needs and life situations. Organizations that provide detoxification services need to ensure that they have standard practices in place to address cultural diversity.


A successful detoxification process can be measured, in part, by whether an individual who is substance dependent enters, remains in, and is compliant with the treatment protocol of a substance abuse treatment/rehabilitation program after detoxification.

Overarching Principles for Care During Detoxification Services

  • Detoxification services do not offer a “cure” for substance use disorders; they are often a first step toward recovery and a “first door” through which patients pass to treatment.
  • Substance use disorders are treatable and there is hope for recovery.
  • Substance use disorders are brain disorders and not evidence of moral weakness.
  • Patients should be treated with respect and dignity at all times.
  • Patients should be treated in a nonjudgmental and supportive manner.
  • Services planning should be completed in partnership with the patient and his or her social support network, including family, significant others, or employers.
  • All health professionals involved in the care of the patient will maximize opportunities to promote rehabilitation and maintenance activities and to link the patient to appropriate substance abuse treatment immediately after the detoxification phase.
  • Active involvement of the family and other support systems, while respecting the patient's right to privacy and confidentiality, is to be encouraged.
  • Patients are treated with due consideration for individual background, culture, preferences, sexual orientation, disability, vulnerabilities, and strengths.

Levels of Care and Patient Placement

In addition to the general placement criteria for the treatment of substance-related disorders, the Patient Placement Criteria, Second Edition, Revised (PPC-2R) of the American Society of Addiction Medicine (ASAM) also indicates a second set of placement criteria, which are more important for the purposes of TIP 45 and this Quick Guide—the five “Adult Detoxification” placement levels of care within Dimension 1 (ASAM, 2001). These “Adult Detoxification” levels of care are:


Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring (e.g., physician's office, home health care agency). This level of care is an organized outpatient service monitored at predetermined intervals.


Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring (e.g., day hospital service). This level of care is monitored by appropriately credentialed and licensed nurses.


Level III.2-D: Clinically Managed Residential Detoxification (e.g., nonmedical or social detoxification setting). This level emphasizes peer and social support and is intended for patients whose intoxication and/or withdrawal is sufficient to warrant 24-hour support.


Level III.7-D: Medically Monitored Inpatient Detoxification (e.g., freestanding detoxification center). Unlike Level III.2-D, this level provides 24-hour medically supervised detoxification services.


Level IV-D: Medically Managed Intensive Inpatient Detoxification (e.g., psychiatric hospital inpatient center). This level provides 24-hour care in an acute care inpatient setting.

It is important to note that ASAM PPC-2R criteria are only guidelines and that there are no uniform protocols for determining which patients are placed in which level of care. For further information on patient placement, readers are advised to consult TIP 13, The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders (CSAT 1995).

Biomedical and Psychosocial Issues

Detoxification presents an opportunity to intervene during a period of crisis and to encourage a client to make changes in the direction of health and recovery. Hence, a primary goal of the detoxification staff should be to build a therapeutic alliance and motivate patients to enter treatment. This process should begin as the patient is being medically stabilized.

Symptoms and Signs of Conditions That Require Immediate Medical Attention

  • Change in mental status
  • Increasing anxiety
  • Hallucinations
  • Temperature greater than 100.4°F (these patients should be considered potentially infectious)
  • Significant increases and/or decreases in blood pressure and heart rate
  • Insomnia
  • Abdominal pain
  • Upper and lower gastrointestinal bleeding
  • Changes in responsiveness of pupils
  • Heightened deep tendon reflexes and ankle clonus, a reflex beating of the foot when pressed rostrally, indicating profound central nervous system irritability and the potential for seizures

Immediate Mental Health Needs

The following are mental health issues that require immediate attention:


  • Patients receiving detoxification services should be evaluated for suicide risk.
  • During acute intoxication and withdrawal, it is important to provide an environment that minimizes opportunities for suicide attempts.
  • Frequent safety checks should be implemented.
  • Patients at risk for suicide should be placed in areas monitored by staff.

Anger and aggression

  • All patients who are intoxicated should be considered potentially violent.
  • Symptoms associated with increased risk for violence include hallucinations, paranoia, anxiety, and depression.
  • Physical restraint should be used as a last resort.

Initial Biomedical and Psychosocial Evaluation Domains

An initial evaluation will help detoxification staff foresee any variables that might complicate withdrawal. The following is a list of biomedical and psychosocial domains that can affect the stabilization of the patient.

Biomedical domains

  • General health history: What is the patient's medical and surgical history? Are there any psychiatric or medical conditions? Any known medication allergies? A history of seizures?
  • Mental status: Is the patient oriented, alert, cooperative? Are thoughts coherent? Are there signs of psychosis or destructive thoughts?
  • General physical assessment with neurological exam: This will ascertain the patient's general health and identify medical or psychiatric disorders of immediate concern.
  • Temperature, pulse, blood pressure (should be monitored throughout detoxification).
  • Patterns of substance abuse: When did the patient last use? What were the substances of abuse? How much of these substances was used and how frequently?
  • Urine and toxicology screen for commonly abused substances.
  • Past substance abuse treatments or detoxification.

Psychosocial domains

  • Demographic features: Gather information on gender, age, ethnicity, culture, language, and education level.
  • Living conditions: Is the patient homeless or living in a shelter? Are significant others in the home (and, if so, can they safely supervise)?
  • Violence, suicide risk: Is the patient aggressive, depressed, or hopeless? Is there a history of violence?
  • Transportation: Does the patient have adequate means to get to appointments? Do other arrangements need to be made?
  • Financial situation: Is the patient able to purchase medication and food? Does the patient have adequate employment and income?
  • Dependent children: Is the patient able to care for children, provide adequate child care, and ensure the safety of children?
  • Legal status: Is the patient a legal resident? Are there pending legal matters? Is treatment court ordered?
  • Physical, sensory, or cognitive disabilities: Does the client have disabilities that require consideration?

Considerations for Specific Populations


  • Adolescents are more likely to drink large quantities of alcohol in a short period of time, making it important that staff be alert to escalating blood alcohol levels.
  • Adolescents are more likely to use drugs they cannot identify, to combine multiple substances with alcohol, to ingest unidentified substances, and to be unwilling to disclose drug use.
  • Asking open-ended questions and using street terminology for drugs can be helpful in both establishing rapport and obtaining an accurate substance use history.

Parents with dependent children

  • It is of vital importance to ensure that the children of someone receiving detoxification services have a safe place to stay.
  • Working with patients to identify supportive family or friends may uncover 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.

Alcohol Intoxication and Withdrawal

The following symptoms of alcohol intoxication can vary greatly with the patient's level of tolerance.

Blood alcohol level is 20–100 mg percent

  • Mood and behavioral changes
  • Reduced coordination
  • Impairment of ability to drive a car or operate machinery

Blood alcohol level is 101–200 mg percent

  • Reduced coordination of most activities
  • Speech impairment
  • Trouble walking
  • General impairment of thinking and judgment
  • Somnolence, combative or “psychotic” behavior
  • “Normal” mental status

Blood alcohol level is 201–300 mg percent

  • Marked impairment of thinking, memory, and coordination
  • Marked reduction in level of alertness
  • Memory blackouts
  • Nausea and vomiting/aspiration

Blood alcohol level is 301–400 mg percent

  • Worsening of above symptoms with reduction of body temperature and blood pressure
  • Excessive sleepiness/comatose
  • Amnesia
  • Nausea and vomiting/aspiration
  • Death

Blood alcohol level is 401–800 mg percent

  • Difficulty waking the patient (coma)
  • Serious decreases in pulse, temperature, blood pressure, and rate of breathing
  • Urinary and bowel incontinence
  • Death

The signs and symptoms of acute alcohol withdrawal generally start 6 to 24 hours after the patient takes his last drink. Acute withdrawal may begin when the patient still has significant blood alcohol concentrations. The signs and symptoms may include the following and are highly variable:

  • Restlessness, irritability, anxiety, agitation
  • Anorexia, nausea, vomiting
  • Tremor, elevated heart rate, increased blood pressure
  • Insomnia, intense dreaming, nightmares
  • Poor concentration, impaired memory and judgment
  • Increased sensitivity to sound, light, and tactile sensations
  • Hallucinations (auditory, visual, or tactile)
  • Delusions, usually of paranoid or persecutory varieties
  • Grand mal seizures
  • Hyperthermia
  • Delirium/disorientation with regard to time, place, person, and situation; fluctuation in level of consciousness

Management of Alcohol Withdrawal Without Medication

  • Indications for the management of alcohol withdrawal without medication have not been established through scientific studies or evidence-based methods.
  • The course of alcohol withdrawal is unpredictable; it is impossible to tell who will or will not experience life-threatening complications.
  • Positive aspects of the nonmedication approach are that it is highly cost-effective and provides inexpensive access to detoxification for individuals seeking aid.

Social Detoxification

Social detoxification programs are short-term, nonmedical treatment service for individuals with substance use disorders. A social detoxification program offers room, board, and interpersonal support to intoxicated individuals and individuals in substance use withdrawal. Social detoxification programs vary widely in services offered, but there should always be medical surveillance, including monitoring of vital signs.

TIP 45 provides several guidelines for social detoxification programs:

  • Such programs should follow local governmental regulations regarding licensing and inspection.
  • It is highly desirable that individuals entering social detoxification be assessed by primary care practitioners with some substance abuse treatment experience.
  • An assessment should determine whether the patient is currently intoxicated and the degree of intoxication, the type of withdrawal syndrome, severity of the withdrawal, information regarding past withdrawals, and the presence of co-occurring psychiatric, medical, and surgical conditions that might require specialized care.
  • Particular attention should be paid to individuals who have undergone multiple withdrawals in the past and for whom each withdrawal appears to be worse than previous ones (the so-called kindling effect). Patients with a history of severe withdrawals are not good candidates for social detoxification.
  • All social detoxification programs should have personnel who are familiar with the features of substance use withdrawal, have training in basic life support, and have access to an emergency medical system that can provide transportation to emergency departments.

Management of Alcohol Withdrawal With Medications

It is believed that only a minority of patients with alcoholism will go into significant alcohol withdrawal requiring medication. Identifying that small minority is sometimes problematic, but there are signs and symptoms of impending problems that can alert the caretaker to seek medical attention.

Deciding whether or not to use medical management for alcohol withdrawal requires that patients be separated into three groups:


Clients who have a history of the most extreme forms of withdrawal, that of seizures and/or delirium. The medication treatment of this group should proceed as quickly as possible.


Patients who are already in withdrawal and demonstrating moderate symptoms of withdrawal also require immediate medication.


The third group includes patients who may still be intoxicated, or who have, at the time of admission, been abstinent for only a few hours and have not developed signs or symptoms of withdrawal. A decision regarding medication treatment for this group should be based on advancing age, number of years with alcohol dependence, and the number of previously treated or untreated severe withdrawals. If there is an opportunity to observe the patient over the next 6 to 8 hours, then it is possible to delay a decision regarding treatment and periodically reevaluate a client of this category.

Benzodiazepine Treatment for Alcohol Withdrawal

These drugs remain the medication of choice in treating withdrawal from alcohol. The early recognition of alcohol withdrawal and prompt administration of a suitable benzodiazepine will prevent further withdrawal reaction from proceeding to serious consequences.

  • Loading dose of a benzodiazepine. Administration of a metabolized benzodiazepine may be carried out every 1 to 2 hours until significant clinical improvement occurs or the patient becomes sedated. In general, patients with severe withdrawal may receive 20 mg of diazepam or 100 mg of chlordiazepoxide every 2 to 3 hours until improvement or sedation prevails. The treatment staff should closely monitor blood pressure, pulse, and respiratory features.
  • Symptom-triggered therapy. Using the CIWA-Ar or similar alcohol withdrawal rating scales, medical personnel can be trained to recognize symptoms of alcohol withdrawal, make a rating, and based on the rating administer benzodiazepines to their patient only when signs and symptoms reach a particular threshold. A typical routine of administration is as follows: Administer 50 mg of chlordiazepoxide for CIWA-Ar >9 and reassess in 1 hour. Continue administering 50 mg chlordiazepoxide every hour until CIWA-Ar is <10.
  • Gradual, tapering doses. Once the patient has been stabilized, oral benzodiazepines can be administered on a predetermined dosing schedule for several days and gradually tapered over time. One example of this regimen is that patients might receive 50 mg of chlordiazepoxide or 10 mg of diazepam every 6 hours during the first day of treatment and 25 mg of chlordiazepoxide or 5 mg of diazepam every 6 hours on the second and third days.
  • Single daily dosing protocol. According to studies, this regimen may be attractive in community or social detoxification settings, particularly if patients could be monitored between doses.

Limitations of Benzodiazepines in Outpatient Treatment

The interaction of benzodiazepines with alcohol can lead to coma and respiratory suppression, motor incoordination, and abuse. Abuse is usually in the context of the concurrent use of alcohol, opioids, or stimulants. There are two other limitations as well:

  • Although benzodiazepines have been studied for 30 years and are effective for suppressing alcohol withdrawal symptoms, their ability to halt the progressive worsening of each successive alcohol withdrawal is in question.
  • Benzodiazepine use to treat outpatients in alcohol withdrawal may “prime” or reinstate alcohol use during their administration.

Other Medications

The following is a list of other medications sometimes used in detoxification from alcohol:

  • Barbiturates
  • Anticonvulsants
  • Beta blockers/alpha adrenergic agonists
  • Antipsychotics
  • Relapse prevention agents

Management of Delirium and Seizures

The major goal of medical detoxification is to avoid seizures and a special state of delirium called delirium tremens (DTs) with aggressive use of the primary detoxification drug. Death and disability may result from DTs or seizures without medical care.

For patients with a history of DTs or seizures, early benzodiazepine treatment is indicated at the first clinical setting. Patients with severe withdrawal symptoms, multiple past detoxifications (more than three), and co-occurring unstable medical and psychiatric conditions should be managed similarly.


  • Giving the patient a benzodiazepine should not be delayed by waiting for the return of laboratory studies, transportation problems, or the availability of a hospital bed.
  • Once full DTs have developed, they tend to run their course despite medication management.
  • Patients presenting in severe DTs should have emergency medical transport to a qualified emergency department and generally will require hospitalization.


  • Seizures usually occur within the first 48 hours after cessation or reduction of alcohol, with peak incidence around 24 hours.
  • Someone experiencing a seizure is at greater risk for progressing to DTs, whereas it is extremely unlikely that a patient already in DTs will also then experience a seizure.
  • The occurrence of an alcohol withdrawal seizure happens quickly, usually without warning to the individual experiencing the seizure or anyone around him.
  • Predicting who will have a seizure during alcohol withdrawal cannot be accomplished with any great certainty.
  • Patients having a seizure can be treated with intravenous (IV) diazepam or lorazepam and advanced cardiac life support protocol procedures.
  • Patients who have had a single witnessed or suspected alcohol withdrawal seizure should be immediately given a benzodiazepine, preferably with IV administration.
  • Benzodiazepine and/or barbiturate intoxication needs to be treated and assessed differently, given the potentially life-threatening implications of withdrawal from either substance in combination with each other and/or alcohol.

Wernicke-Korsakoff's Syndrome

  • Wernicke-Korsakoff's Syndrome is composed of Wernicke's encephalopathy and Korsakoff's psychosis.
  • Wernicke's encephalopathy is an acute neurological disorder featuring oculomotor dysfunction (bilateral abducens nerve palsy-eye muscle paralysis), ataxia (loss of muscle coordination), confusion, and weakness.
  • Korsakoff's psychosis is a chronic neurological condition that includes retrograde and antegrade amnesia (profound deficit in new learning and remote memory) with confabulation (patients make up stories to cover memory gaps).
  • Both syndromes are related to thiamine deficiency.
  • Thiamine initially is given parenterally (in a manner other than through the digestive tract, as by intravenous or intramuscular injection). Afterward, oral administration is the treatment of choice.
  • Always give thiamine prior to glucose administration.


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